AC 439 (1) HARR 30 BOROUGH OF HARROW Annual Report OF THE Vi£DICAL OFFICER OF HEALTH FOR THE YEAR 1963 WILLIAM CORMACK, M.B., Ch.B., D.P.H. \ BOROUGH OF HARROW Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1963 WILLIAM CORMACK, M.B., Ch.B., D.P.H. TABLE OF CONTENTS page General Statistics (With Tables) 12 Health Services of the Area Personal Health 21 Care of Mothers and Young Children 21 Day Nurseries 22 Midwifery 22 Home Nursing 23 Health Visiting 24 Vaccination and Immunisation 26 Chiropody 27 Domestic Help 28 School Health and Dental Services 29 Clinics and Treatment Centres in the Area Child Guidance Centre 32 Chest Clinics 32 Family Planning and Marriage Guidance 32 Hospitals 33 Nursing Homes 36 Establishments for Massage and Special Treatment 37 Provision for Special Classes of Persons 39 The Deprived Child 39 The Mentally 111 and Mentally Sub-normal 39 Persons in need of Care and Attention 40 The Aged 41 Advisory Clinics for the Elderly 42 Laboratory Facilities 43 Ambulance Service 43 Health Education 43 Sanitary Circumstances of the Area Water 45 Drainage 45 Public Cleansing 46 Swimming Baths 46 Disposal of the Dead 47 Sanitary Inspection Housing 50 Factories 53 Shops Act 55 Control of Nuisances 56 CLEAN Air 59 Inspection and Supervision of Food 62 Infectious and Other Diseases 68 PUBLIC HEALTH COMMITTEE 1963—1964 Councillor N. G. Hines (Chairman) Councillor H. A. Maun, a.f.i.c.d., c.c. (Vice-Chairman) His Worship The Mayor (ex-officio) Alderman Mrs. Nott Cock, s.r.n., s.c.m., m.r.s.h. Councillor E. S. W. Atherton, f.r.i.b.a., a.m.p.t.i. Councillor Mrs. A. M. Carey Councillor W. S. Clack, m.i.ex., m.inst.m.s.m. Councillor Mrs. E. J. Colledge Councillor B. M. Cohen Councillor Mrs. E. E. Davies Councillor Mrs. D. I. Edwards Councillor H. I. Harris Councillor Dr. I. M. Roitt, m.a., b.sc., d.phil.(oxon). Councillor D. B. Rouse Councillor A. G. Sellers Councillor H. V. Shaw, l.r.i.b.a. STAFF Medical Officer of Health: W. Cormack, m b , Ch.b., d p h. Deputy Medical Officer of Health: R. A. Strang, m.b., Ch b., d.p.h.. Chief Public Health Inspector: S. N. King, m.a.p.h.i. Deputy Chief Public Health Inspector: H. Drabble, m.a.p.h.i. Public Health Inspectors: D. J. Anderton, m.a.p.h.i. B. A. Cantwell, m.a.p.h.i. J. K. Edson, m.a.p.h.i. F. H. Farrow, m.a.p.h.i. K. F. Johnson, m.a.p.h.i. C. E. Newbegin, m.a.p.h.i. C. F. pldgeon, m.a.p.h.i., tO 11.8.63 l. p. Watson, m.a.p.h.i. Assistant to Public Health Inspectors: J. Clements, to 1.9.63 Chief Clerk: S. Wharton Clerical Officer: Miss P. Rawlinson Clerical Assistants: Miss M. Bourner Mrs. D. L. Hilliard, from 12.8.63 Miss P. Leach Miss G. Mason Miss P. Palmer, from 7.1.63 Miss J. Todman Mortuary Keeper: C. Russell Disinfector: R. Whitaker Rodent Operatives: W. A. Farman J. Jackson C. Paradine 7 ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH Public Health Department, "Kynaston Court", Harrow Weald. To His Worship the Mayor, Aldermen and Councillors of the Borough of Harrow. Mr. Mayor, Ladies and Gentlemen, 1 have the honour to submit the Annual Report on the health and sanitary conditions of the district for the year 1963. The vital statistics for the year show the usual annual variations and compare favourably with those for the country as a whole. The figures for 1963 show that there was a slight fall in the total population, a slight fall in the birth rate, a static death rate, a considerable fall in both the infant and neonatal mortality rates, no maternal deaths and even though there was a slight increase in the stillbirth rate, the fall in the early neonatal death rate produced a lower perinatal mortality rate. Although the perinatal mortality rate has dropped the figure is still too high and represents a large number of children who have died because of some factors having effect in the pre-natal period or during labour. It must also be borne in mind that in addition to the children who actually die as a result of these factors there are probably many more who survive, but as a result of factors such as prematurity, Rhesus incompatibility, asphyxia during labour, are so damaged both physically and mentally that their hold on life becomes very precarious. The rearing of some of these "damaged children can in some instances place an almost intolerable burden on parents and, indeed, on a family group as a whole. Research into causes of perinatal mortality with the object of reducing both the number of deaths and also as a corollary the amount of physical and mental damage to the ones who survive, has been undertaken and in 1963 the first report of the British Perinatal Mortality Survey was issued. This survey was initiated under the aegis of the (National Birthday Trust Fund and resulted in the nation-wide Perinatal Survey carried out in 1958. Detailed information was collected and collated regarding over 17,000 births and over 7,000 stillbirths occurring during one week in March 1958. A vast quantity of sociological, clinical and pathological data has been obtained and will prove invaluable in assessing the perinatal mortality risks for different maternal ages, parities and social groups. Some of these results are discussed later in this report. 8 1963 was another busy year for the administrative, clerical and inspectorate members of the Health Department. Much of the work is routine in nature but once let the routine inspection work lapse and bad health habits tend to creep back again. Maintenance of high health standards needs a little effort and I suppose it is a human failing that once the "persuasion" is relaxed the "effort" flags somewhat. This is especially so in the case of food hygiene. It is very encouraging however to see the great interest displayed by the public in this aspect of public health. We get many queries in the Department from members of the public seeking opinion as to whether some particular practice they have observed is in the best interests of health. This shows that health propaganda is having an effect and one does not feel that Health Departments are fighting alone in the wilderness! The public health inspectors with their technical knowledge and their ability to meet the public are in an unique position and in my opinion are the health educators par excellence. Although stronger measures by way of court action had to be taken in a few cases the vast majority of the improvements sought were achieved by friendly advice and persuasion. Work on the Borough's Smoke Control programme progressed during the year and by the end of 1963 the whole of the wards of Roxeth and Roxbourne and part of West Harrow were the subject of operative Smoke Control Orders. Some difficulties over fuel storage were encountered during the year, but were resolved with the help and cooperation of the Housing Committee. Unfortunately I regret to report very little reduction in the number of complaints regarding the accumulations of rubbish repeatedly and indiscriminately dumped on sites in the Borough. Under the Public Health Act, 1936, the Health Department can only initiate action for clearance it there is a danger to health, e.g. the presence of putrescible material. This occurs only rarely with the result that the matter has to be referred to other departments for action. This problem has been with us for a number of years but instead of improving seems to be on the increase, so much so that any open space seems to be fair game for this indiscriminate dumping! The Council has discussed this problem on numerous occasions and in 1959 the Highways and Cleansing Committee agreed to widen the interpretation of what constituted household refuse and to continue the existing practice of making a nominal charge for special collections of items such as old water tanks, rubble, garden rubbish and trade refuse. Still the dumping goes on apace! Blame is laid on "visitors to the Borough but when one considers the amount of rubbish, this takes a lot of believing! What is the answer? A free collection service? Possibly this is the answer, however it must be borne in mind that a large amoun of ratepayers money is already expended each year on the collection an disposal of refuse. Surely it is not too much to ask that individuals who have some "non-conforming" refuse for disposal, should get in touc with the Cleansing Department who for a nominal sum will do the wor for them. To my mind this would be a much more public spirited action than to dump the refuse behind some garden fence. A little more consideration and thought on the part of these offenders whould help to keep 9 open spaces, woodlands, back-lanes and hedgerows of Harrow in their natural state rather than the glorified "middens" so often found today, which apart from being unsightly and a disgrace to the neighbourhood are potential breeding grounds for rats and flies. In the case of infectious diseases the year was marred by the usual biennial rise in the incidence of measles with 1,868 notifications. Usually a mild illness in the normally fit child, measles can however produce a "chesty" child and be a worrying problem in a sickly child. This, plus the great disruption an epidemic of this type can cause in schools, seems to offer a good case for the new vaccine at present undergoing research trials. There was also an increase in the number of cases of whooping cough, pneumonia and dysentery and a fall in the number of cases of food poisoning and scarlet fever. There was one case of typhoid fever in the district. This was contracted in the outbreak in Zermatt in Switzerland. Letters were sent to all food handling establishments in the district giving advice regarding staff" who may have holidayed in Zermatt during the period of the outbreak. Ministry of Health Circular 28/62 stated that the Minister of Health was ready to approve under Section 28 of the National Health Service Act proposals from local health authorities to make arrangements with water undertakers for the addition of fluoride to water supplies which were deficient in it naturally. In view of this, a comprehensive report on fluoridation was considered by the Public Health Committee in February 1963. The Committee in view of the importance of and the publicity given to the subject during the previous months, arranged for a copy of the report to be sent to each member of the Council. They also recommended that the Borough Council fully support the Middlesex County Council as local health authority in their decision to make arrangements with water undertakers in the County for the addition ot fluoride to public water supplies deficient in it naturally. The Council ratified this recommendation in March 1963. In April 1963 the Middlesex County Council submitted its proposals for fluoridation to the Ministry of Health for approval. In June 1963 in Circular 12/63 the Minister of Health issued a general approval to all local health authorities to make arrangements for the addition of fluorides to public water supplies to the level of one part per million and expressed the hope that these arrangements would be made as soon as possible. The London County Council approached its neighbouring counties asking for their support in making representations to the Metropolitan Water Board to fluoridate its water supply. Middlesex, Buckinghamshire and Essex agreed to the proposals and up to date that is where the matter rests! However, like certain other Public health measures in the past such as chlorination of water supplies and pasteurization of milk, the proposal to have fluoridation has caused a minor storm of protests which appears to be confined to a comparatively small section of the population. The objections have ranged from the question of (a) cost, (b) causation of illness, (c) lack of knowledge regarding oxicity to the question of ethics and compulsory medication. To my mind 10 apart from the fact that the monumental mass of scientific and medical evidence has proved the efficacy of fluoride as a caries inhibitor and also its extremely wide safety margin in use, the main protagonist for its use would be the appalling amount of dental caries found in young children. If something can improve this situation and with relative safety, why argue against its use? True our sophisticated diet aids and abets the onset of caries but experience has shown that to change a nation's dietary habits—especially when it concerns sweets, sugar and carbohydrates in any form—is an almost hopeless task! This task will not be relinquished but we must have fluoridation if dental health, and as a corollary, general health is to be improved. The findings of the Royal College of Physicians of London in 1962 regarding the connection between cigarette smoking and lung cancer were confirmed by the studies carried out in the United States and reported by the Surgeon General in his report on "Smoking and Health" published in 1963. However, just to confuse the issue West German scientists have been investigating the hazards of smoking over the past five years and their report to be published soon claims that air pollution is more likely to cause lung cancer than cigarette smoking! The report states that although heavy cigarette smoking shortened expectation of life other contributory factors were involved, but people most likely to get cancer were those working in dusty and smoke-ridden atmospheres. Education of the public and especially of the young person regarding the hazards of smoking continued during the year. Full use was made of all Ministry posters and in May 1963, the Mobile Unit of the Central Council for Health Education visited the district. Films, publicity material and informal discussions were in the programme which was aimed at the 13+ age group as being the one most likely to benefit by the impact of the campaign. The interest shown as judged by the quantity and quality of the questions asked by the pupils was very heartening. However ont wonders how lasting is the impact of poster, pamphlet, lecture and film Cancer is a "nasty" word to the public mainly because of the fear it conjures up. Smoking to the young is a status symbol, a sign of maturity,a sign of "being with it". To grown-ups it is a comforter both in time of stress and also in time of relaxation—unfortunately a comforter which so easily becomes an addiction. Central Government acton regarding banning smoking seems out of the question. Apart from the fact that so inuc big business and revenue from taxation is involved, the public themselves would never stand for such a ban. This is something which they will have to assess for themselves by studying the pros and cons and then making their own decision. Meanwhile Health Departments, together with other health educational organisations, will just have to carry on pointing out the dangers and hoping that eventually their efforts will bear fruit. The latter part of the year saw the beginning of the preparatory work for the 1st April, 1965, when Borough 29 comes into being under the Re-organisation of London Government. Under the London Government Bill the new London Borough Councils become local health authorities 11 (except for the Ambulance Service, for which the Greater London Council will be responsible); they are also to be the local authority for the purpose of the accommodation and welfare of the disabled and the elderly; they will be the children's authority and the local authority for food and drugs and for other specified matters. The tentative proposals for the London Borough of Harrow are that in addition to Personal, Environmental and Mental Health, Children's, Welfare and Food and Drugs with certain other specified matters will be placed under the jurisdiction of the Health Department. The integration of these allied services into a unified whole with the resulting benefits of much closer liaison would appear to have much to recommend it. Once again I would like to thank the Chairman and Members of the Public Health Committee for their interest and support and also acknowledge with thanks the friendly co-operation of my colleagues in the other departments of the Council. Finally to Mr. S. N. King, the Chief Public Health Inspector, Mr. Wharton, Chief Clerk, and all members of the Department, my sincere thanks for their most willing and able assistance during the year. I have the honour to be Your obedient servant WILLIAM CORMACK Medical Officer of Health. 12 STATISTICS AND SOCIAL CONDITIONS OF THE AREA General Statistics. Area in acres 12,500 Population (Registrar General's estimate) 209,520 Number of inhabited houses 66,103 Rateable value £10,640,917 Sum represented by a penny rate £43,350 Vital Statistics. Live Births:— Male Female Total Legitimate 1,578 1,445 3,023 Illegitimate 91 76 167 Total 1,669 1,521 3,190 Live Birth rate per 1,000 population 15.2 Adjusted Live Birth rate 15.5 Birth Rate for England and Wales 18.2 Illegitimate live births per cent of total live births 5.2 Stillbirths:— Male Female Total Legitimate 25 26 51 Illegitimate 0 2 2 Total 25 28 53 Still Birth rate per 1,000 Live and Still Births 16.6 Total Live and Still Births 3,243 Still Birth rate for England and Wales 17.2 Infant Deaths (under 1 year of age) Male Female Total Legitimate 23 20 43 Illegitimate 6 3 9 Total 29 23 52 Infant Mortality Rate per 1,000 live births 16.3 Legitimate Infant Mortality rate per 1.000 legitimate live births 14.2 Illegitimate Infant Mortality rate per 1,000 illegitimate live births 53.9 Infant Mortality Rate for England and Wales 21.1 13 Neo-Natal Deaths (under four weeks of age):— Male Female Total Legitimate 16 15 31 Illegitimate 6 1 7 Total 22 16 38 Neo-natal mortality rate per 1,000 live births 11.9 Neo-natal mortality rate for England and Wales 15.1 Early Neo-natal Mortality rate (first week) per 1,000 live births 11.3 Peri-natal mortality rate per 1,000 live and still births 27.4 Maternal Mortality:— Maternal deaths NIL Maternal Mortality rate per 1.000 live and still births NIL Maternal Mortality rate for England and Wales 0.4 Deaths:— Male Female Total 1.092 1.079 2,171 Death rate per 1,000 population: Crude Death Rate 10.4 Comparability Factor 1.08 Adjusted Death Rate 11.2 Death rate for England and Wales 12.2 Population. The estimated mid-year population for the Borough was 209,520 which, in spite of a natural increase in population—excess of births over deaths—of 1,019 was a continuation in the fall in population noted since 1551, The number of occupied houses and fiats rose by 761 to 66,103. This number has increased year by year and when considered in conjunction with the fall in population probably accounts to some extent for the gradual reduction in the number of cases of overcrowding noted since 1951 and which was clearly depicted in the Overcrowding Histogram in the annual report for the year 1962. Births. The total number of births registered during the year was 3,190 1,669 male and 1,521 female). 167 of these births were illegitimate, giving a percentage of total births of 5-2 as compared with a percentage of 5.1 for 1962. one thousand and four births occurred in the district—956 as a result of domiciliary confinement and 48 in local nursing homes. 2,238 14 (2,184 live ana 54 still) birth notifications were transferred from other districts being mostly of births occurring to Harrow mothers in hospitals in Middlesex or in London. The birth rate was 15.2 per 1,000 population which when corrected by the application of the Registrar General's area comparability factor gives a birth rate of 15.5 as compared with the birth rate of 18.2 per 1,000 population for England and Wales. Stillbirths. Fifty-three stillbirths were registered last year giving a stillbirth rate of 16.6 per 1,000 total births, which compaies with the rate of 17.2 for the country as a whole. Infantile Mortality. Last year 52 (29 male and 23 female) infants living in the district or born to mothers ordinarily resident here died under one year of age. This was a fall of 21 on the figure for 1962 and with 3,190 live births gives an infant mortality rate of 16.3 as compared with that of 22.5 in 1962. The rate for the country as a whole was 21.1. The majority of these infant deaths occurred in infants under one month of age, giving a neo- natal mortaility rate of 11.9. 95 per cent of these neo-natal deaths occurred before the age of one week and once again were due to congenital malformations and prematurity. These early neo-natal deaths added to the stillbirths give a perinatal mortality rate for 1963 of 27.4 per 1,000 live and stillbirths as compared with a rate of 28.3 for 1962. A report published this year showed that perinatal mortality is influenced by (1) region, (2) age, parity and social class, (3) past obstetric history, (4) place of booking and delivery, (5) pre-natal care, (6) toxaemia, (7) gestation, (8) birthweight, (9) type of labour and delivery. Some of the lessons brought out by the survey are the need for better selection of women for hospital, pre-natal care and confinement, earlier recognition and treatment of toxaemia in pregnancy, greater recognition of the importance of the length of gestation and above all, unification and extension ot the maternity services. The perinatal mortality rate for England and Wales was 35.1 per thousand in 1958 (Harrow29-8)andthis has fallen to 29.3 per thousand in 1963 (Harrow 27.4). It seems there is still room for improvement. Research work still goes on and at the end of the year the Ministry of Health devised a scheme for the notification of congenital abnormalities which are apparent at birth. The scheme rests on information being sent to the Medical Officer of Health by the doctor or midwife notifying birth as required by Section 203 of the Public Health Act, 1936 (Section) 255 of the Public Health (London) Act, 1936) of any malformation observed at the time of birth and described as accurately as is possible at the time. This information is supplied for still as well as live births. the existing birth notification forms were revised so that the necessary 15 mation regarding any abnormality could be included on the one form. This material will be collated by the Registrar General and help to give further useful information on rates of incidence for various abnormalities. Maternal Mortality. No deaths occurred during 1963 due to causes associated with pregnancy and child birth. Deaths. The total number of deaths of residents of the Borough was 2,171, giving a death rate of 10.4 per 1,000 population. Liability to death varies at different ages and also between the sexes. In order to offset the effects of these variations and so produce a rate which can be used for comparison purposes with other districts and the country as a whole, the RegistrarGeneral calculates for each district a comparability factor which when applied to the crude death rate of 10.4 gives an adjusted death rate of 11.2, which then compares with a death rate of 12.2 per 1,000 population for England and Wales. Comparison of the Registrar-General's abridged list of causes of death in the district for 1962 with the list for 1963 shows little change in the chief causes of death. These are:— 1. Diseases of the circulatory system 851 deaths 2. Cancer 461 deaths 3. Vascular diseases of the central nervous system 284 deaths Nine hundred and forty-one deaths registered were of people over 75 years of age, i.e. 48 per cent of the total deaths registered in the district. Deaths from Cancer. In 1963 the number of deaths from cancer was 232 males and 229 females. Of deaths from this cause in males, in 92 the site was the lungs. in 32 the stomach. Of deaths amongst females, the breast was the site in 51, the stomach in 21 and the lung in 17 and the uterus in 16. Deaths from lung cancer show a small but nevertheless very welcome drop of 24 to a figure of 103 for 1963, as compared with 133 for 1962 or a rate for 100,000 population of 52 07 and 68-22 respectively. Whereas this fall in incidence seems satisfactory on first examination, one must warn against placing too much significance in the figures as between one year and another. Yearly changes do occur but the figures must be studied over a period of years before arriving at conclusions telative to the trend in a specified disease. Measures to bring the association of cigarette smoking with lung cancer to the attention of the public continued during the year. Deaths from Accidents. Motor vehicle and other accidents caused the deaths of 54 Harrow residents during 1963. In the classification of other accidents 43 per cent of the death occurred in the 75 years and over age group. Many of these deaths are due to accidents in the home which should be preventable. every opportunity is taken by all members of the department in advising the elderly and indeed all members of the public on measures to promote safety in the home. 16 Deaths from Suicide. Twenty-eight people committed suicide during 1963, an increase of two as compared with 1962. Fifty per cent of these deaths occurred in the 45-65 age group, the highest proportion being female. Deaths from Infectious Disease. There were six deaths from tuberculosis, seven from influenza and one from meningococcal infection during 1963. There were none from measles, whooping cough or poliomyelitis. TABLE I Summary of Vital Statistics 1939-1963 Estimated Civilian Population Birth Rate per 1,000 Population Death Rate per 1,000 Population Infant Mortality Rate—Deaths under 1 year per 1,000 Neonatal Mortality Rate—Deaths under 1 month per 1,000 Maternal Mortality Rate per 1,000 live and still births Still Birth Rate per 1,000 live and still births 1939 190,200 17.5 7.4 38.5 – 2.33 31.3 1940 188,710 16.7 9.7 50.0 – 0.62 27.2 1941 195,480 14.7 9.1 55.6 – 3.18 27.8 1942 195,100 16.6 9.3 31.5 – 1.50 24.1 1943 191,660 18.2 9.1 38.0 – 2.57 28.0 1944 185,090 18.1 9.3 34.8 – 0.56 33.6 1945 191,710 16.0 9.0 32.2 – 1.26 29.1 1946 210,890 18.0 8.6 31.0 – 0.75 30.0 1947 215,930 17.7 8.5 24.0 – 1.00 23.2 1948 218,700 14.7 8.4 28.8 – 0.60 20.9 1949 220,300 13.9 8.5 20.7 – 1.60 20.9 1950 222,300 12.8 8.9 13.6 – 1.30 21.6 1951 220,000 13.1 9.5 22.1 – 1.00 23.9 1952 219,000 13.1 8.7 21.7 – 1.30 18.2 1953 217,900 12.5 8.8 16.9 – 0.30 25.4 1954 217,700 12.6 8.2 16.7 11.3 0.70 20.0 1955 217,100 12.7 8.9 17.6 12.0 0.35 17.8 1956 216,200 12.9 8.8 21.1 16.7 0.70 20.4 1957 215,000 12.9 9.0 14.0 9.7 0.30 21.9 1958 214,300 13.2 9.3 17.0 13.5 0.70 16.3 1959 213,700 13.7 9.7 15.0 11.6 Nil 14.4 1960 214,370 14.5 9.4 18.6 14.4 0.32 18.2 1961 209,580 14.7 10.2 18.1 12.6 0.30 14.7 1962 209,600 15.5 10.4 22.5 17.6 Nil 13.4 1963 209,520 15.2 10.4 16.3 11.9 Nil 16.6 TABLE II Comparative Vital and Mortality Statistics for the Borough of Harrow and for England and Wales for years 1953-1963 year Birth Rate Death Rate Infant Mortality Harrow England and Wales Harrow England and Wales Harrow England and Wales 1953 12.7 15.5 10.3 11.4 16.9 26.8 1954 12.8 15.2 9.3 11.3 16.8 25.4 1955 12.9 15.0 10.1 11.7 17.6 24.9 1956 13.1 15.6 10.5 11.7 21.1 23.7 1957 13.2 16.1 10.5 11.5 14.0 23.1 1958 13.5 16.4 11.1 11.7 17.0 22.6 1959 14.1 16.5 11.5 11.6 15.0 22.2 1960 14.9 17.1 11.1 11.5 18.6 21.9 1961 15.3 17.4 11.9 12.0 18.1 21.6 1962 16.1 18.0 12.1 11.9 22.5 20.7 1963 15.5 18.2 11.2 12.2 16.3 20.9 17 TABLE III DEATHS OF HARROW RESIDENTS DURING 1963 Registrar General's Return Cause of Death Males Females Total 1. Tuberculosis, respiratory 4 – 4 2. Tuberulosis, other 1 – 1 3. Syphilitic disease 2 – 2 4. Diphtheria – – – 5. Whooping Cough – – – 6. Meningococcal infections – 1 1 7. Acute Poliomyelitis – – – 8. Measles – – – 9. Other infective and parasitic diseases 1 2 3 10. Malignant neoplasm, stomach 32 31 63 11. Malignant neoplasm, lungs, bronchus 92 17 109 12. Malignant neoplasm, breast 1 50 51 13. Malignant neoplasm, uterus – 16 16 14. Other malignant and lymphatic neoplasms 107 115 222 15. Leukaemia, aleukaemia 6 8 14 16. Diabetes 4 7 11 17. Vascular lesions of nervous system 110 174 284 18. Coronary disease, angina 277 177 454 19. Hypertension with heart disease 17 27 44 20. Other heart disease 78 144 222 21. Other circulatory disease 59 72 131 22. Influenza 4 3 7 23. Pneumonia 55 71 126 24. Bronchitis 74 25 99 25.Other diseases of respiratory system 14 11 25 26. Ulcer of stomach and duodenum 13 9 22 27. Gastritis, enteritis, diarrhoea 6 1 7 28. Nephritis and nephrosis 6 5 11 29. Hyperplasia of prostate 9 – 9 30. Pregnancy, childbirth, abortion – – – 31.Congenital malformations 12 8 20 32. otherdefined and ill-defined diseases 56 74 130 33. Motor vehicle accidents 15 2 17 34. All other accidents 21 16 37 35. Suicide 15 13 28 36. Homicide and operations of war 1 – 1 Total 1,092 1,079 2,171 18 TABLE IV Causes of Death (Males) at various ages 1963 Cause of Death All Ages Under 4 weeks 1 month to 1 year 1- 5- 15- 25- 35- 45- 55- 65- 75Over 1. Tuberculosis, respiratory 4 – – – – – – – 1 1 2 – 2. Tuberculosis, other 1 – – – – – – 1 – – – – 3. Syphilitic disease 2 – – – – – – – – 1 – 1 4. Diphtheria – – – – – – – – – – – – 5. Whooping cough – – – – – – – – – – – – 6. Meningococcal infections – – – – – – – – – – – – 7. Acute Poliomyelitis – – – – – – – – – – – – 8. Measles – – – – – – – – – – – – 9. Other infective and parasitic diseases 1 – – – – – – – 1 – – – 10. Malignant neoplasm, stomach 32 – – – – – – 1 2 12 8 9 11. Malignant neoplasm, lungs, bronchus 92 – – – – – – – 7 42 30 13 12. Malignant neoplasm, breast 1 – – – – – – – – 1 – – 13. Malignant neoplasm, uterus – – – – – – – – – – – – 14. Other malignant and lymphatic neoplasms 107 – – 2 – 2 – 2 9 31 36 25 15. Leukaemia, aleukamia 6 – – 1 – 1 – 1 – – – 3 16. Diabetes 4 – – – – – – – – 3 – 1 17. Vascular lesions of nervous system.. 110 – – – – – – 2 5 14 29 60 18. Coronary disease, angina 277 – – – – – – 11 28 95 84 59 19. Hypertension with heart disease 17 – – – – – – – 1 1 5 10 20. Other heart disease 78 – – – – – – 1 3 12 16 46 21. Other circulatory disease 59 – – – – – – – 6 8 16 29 22. Influenza 4 – – – – – – 1 – 1 1 1 23. Pneumonia 55 – 3 – – – – 2 3 7 10 30 24. Bronchitis 74 – – 1 1 – – – 3 23 27 19 25. Other diseases of respiratory system 14 – – – – – – – – 3 3 8 26. Ulcer of stomach and duodenum 13 – – – – – – – – 3 3 7 27. Gastritis, enteritis, diarrhoea 6 1 – 1 – – – – 1 2 1 – 28. Nephritis and nephrosis 6 – – – – – – – – 1 3 2 29. Hyperplasia of Prostate 9 – – – – – – – – 1 2 6 30. Pregnancy, childbirth, abortion – – – – – – – – – – – – 31. Congenital malformations 12 6 3 – – – – – 2 1 – – 32. Other defined and ill-deflned disease 56 14 1 1 – 2 – 2 6 9 11 10 33. Motor vehicle accidents 15 – – – 1 2 – 1 2 3 1 5 34. All other accidents 21 1 – – – 1 1 3 1 3 5 6 35. Suicide 15 – – – – 1 3 – 1 4 4 2 36. Homicide and operations of war .. 1 – – 1 – – – – – – – – Total 1,092 22 7 6 2 10 4 28 82 282 297 352 19 TABLE V Causes of Death (Females) at various ages 1963 Cause of Death All Ages Under 4 weeks 1 month to year 1- 5- 15- 25- 35- 35- 55- 65- 75over 1. Tuberculosis, respiratory – – – – – – – – – – – – 2.Tuberculosis, other – – – – – – – – – – – – 3. Syphilitic disease – – – – – – – – – – – – 4. Diptheria – – – – – – – – – – – – 5. Whooping cough – – – – – – – – – – – – 6. Meningococcal Infection 1 – – – – – – – 1 – – – 7. Acutc Poliomyelitis – – – – – – – – – – – – 8. Measles – – – – – – – – – – – – 9. Other infective and parasitic diseases 2 – – – – – – – – 1 1 – 10. Malignant neoplasm, stomach 31 – – – – – – – 5 8 5 13 11. Malignant neoplasm, lungs , bronchus 17 – – – – – – – 3 9 4 1 12. Malignant neoplasm ,breast 50 – – – – – 1 4 14 16 7 8 13. Malignant neoplasm, uterus 16 – – – – – – 2 3 4 5 2 14. Other malignant and lymphatic neoplasms 115 – – – – 1 – 3 11 29 35 36 15. Leukaemia, aleukaemia 8 – – – 2 – – – 2 – 1 3 16. Diabetes 7 – – – – – – 1 – 1 1 4 17. Vascular lesions of nervous system 174 – – – 1 – – 7 2 16 33 120 18. Coronary dieases angina 177 – – – – – – – 8 18 49 102 19. Hypertension with heart disease 77 – – – – – – – – 2 5 20 20. other heart disease 144 – – – – – 2 – 2 7 23 110 21. Other circulatory disease 72 – – – – – – 1 – 5 14 52 22. Influenza 3 – – – – – – – – 1 – 2 23. Pneumonia 71 – 5 – – 1 2 1 – 6 13 43 24. Bronchitis 25 – 1 – – – – 1 – 4 3 16 25. Other diseases of respiratory system 11 – – – – – – – – 1 3 7 26.Ulcer of stomach and duodenum 9 – – – – – 1 – – – 5 3 27. gastritis, enteritis, diarrhoea 1 – – – – – – – – – – 1 28. Nephritis and nephrosis 5 – – – – – – – – – – 5 29. Hyperplasia of Prostate – – – – – – – – – – – – 30. Pregnancy, childbirth, abortion – – – – – – – – – – – – 31.Congenital malformations 8 3 1 2 – 1 – 1 – – – – 32. Other define and ill-define deseases 74 13 – – 1 1 1 5 4 10 9 30 33. motor vehicle accidents 2 – – – – – – – – – 1 1 34. All other accidents 16 – – – – – – – 1 3 2 10 35. Suicide 13 – – – – – 1 3 6 3 – – 36. Homicide and operations of war – – – – – – – – – – – – Total 1,079 16 7 2 4 4 8 24 62 144 219 589 20 TABLE VI Deaths of Harrow Infants under 1 year of age 1963 Causes of Death AGE Under 1 day 1-7 days 1-2 weeks 2-3 weeks 3 weeks to 1 month Total under 1 month 1-3 months 3-6 months 6-9 months 9-12 months Total under 1 year Bronchopneumonia – – – – – – 5 1 – 1 7 Dermatitis Exfoliative Neonatorum – – – 1 – 1 – – – – 1 Acute Asthma – – – – – – – – – 1 1 Congenital Abnormalities 3 5 – – – 8 3 – 1 – 12 Mongolism – 1 – – – 1 – – – – 1 Prematurity 8 5 – – – 13 – 1 – – 14 Atelectasis 3 5 – – – 8 – – – – 8 Hydrocephalus 1 – – – – 1 – – – – 1 Acute Suppurative Bronchitis – – – – – – 1 – – – 1 Bilateral Hydronephrosis. . 1 – – – – 1 – – – – 1 Cerebral Anoxia/ Compression of Cord . 1 – – – – 1 – – – – 1 Cerebral Haemorrhage 1 1 – – – 2 – – – – 2 Subdural Haemorrhage due to head injury 1 – – – – 1 – – – – 1 Non-Specific Enteritis – – – – 1 1 – – – – 1 Total 19 17 – 1 1 38 9 2 1 2 52 TABLE VII PULMONARY TUBERCULOSIS: CANCER OF LUNG AND BRONCHUS DEATHS WITH RATE PER 100,000 POPULATION 1953-1963 Year Population Deaths/Pulmonary Tuberculosis Deaths/Lung Cancer Number Rate per 100,000 Number Rate per 100,000 1953 217,900 26 11.93 75 34.42 1954 217,700 28 12.86 83 38.13 1955 217,100 13 5.99 96 44.22 1956 216,200 13 6 .01 81 37.4/ 1957 215,000 12 5.58 97 45.12 1958 214,300 8 3.73 82 38.27 1959 213,700 6 2.80 104 48.67 1960 214,370 10 4.66 135 62.98 1961 209,580 9 4.29 130 62.03 1962 209,600 5 2.38 133 68.22 1963 209,520 4 1.91 109 52.07 21 HEALTH SERVICES OF THE AREA (A) PERSONAL HEALTH In Middlesex, the Local Health Authority under the National Health Service Act, 1946, is the Middlesex County Council. The County Council under its scheme of decentralized administration has divided the County into ten local health areas, each with a local health committee to deal with the day to day administration of the delegated functions of Part III of the National Health Service Act and the Nurseries and Child Minders Regulation Act. The Borough of Harrow constitutes Health Area 5 and through its local area committee provides certain services under the following sections of the Act:— Section 22 Care of Mothers and Young Children. Section 23 Midwifery. Section 24 Health Visiting. Section 25 Home Nursing. Section 26 Vaccination and Immunisation. Section 28 Prevention of Illness, Care and After-care. Section 29 Domestic Help. Care of Mothers and Young Children. Under this section regular clinic sessions are held each week throughout the Area. Here expectant mothers are provided with ante-natal care throughout pregnancy, receive advice and care of the expectant mother and child through the medium of mothercraft classes, and also take part in ante-natal relaxation classes which have undoubtedly proved of great value and assistance to the mother at the time of the confinement. In addition, at the infant welfare sessions, advice on the feeding, hygiene and general management of young children is available, together with facilities for vaccination against smallpox, immunisation against diphtheria, whooping cough, tetanus and poliomyelitis. Dental clinics are available, providing complete dental treatment for expectant and nursing mothers and children. The practice of sending ante-natal patients to Edgware General Hospital for the necessary blood examinations had to be reviewed during the year as the hospital authorities advised that they could only deal with patients actually booked for confinement at the hospital. As they could carry out the necessary examinations but could not take the specimens, arrangements were made for the specimens to be taken at the local ante-natal clinics and then sent to the hospital laboratories tor report. At the same time all general practitioners were advised about this service and the offer made to take blood specimens from their patients if they cared to send them to the local clinics. Judging by the number of specimens taken at the clinic this service seems to be serving a useful Purpose. 22 Day Nurseries. Two day nurseries (a) Headstone Drive Nursery, Wealdstone, with 50 places, and (b) Walton Avenue Nursery, South Harrow, with 60 places, provide for the needs of children aged 0-5 years for whom it is considered nursery provision is needed on health grounds. Headstone Drive Nursery is recognised as a training nursery for the purposes of students seeking the qualification of the National Nursery Examination Board. The course extends over a period of two years and the students have their practical training in the nuisery and for theoretical instruction attend Chiswick Polytechnic. Two students are taken on each year and the demand for places is high. Students are also enrolled by the Education Officer for training in the nursery schools in the Borough and in order that these students can gain experience in dealing with children under the age of three years, an interchange of students attending the day nursery and the nursery schools is arranged in co-operation with the Education Department. It is hoped that the nursery at Walton Avenue may soon be approved for student training. Midwifery. The Area establishment of midwives was increased during 1963 to 16. It was possible to recruit up to this figure during the year. The conversion of the house at 109 Parkside Way into two flatlets, and the completion of the flat at the Caryl Thomas Clinic, Headstone Drive, have provided much needed accommodation. The midwives, working in liaison with the general practitioners, provide ante-natal supervision of mothers expecting to be confined at home. They hold regular booking clinics and also visit the homes to ensure that everything is in order for a home confinement. Sterilized maternity outfits are available to all expectant mothers, except those who have booked a hospital bed for their confinement. Gas and Air and Trilene analgesia is available for confinements. Pupil midwives attended during the year to undertake their training in preparation for Part 2 of the examination of the Central Midwives Board. Last year the midwives attended the confinements of 953 women in their homes. The increase in the establishment of midwives made the introduction of a day and night rota system for the midwives possible. This ensured that the midwives off-duty time, so often disturbed in the past, could be enjoyed without interruption and undoubtedly proved beneficial both to patients, staff and the maternity services in general in the area. The night rota system works with the co-operation of the Central Ambulance Control at Kenton. Briefly the details are as follows:— A four-weekly night rota of midwives is prepared and sent to Ambulance Control, but a daily telephone call is made to the Contro approximately 5 p.m. each day confirming which midwives are on call for 23 that night. Each midwife on the rota is on call from 6 p.m. to 6 a.m. and will be called to patients through the Ambulance Service during these hours. When a midwife is summoned out she telephones Ambulance Control on her return from the case. Each expectant mother is given a card containing details of the midwife who will attend if she is confined during the day and details of what to do should she require a midwife during the hours of 6 p.m. to 6 a.m. During the year the North West Metropolitan Regional Hospital Board wrote to the Edgware Group Services Liaison Committee pointing out that pressure on maternity beds would soon be greatly increased and asking that consideration be given either to the introduction of a 48-hour discharge scheme for maternity patients, or if already in being, an increase in the number of patients discharged after 48 hours. Previously the limiting factor as to when such a scheme could start was the number of midwives employed by the Local authority. However, with the increase in establishment this year, it was possible to proceed with the 48-hour discharge scheme and this was introduced in November 1963 and deals with approximately 10 cases per month. In this scheme the patients are booked for early discharge only when home conditions are satisfactory and where for some medical or obstetric reason it is considered by the hospital medical officer to be safer for the actual delivery to take place in hospital. Many mothers are so keen to have home confinements that even when on account of some medical or obstetric reason hospital confinement is indicated, they still need much persuasion. They are, however, more willing to accept hospital confinement if they know they will be discharged after 48 hours, provided the obstetrician is satisfied with the condition of mother and child. No mother is pressed to come out of hospital against her will. The work of the midwives is co-ordinated by the Non-Medical Supervisor of Midwives, Miss R. C. Speaight, of 585 Honeypot Lane, Stanmore, telephone number Wordsworth 5564. Home Nursing. The area has an establishment of 23 home nurses, who work under the instruction of the general practitioners responsible for the patient, ihey carry out treatment such as general nursing care of the acute and chronic sick, blanket baths, injections, etc., and are supervised by the area Superintendent of Home Nurses, Miss R. C. Speaight. The number of nurse employed during the year was the equivalent of 23 whole-time staff and during the year they paid in all 56,049 visits. A point of clinical interest is that during this year all injections have been carried out using sterile disposable syringes. This gets over the Problems of trying to sterilise syringes in the unsatisfactory conditions sometimes found in domiciliary practice—it saves valuable nursing time and of course ensures a sterile instrument at all times. 24 Nursing equipment is made available on loan to patients being nursed at home. The Middlesex Branch of the British Red Cross run this loan of equipment service on behalf of the County Council. The Red Cross depot in this area is at 39 Sheepcote Road, Harrow (Telephone No. Harrow 8788). Health Visiting. During 1963 the area was again working with an establishment of health visitors which was much understrength. It says a great deal for these members of the staff who although working under difficulties managed to carry out their clinical duties and also cope with the heavy demands of social work in the homes in an exemplary manner. Three fulltime and five part-time health visitors were appointed during the year, but this was offset by the resignations of five full-time and two part-time members of the staff. Reasons for resignation were in the main retirement from service or moving away from the district. Two students were appointed to the Sponsored Health Visitors Training Course. In this course they attend for theoretical training at Chiswick Polytechnic and come back to their parent area for practical instruction. We hope to welcome them as fully qualified health visitors in July 1964. The shortage of health visitors has been offset to some extent by employing clinic nurses who can carry out some of the less specialised duties in the clinics and schools and so allow the health visitors to carry out their educational and social work in the home. A liaison scheme between the Health Department and the Paediatric Department of Edgware General Hospital has been established. A health visitor pays periodic visits to Dr. Baber's wards and acts as a liaison between hospital and the home in the complete rehabilitation of the sick child. The scheme appears to be working well. Work with the elderly has increased due to an increase in number of requests from general practitioners and hospital almoners for supervisory visits. Over one hundred such visits are recorded whereby a variety of services and types of care were suggested and implemented for the old folk concerned. By far the most important result of these visits is that a link is forged between these elderly people and the various statutory and voluntary bodies who can help each in their individual ways. In other words a register is in the making which to my mind is fundamental to carry out any programme of community welfare for the elderly, especially for those who live alone. During the year the Department helped in the important work ol training members of allied professions. Approximately 70 students from various training establishments attended for varying periods in order to get an insight into the work of a local health department. I am sure both staff and students found these visits to be mutually stimulating. 25 Last, but not least, the health visitors continued their important work of health education. Many more groups of the public approached the department with requests for "talks" on a variety of health topics. Every effort was made to fulfil these requests. Seven evening film shows were organised for groups of "expectant" parents with gratifying attendances of between 40 and 60 people at each showing. In addition, Fathercraft Classes were held at the Cecil Park and Honeypot Lane Clinics. This was a new venture and as the response has been encouraging it seems to have been a well worthwhile experiment. Miss Watson, the Superintendent Health Visitor, is making plans to extend these lectures and anticipates using the Caryl Thomas Clinic as it is more central for the whole area. Good reports come from the young mothers and appreciation from the husbands has been expressed. This series of four evening lectures helps to give a better understanding of the changes a baby makes to home life and assists both parents to overcome minor difficulties that can so easily become problems of our day. Much medical and social research sponsored by a variety of bodies is carried out during each year and, as is so often the case in research, much field work is involved. In this facet of the research the local health authority is often asked to help. Both medical and nusing staff are involved, but in the main the heavier load falls on the health visiting staff, who are often busy obtaining replies to questionnaires addressed to mothers and young children. Among other research projects carrying on from previous years, in 1963 the Department co-operated in a new project being undertaken by the Department of Medicine of St. Thomas's Hospital Medical School. The project is under the general direction of Dr. W. W. Holland, Senior Lecturer in Social Medicine. The aim of this research is to carry out a prospective investigation into the susceptibility of respiratory disease on children born inthe Wards of Stanmore South, Belmont, Kenton, Roxeth, Roxbourne and West Harrow. This research involves all babies born in these districts from the 1st July, 1963, being visited by the health visitors who give a short questionnaire on conditions of birth and illnesses in other members of the family. A one-in-three sample of these is visited by members of the Hospital's Social Medicine Department, who test the lung function of the babies and other members of the family. The object of the research is to try and obtain the same data on the alterations in lung function in babies in relation to other members of their family and further to see how this may correlate with serious respiratory disease in childhood. No medical advice is given. If anything of note is found by the team from St. Thomas's, this is only disclosed to the general practitioner and suggestion made to the patient that he/she consults the practitioner for advice. 26 This seems to be a very worthwhile project, the results of which it is hoped may throw some light on the respiratory diseases and their aetiological factors. This project will go on for some years in the subsequent following up research. Vaccination and Immunisation. Arrangements for vaccination against smallpox and immunisation against diphtheria, whooping cough, tetanus and poliomyelitis were made available as in previous years at all clinics and, of course, can be obtained through the general practitioner if so desired. Every opportunity is taken by the health staff to encourage parents to have their children protected against these diseases. This personal advice goes on from day to day, but in addition, in 1963 it was decided as a result of a recommendation from the London and Home Counties Co-ordinating Committee for Health Education to hold a crash programme of publicity twice yearly throughout London and the Home Counties. With the aid of posters, pamphlets, press and radio, an immunisation campaign was held during the two weeks commencing 23rd and 30th September and will be repeated during two weeks in April 1964. Personally, I am very doubtful as to the value of these campaignsa tremendous amount of preparatory work is involved for very little return. However, I suppose even if only a few non-immunised children are protected as a result of the campaign, we have achieved some good. I think the continous person to person effort brings the best results in the long run. Smallpox Vaccination. A report was published by the Standing Medical Advisory Committee late in 1962. In this report the Committee reviewed the existing policy on routine vaccination against smallpox in the light of recent criticism. The suggestion had been made that routine infant vaccination should cease and that reliance should be placed upon outbreak control measures to prevent the spread of infection from an importation of smallpox. Outbreak control measures comprise the ascertainment and isolation of cases of smallpox, the identification, vaccination and surveillance ol contacts, and the disinfection of contaminated premises or articles. These measures have met with considerable success in this country, but it must be remembered that the population of this country is partly protected by vaccination and this has undoubtedly aided outbreak control as outlined above. Outbreak control could hardly prove as effective in an unvaccinate population as in a partly vaccinated population. In view of this the Committee concluded that there was no evidence to justify the suggestion that outbreak control alone should prove effective in an unvaccinated population and have advised that routine vaccination should continue in early childhood. 27 The optimum age at which routine vaccination should be performed was also considered because of complications which sometimes follow vaccination. Statistics vary from country to country, but the figures for the United Kingdom suggest that any hazard associated with vaccination is somewhat less above the age of one year than below it. At present there is no date from which it is possible to determine whether the risk varies at different periods of the first year of life. Before this feature can be investigated changes in the methods of reporting and assessing complications of vaccination will be necessary and this matter is under review at present. In the meantime, the Standing Medical Advisory Committee, in the light of present information, have now advised that smallpox vaccination should be offered to children during their first two years of life, but preferably during the second year. This report was considered by medical officers on the area staff and the consensus of opinion was that waiting until the second year before vaccination against smallpox would cause a falling off in the number of children presented for smallpox vaccination, and also it was felt there would be risks of complications in vaccinating an active toddler. It was decided as a compromise to vaccinate when the child was one year old and take the opportunity of carrying out this procedure at the child's first annual medical examination. The following is the schedule of immunisation at present used in the area clinics:— Age Type of Immunisation or Vaccination 3-6 months 1st, 2nd and 3rd "Triple" Diphtheria/ Whooping Cough/Tetanus. 8-10 months 1st, 2nd and 3rd doses of oral POLIO vaccine. 12-18 months Smallpox vaccination. 18 months 4th "TRIPLE" 5 years "BOOST" injection Diphtheria/Tetanus. "BOOST" dose oral POLIO. 13 years (approx.).. B.C.G. vaccination against Tuberculosis. Chiropody. Demands on the Chiropody Service were as high as ever during 1963 with the greatest number of requests coming from the elderly. Facilities are available from chiropodists in private practice, from the British Red Cross—who can also treat a certain number of homebound cases and from the services provided by the County Council at certain clinics. As regards the latter, it was possible to increase the number of sessions being held each week from twelve to sixteen from October 1963. Patients who, on account of their medical conditions, require transport to and from the clinics are taken by ambulance—a medical certificate is required in support of this facility. 28 Since the scheme started the following have applied for treatment:— Elderly persons 710 441 receiving treatment Physically handicapped 16 16 „ „ Other 21 20 Nursing mother 1 Waiting list—98 elderly persons. The need for chiropody in the elderly is a continuing process, so much so that it is seldom possible to discharge this type of patient from treatment. By lengthening the periods between follow-up treatments it is possible to take on new cases, but this is rather a slow process. The only answer is more sessions for chiropody and here the limiting factor is the shortage of chiropodists. Sixteen sessions are held each week and in order to try and serve the needs of as wide an area as possible, these sessions are held at various clinics throughout the district. Domestic Help. Essentially set up as an emergency service for providing domestic help for households faced with some sudden medical crisis, this service is mainly concerned now with providing help to the aged and those suffering from some longstanding illness. Shortage of staff, together with difficulties in recruitment has necessitated the need for a very careful assessment of help granted in individual cases, and also the institution of a scheme of priorities with cases of home confinements and acute illness of a mother with a young family high on the list. By careful budgeting the Home Help Organiser and her Deputy, although not being able to give the full quota ol help asked for in all cases, at least try to supply some degree of help each week to each case. The average number of home helps employed was 1 full-time and 78 part-time being an equivalent of 48 full-time home helps. Assistance was given as follows during the year:— 1. Maternity Cases 380 2. Acute Illness 220 3. Chronic Sick and Tuberculosis 116 4. Mentally Disordered 7 5. Aged and Infirm 693 Total 1,416 Demands on this service are heavy and are likely to increase in years to come. The development of health and welfare services in the future places much emphasis on the expansion of domiciliary care and while this will affect all services this is especially so in the case of domestic help 29 Recruitment is difficult with competition from industrial and private concerns. We are fortunate in having a few home helps who have been with the department for a good few years and have given loyal and devoted service, but many more are needed! Every effort is made by press advertising and personal contact by the organisers with local organisations to encourage recruitment to the service. Neighbourly Help Scheme introduced in 1961 has proved a useful adjunct to the Home Help Service. In this scheme the person employed is paid for a service rather than for any stated number of hours. During 1963 fifteen cases were helped by means of this scheme. (B) SCHOOL HEALTH AND DENTAL SERVICES The Middlesex County Council discharges its medical and dental duties under the Education Act, 1944, by making use of the same staff employed by the County Council as local health authority. This has the advantage that doctors and nurses who see the child from 0-5 years will continue the medical supervision throughout school life. This makes for the earliest possible detection of defects which may have a bearing on the child's ability to progress in school and thus enables remedial action to be taken at a very early age so that the child may then be in a position to derive the maximum benefit from the education provided. The following services are provided:— 1. Periodic medical inspection of pupils. 2. Cleanliness surveys of pupils. 3. Dental inspection and treatment. 4. Ascertainment of handicapped pupils in need of special education. 5. Provision of clinics. Children attend these clinics at the request of the parents or of the teachers or they are referred there by school medical staff. Treatment for minor ailments is available. In addition these clinics are used for follow-up observation examinations of specific defects noted at a previous periodic medical inspection in school. Special clinics are run for defects of vision, hearing and speech and also provision is made for children requiring child guidance treatment. In certain cases by arrangement with appropriate hospital boards, specialists attend some of these special clinics. 6. Provision of audiometric sweep testing of all pupils in order to detect defects in hearing which can pass unnoticed and may be having an adverse effect on a child's educational progress. 7. Provision of convalescent holidays. 8. Ascertainment of children unsuitable for education. General provision has been made in the County for three special units where expert advice and treatment can be obtained for children afflicted with hearing loss or the defects associated with cerebral palsy. 30 These units are situated in Tottenham, Hounslow and Neasden. The Neasden unit opened in 1963 and has brought these facilities much nearer to the Borough of Harrow, thus saving much time before spent in travelling to the other units. (C) CLINICS AND TREATMENT CENTRES IN AREA The following is a list of clinics and treatment centres in, or serving the district:— Infant Welfare Services The Clinic Alexandra Avenue, South Harrow Broadway Clinic, The Broadway, Wealdstone All Saints Hall, Roche Avenue, Edgware Elmwood Clinic, Elmwood Avenue, Kenton Elstree Clinic, "Schopwick", Elstree, Herts. The Clinic, Cecil Park, Pinner Memorial Hall, High Road, Harrow Weald The Clinic, Honeypot Lane, Stanmore The Clinic, Kenmore Road, Kenton Methodist Church Hall, Walton Avenue, South Harrow St. Alban's Church Hall, North Harrow St. Anselm's Hall, Hatch End Caryl Thomas Clinic, Headstone Drive, Wealdstone Baptist Church, Northolt Road, South Harrow Spiritualist Church Hall, Vaughan Road, Harrow Stanmore Park (R.A.F.) Station The Clinic, Whittlesea Road, Harrow Weald Ante-Natal Clinics The Clinic, Alexandra Avenue, South Harrow Broadway Clinic, The Broadway, Wealdstone All Saints Hall, Roche Avenue, Edgware Elmwood Clinic, Elmwood Avenue, Kenton Elstree Clinic, "Schopwick", Elstree, Herts. Memorial Hall, High Road, Harrow Weald The Clinic, Honeypot Lane, Stanmore The Clinic, Kenmore Road, Kenton Caryl Thomas Clinic, Headstone Drive, Wealdstone The Clinic, Cecil Park, Pinner Methodist Church Hall, Walton Avenue, South Harrow St. Alban's Church Hall, North Harrow Baptist Church Hall, Northolt Road, South Harrow St. Anselm's Hall, Hatch End Spiritualist Church Hall, Vaughan Road, Harrow The Clinic, Whittlesea Road, Harrow Weald Mon. & Fri. p.m. Wed. a.m. & p.m. Thur. & Fri. p.m. Mon. & Wed. p.m. 2nd & 4th Wed. p.m. Mon. p.m. Thur. p.m. Mon. & Wed. p.m. Wed. a.m. & p.m. Thur. p.m. Thur. a.m. Thur. p.m. Mon. & Fri. p.m. Tue. & Thur. p.m. Wed. p.m. Thur. p.m. Tues. & Wed. p.m. Wed. p.m. Thur. p.m. Fri. a.m. Tue. p.m. 2nd & 4th Wed. p.m. Tue. p.m. Tue. p.m. Fri. p.m. Mon. p.m. Fri. p.m. Alternate Thur. a.m. Tue. a.m. Tue. a.m. Alternate Thur. a.m. Wed. a.m. Fri. p.m. EXERCISE AT ORTHOPTIC CLINIC Reproduced by kind permission of Harrow Observer 31 Toddlers Clinics The Clinic, Alexandra Avenue, South Harrow Mon. a.m. All Saints Hall, Roche Avenue, Edgware Thur. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Fri. a.m. Caryl Thomas Clinic, Headstone Drive, Wealdstone Alternate Thur. a.m. The Clinic, Honeypot Lane, Stanmore Mon. a.m. The Clinic, Cecil Park, Pinner Mon. a.m. The Clinic, Kenmore Road, Kenton Thur. a.m. Spiritualist Church Hall, Vaughan Road, Harrow 1st Mon. a.m. The Clinic, Whittlesea Road, Harrow Weald Wed. a.m. These clinics are to enable children who are too old to be brought regularly to the infant welfare sessions to be kept under medical supervision. In order to allow time for examination and also discussion between parents and doctors, attendance is by appointment only. School Minor Ailment Clinics The Clinic, Alexandra Avenue, South Harrow Mon. Fri. Broadway Clinic, The Broadway, Wealdstone Thur. a.m. All Saints Church Hall, Roche Avenue, Edgware Thur. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Fri. a.m. The Clinic, Honeypot Lane, Stanmore Mon. a.m. The Clinic, Cecil Park, Pinner Mon. a.m. The Clinic, Kenmore Road, Kenton Thur. a.m. The Clinic, Whittlesea Road, Harrow Weald Wed. a.m. Caryl Thomas Clinic Headstone Drive, Wealdstone Tues. a.m. The clinics are used for the treatment of minor ailments and in addition for consultation purposes where children attend at the request of the parents or of the teachers or for either the more detailed examination or follow-up examination of a particular child seen at a routine inspection in school. Ophthalmic Clinics Sessions are held at the Honeypot Lane Clinicon Thursday mornings, Caryl Thomas Clinic, Headstone Drive on Wednesday mornings and Thursday afternoons, and at the Alexandra Avenue Clinic on Thursday mornings. Children with defective vision found at routine inspections are referred for examination by ophthalmic surgeons who are on the staff of the Regional Hospital Board. Arrangements are made to keep these children under careful periodic review. In addition, facilities for orthoptic treatment are available at the Caryl Thomas Clinic. 32 Speech Clinics Speech clinics are provided at the Caryl Thomas Clinic, Headstone Drive, where two speech therapists are engaged. Cases are referred by school medical officers and by the teachers. In addition, the therapists visit the schools to discuss with and give advice to teaching staff on cases with minor degrees of speech defect. Therapy sessions are now being held in some of the peripheral clinics. This cuts down travelling distances and is welcomed by parents. Child Guidance Centre At the County Council's Child Guidance Centre at 82 Gayton Road, Harrow, the child guidance team consisting of psychiatrist, educational psychologist, psychiatric social workers and psycho-therapists, provide a service giving advice and treatment to children whose education is suffering as a result of some form of emotional difficulty. Dental Treatment This service is under the administration of the Area Dental Officer, Mr. A. G. Brown. Treatment is available for school children, children under 5 and expectant and nursing mothers at seven centres:— Caryl Thomas Clinic, Headstone Drive. Elmwood Avenue Clinic. Roxeth Hill Clinic. Honeypot Lane Clinic. Alexandra Avenue Clinic. Whittlesea Road Clinic. Cecil Park Clinic. Children found to require treatment at routine school dental inspections are offered this treatment at one of the above centres. Facilities for any necessary X-ray and orthodontic treatment are available. Chest Clinics The Chest Clinic serving most of the district is that at 199 Station Road, Harrow (Telephone No. Harrow 1075). The physician-in-charge is Dr. Grenville Mathers. Serving part of the district on the eastern side is the Chest Clinic at the Edgware General Hospital (Telephone No. Edgware 4467). The physician-in-charge is Dr. Trenchard. Family Planning and Marriage Guidance Sessions of the Family Planning Association Clinic are held at the Elmwood Avenue Clinic on Monday evenings, Thursday afternoons, and on the second and fourth Wednesday evening each month. In addition, a clinic is held on a Tuesday morning at Alexandra Avenue Clinic. The Marriage Guidance Council have their offices at 36 College Road, Harrow. PICTURE AIDS TO SPEECH TRAINING Reproduced by kind permission of Harrow Observer 33 (D) HOSPITALS Present Facilities. Most of the hospitals in, or serving this district are in the region covered by the North West Metropolitan Regional Hospital Board and are controlled and administered by two Hospital Management Committees. (a) Hendon Group Hospital Management Committee:— Edgware General Hospital 647 beds and 64 maternity cribs Hendon District Hospital 63 beds Colindale Hospital 205 beds West Hendon Hospital 112 beds Bushey Maternity Hospital 36 lying-in and 14 ante-natal beds Stanmore Cottage Hospital 10 beds Roxbourne Hospital 50 beds Oxhey Grove 42 beds (b) Harefield and Northwood Hospital Management Committee:— Harrow Hospital 122 beds Pinner, Northwood and District Hospital 36 beds Mount Vernon Hospital and Radium Institute 427 beds Future Development. Generally speaking, the Borough of Harrow is very poorly provided for in the terms of hospital beds. The only general hospital within its boundaries is Harrow Hospital at Roxeth Hill, which with its 122 beds has done and still is doing yeoman work in providing for some of the hospital bed needs of the district. This small hospital cannot possibly rope with all the local needs for hospital treatment and as a result, Harrow residents have had to obtain such treatment in the general hospitals at Edgware and Mount Vernon. The need to develop the hospital service for the part of the Harrow and Wembley district centring on Northwick Park with a population of nearly 150,000 has been recognised for many years. At one time it was planned that the new Charing Cross Teaching Hospital be established in this Area. However, this plan was abandoned, when it was finally decided to build the new teaching hospital on the site of Fulham Hospital and the responsibility of providing hospital beds for this district's needs was taken up by the North West Metropolitan Regional Hospital Board. The Board started to plan a District Hospital and then the opportunity of collaborating with the Medical Research Council presented itself, with the result that in 1961 the Minister announced that the District Hospital would be established in association with a Clinical Medical Centre under the aegis of the Medical Research Council. 34 The Medical Research Council have long supported research directly related to the needs of patients. They maintain a number of clinical research units attached to hospitals throughout the country, and award grants to individual doctors carrying out their own programmes of research. However, medical knowledge is steadily becoming more complex and to find solutions to particular problems it becomes more and more necessary to enlist the collaborative efforts of numbers of research workers possessing different skills and experience. The setting up of a national centre which would act as a focal point for clinical research for the whole country seemed to be the answer to this problem. In order that such a Research Centre be in constant touch with trends and changing patterns of disease in day-to-day medical practice it seemed reasonable that the Centre should be incorporated within a general hospital providing a full range of services to the community and dealing with current medical problems. The Northwick Park Hospital and Clinical Research Unit will be the outcome of this joint development. The project took a significant step forward in 1963 when the Project Committee submitted plans to the County Planning Authority and the public were given an opportunity of seeing the proposed layout at a most excellent local exhibition. The District Hospital has been designed with the specific intention of meeting the present and future needs of the population living in nearby parts of Harrow and Wembley and in neighbouring parts of Willesden, Hendon and Edgware. The site is centrally situated and reasonably easy of access by public transport from all parts of the area. The hospital's size and the range of services it will offer have been determined by the number of people it has to serve and by seeing it as part of the hospital plan for the whole region. In addition, the special needs arising from the presence of the Clinical Research Centre have been taken into account. On this basis it has been estimated that the combined unit should provide accommodation for about 800 patients. The plans for the hospital include provision for 100 maternity beds, 50 beds for actually ill old people and a unit of 75 beds for the treatment of mental illness. The wards have been specially designed to be flexible in use; one ward may be used for either medical or surgical patients so as to meet seasonal changes in demand, and in the children's ward there will be rooms where mothers can be with their children in hospital. The out-patients department has been planned so that there are separate waiting spaces for each clinic. The ante-natal clinic will be on the ground floor of the maternity unit, which has been sited as conveniently as possible for the hospital entrance and the bus stops, and on the groun floor of the psychiatric block will be a day hospital and treatment centre to which patients can come for treatment without having to be admitted as in-patients. The out-patient services will also include a Hearing Aid Centre. 35 The hospital will have an Accident department open 24 hours a day. This is provided with a 10 bed observation ward, a pair of operating theatres, special resuscitation rooms and multi-purpose examination and treatment cubicles. Similar emergency services (e.g. a "flying squad" and an admissions section next to the delivery suite) will operate in the maternity unit. In the Department of Physical Medicine the accent will be on the full medical and social rehabilitation of the patients; there is, for example a gymnasium equipped with special apparatus; a modelkitch en; a section to develop aids for disabled patients and workshops where patients can make a start in re-learning or acquiring particular skills. A Nurses' Training School and a School of Radiography attached to the hospital will provide opportunities for training young people of the district. The Clinical Research Centre. The field of clinical research can broadly be defined as research into the mechanisms and causes of disease, and its prevention and cure. The Research Centre's ward block will be situated close to and intercommunicate with the District Hospital wards. Research facilities will also be provided within the Maternity, Psychiatric and Infectious Diseases blocks. Research will also be carried out in the various out-patient departments, so that the Centre may identify and work on the problems of disease as they actually arise in the community. Research workers in the laboratories will work in close collaboration with their clinical colleagues to bring an integrated effort to bear on the health problems. A medical library and lecture hall for scientific meetings will also be built and these will be open not only to members of the Research Centre, tot also to the staff of the District and other local hospitals and other Members of the medical profession working in the area. It is hoped that the above, together with other facets in the new development will help to foster contact between the different branches of te health service. Infectious Diseases Hospital West Hendon Hospital (Telephone No. Colindale 8182) provides accommodation for cases of infectious disease which require admission to hospital. Chest Hospitals Clare H?all, South Mimms, Harefield Hospital and Colindale Hospital are used for patients suffering from respiratory tuberculosis. In addition, there are also beds at Edgware General Hospital and Hillingdon Hospital for those suffering from this complaint. 36 Mental and Mental Deficiency Hospitals Shenley Hospital, near St. Albans, provides facilities for those suffering from mental illness requiring treatment in hospital. Observation wards are available in three general hospitals, North Middlesex, Central Middlesex and West Middlesex Hospital. In the main mentally subnormals are admitted to Harperbury Hospital, near St. Albans, and to a lesser extent at Leavesdon Hospital, Abbots Langley. Maternity Hospitals Edgware General Hospital maternity unit of 64 beds and Bushey Maternity Hospital—36 lying-in and 14 ante-natal beds, are the main hospitals with facilities for expectant mothers from this district who wish to be confined in hospital. A few cases from the Kenton and Kingsbury district are admitted to the Kingsbury Maternity Hospital—56 beds, which is in the Wembley area. This accommodation has to serve a large population and is insufficient to meet the demand. As mentioned under Future Development provision of 100 maternity beds has been made in the new hospital at Northwick Park. Geriatric Hospitals Edgware General Hospital and Roxbourne Hospital, together with certain small annexes provide about 267 beds to meet the needs of the area as regards geriatric beds. Demands on these beds are always heavy and as a result many cases which should be in hospital have to be coped with at home, sometimes under very trying circumstances. (E) NURSING HOMES These are private establishments which provide accommodation for various types of patients. Section 187 of the Public Health Act, 1936. requires that these homes shall be registered with the local health authority. The County Council decided that the responsibility for registering and supervising them should rest not with the local Area Committee, but with the Health Committee of the County Council. Applications for registration have to be made to the Clerk of the County Council. Up to 1962 the responsibility of the local health authority in regard to nursing homes has been ill-defined, but this situation has been improved by the Nursing Homes Act, 1963. Nursing Homes Act, 1963. Section I of the Act empowers the Minister to make regulations to the conduct of nursing homes registered under Part IV of the Public Health Act, 1936. These regulations have now been drafted and are embodied in the Conduct of Nursing Homes Regulations, 1963, which came into operation in August 1963. Briefly, the Regulations require the managers of nursing homes to provide accommodation, care and staffing 37 of satisfactory standard as specified in the Regulations. Powers are now given to authorities to give managers written notice specifying in what respect the conduct of the home falls short and what needs to be done to satisfy the requirements. Failure to comply with these notices or contravention of the Regulations can lead to proceedings against the managers in a magistrate's court. The Regulations are wide enough to ensure that suitable and adequate facilities to meet the requirements of differing types of patient are provided in the various nursing homes, e.g. in maternity homes provision of proper facilities for preparation of babies feeds, separate labour room, single room for observation or isolation. The Regulations also permit private interview between inspecting officers and patients to investigate complaints; empower an authority to define numbers to be received in a particular home and after May 1964 will cancel the exemption from registration of certain voluntary hospitals or institutes not carried on for profit. The following table sets out the particulars of the various homes registered at the end of the year, with details of their ownership and their accommodation:— Beds Type of Case Bermuda House, Mount Park, Harrow. Mrs. A. M. Elphick 13 Medical or Chronic Mr. A. E. Elphick Beverley Maternity Home, 170 Whitchurch Lane, Edgware. Miss C. Dear 2 Maternity 2 Chronic Brockenhurst Nursing Home, 84 Hindes Road, Harrow. Mrs. T. O'Donnell 6 Chronic Calvary Nursing Home, Sudbury Hill, Harrow. Mother Superior 48 Medical or Chronic Heywood Nursing Home, London Road, Stanmore. Mrs. M. Guyatt 4 Medical 1 Maternity Hillmede Nursing Home, Lansdowne Road, Harrow. Mrs. D. M. Woodman 10 Chronic St. Michael's Nursing Home, 11 Hindes Road, Harrow. Mrs. T. O'Donnell 8 Medical or Chronic (F) ESTABLISHMENTS FOR MASSAGE AND SPECIAL TREATMENT By Section 355 of the Middlesex County Council Act of 1944, no person shall carry on in this district an establishment for massage or special treatment without a licence from the District Council authorising him to do so. There is a saving clause for registered members of the Chartered Society of Physiotherapy and for members of the medical profession. 38 Before approving the licensing of any premises, the Public Health Committee requires to be satisfied about the general suitability for the work to be done in it, and about the equipment. Those in whose name the premises are licensed have to comply with the bye-laws relating to the conduct of these premises. Licences are renewed annually. It is the premises which are licensed. Anyone who carries on similar treatment not at any premises but at the homes of patients does not need to be licensed. The Authority may refuse to grant a licence in respect of any establishment in which massage or special treatment is or may be administered by any person who does not possess such treatment qualifications as may be reasonably necessary. Unfortunately no minimum standards of qualification are laid down and when this Council applied some few years ago to be allowed to make a bye-law prescribing minimum standards, the request was not granted. The vast majority of chiropodists practise their profession after undertaking a 3 year course of instruction—theoretical and practicalat a recognised school of chiropody. On the other hand, some people practise chiropody and offer by way of qualifications a variety of diplomas granted after taking courses of instruction of varying duration and content—in some the theoretical part is done by way of correspondence courses, with a short practical course at the end. There is obviously no comparison possible between these two courses and one is naturally suspicious that the latter can be classified as "being suitably qualified". No doubt some of these practitioners by dint of many years of practical experience become very skilled in their work, but basically I think it is wrong that persons whose qualifications are not sufficient to enable them to get employment in the National Health Service can treat the public in their own private establishments. It may be that this invidious situation may be remedied in the not too distant future. In 1961 certain provisions of the Professions Supplementary to Medicine Act, 1960, came into operation. The Act provides for the establishment of Boards to promote a high standard of professional education and conduct for Chiropodists, Physiotherapists, Occupational Therapists and other medical auxiliaries. In 1961 the Council and Boards for the various professions were established and during 1962 the preparation of registers began and qualifications for registration were prescribed The Physiotherapist's Register has been completed and this will soon be followed by the Chiropodist's Register. Admission to the various registers will follow attendance at courses of training approved by the various Boards, or in the case of existing practitioners those who are considered suitably qualified by reason of practical experience before the appointed day. 39 It is interesting to note that under the National Health Services (Medical Auxiliaries) Regulations, 1962, registration under the Professions Supplementary to Medicine Act became a qualification for employment as a medical auxiliary in the National Health Service. One would very much like to see State Registration being laid down as a minimum qualification requirement before a licence is issued to practise chiropody or physiotherapy in a private capacity. At the beginning of the year 27 establishments were licensed and at the end of the year the number licensed was 27, there being one deletion and one addition to the list. The deletion was due to the relinquishing of the practice. Two members of the Chartered Society of Physiotherapists were in practice at the beginning and the end of the year. (G) PROVISION FOR SPECIAL CLASSES OF PERSONS The Deprived Child The County Council as the local authority under the Children's Act has a duty to take into care children under the age of seventeen who are without parents or have been lost, or abandoned by, or are living away from their parents or when their parents are unable to take care of them and the intervention of the authority is necessary in the interests of the welfare of the child. These children are either placed in residential homes or boarded out with foster parents. In certain circumstances the authority may assume parental rights of a child. It may also act as a fit person under the Children and Young Persons Act, 1953, when the Court commits a child to their care. It also has the responsibility for the supervision of children who are maintained apart from their parents for reward. The powers and duties of local authorities were further confirmed and extended by the Children and Young Persons Act, 1963. The main function is to promote action to prevent the necessity of receiving children into care. In this area the work is carried out under the direction of the Area Children's Officer, Miss Susan Boag, at Kynaston Court (Telephone No. Grimsdyke 3131). The Mentally III and the Mentally Subnormal The Health Committee of the County Council is responsible for the mental health functions of the authority. The duties of the authority include responsibility for the initial care and admittance to hospital of Patients who need to be dealt with under the Mental Health Act and for the ascertainment and community care of the mentally subnormal. Harrow is part of the central division of the County which is served by Shenley Hospital. The Senior Mental Welfare Officer, Mr. D. L. Richards, and other officers work at Balnacraig Avenue, Neasden, N.W. 10., (Dollis Hill 7722). The services of a mental welfare officer out of 40 office hours can be obtained by telephoning County Ambulance Control (Dryden 0231) who will arrange for the message to be passed on to the mental welfare officer who is on call. A consulting clinic is attended on the morning of the fourth Wednesday in each month at the Clinic, Elmwood Avenue, Kenton, by Dr. Fidler of the Mental Health Section of the County Health Department. This is particularly useful for helping parents with problems associated with the care of a mentally subnormal child. Mentally subnormal children who do not need treatment in hospital normally live with their parents and attend a junior training school at which, in the earlier stages, emphasis is placed on habit training in order to help the children to become socially adapted. The school for this area is now held in new purpose-built premises at Whittlesea Road, where the pleasant, commodious and well equipped surroundings must be of great benefit to these handicapped children. In addition, arrangements can be made for these children to be placed in foster care or placed under guardianship, or admitted to the County Council's Weekly Boarding Unit, or admitted to hospital. This accommodation can also be used as temporary placement of a child in order to give the parents some relief from the strain of his constant care. Mentally subnormal adults who require alternative accommodation can receive residential care either through guardianship, foster care, or in a hostel. Mentally ill persons under the provisions of the Mental Health Act. 1959, are now being cared for more in the community, rather than in a hospital. Hostel accommodation is a valuable link in this rehabilitation movement, acting as a halfway house between hospital and community. Naturally, some of these people may find the change to ordinary life too much for them to cope with and so may require re-admission either to hospital or even back to the sheltered environment of hospital. It is essential that the movement from hospital to hostel to community and vice-versa should be easy and to achieve this there must be very close and harmonious working arrangements between the hospital and community services. Persons in Need of Care and Attention Under the National Assistance Act, 1948, the County Council as the local authority concerned makes provision for the welfare of aged, physically handicapped, blind and partially sighted, deaf and dumb, epileptic and crippled persons, and also provides (a) residential accommodation for people who by reason of age, infirmity, or any other circumstances, are in need of care and attention which is not otherwise available to them, and (b) temporary accommodation for persons who are in urgent need thereof. 41 Section 47 of the Act enables the Court on the application of the Medical Officer of Health to grant an order for the removal of a person to a Welfare Home or Hospital. This Section can be invoked for the compulsory removal of a person who (a) is suffering from grave chronic disease or being aged, infirm or physically incapacitated, is living in insanitary conditions, and (b) is unable to devote to himself and is not receiving from others proper care and attention. It was not found necessary to take action under this Section of the Act during the year. My attention was brought to the case of an elderly woman who was living in very poor circumstances in old property subject to a Closing Order. These elderly people are often very unco-operative and suspicious of any offers of help and assistance made to them—this old lady was no exception! However, after several visits with the Chief Public Health Inspector and the Area Welfare Officer she was persuaded to accept a vacancy in one of the County Council's old people's homes, and no action under Section 47 was required. I may add that this is the usual pattern in dealing with this type of case. Every effort is made to solve the problem by using the Home Help Service, the Home Nursing Service and the help provided by voluntary bodies, etc., and only invoking action under Section 47 as a last resort when everything else has failed. For administration of the Welfare Service the County is divided in the same ten areas as for the County Council's functions under Part III of the National Health Service Act. Each has an Area Welfare Officer acting under the supervision of the Chief Welfare Officer for the County. The area officer for this district is Mr. H. G. Plummer, Kynaston Court, Boxtree Road, Harrow Weald. (Telephone No. Grimsdyke 3131). The Aged The care of the aged is an ever increasing problem, which taxes the energies and the resources of both the statutory authorities and the voluntary agencies who devote much of their time to helping this section of the population. The services available in the Borough through various agencies consist of:— (1) Luncheon Clubs. (2) Meals on Wheels. (3) Holiday Scheme. (4) Window Cards—for display in case of emergency. (5) Chiropody. (6) Laundry Service. (7) Domestic Help. (8) Home Nursing. (9) Visiting of Housebound. (10) Social clubs. 42 Each of these services plays a part in keeping old people active and interested in life. Generally, apathy and loneliness are the main problems. Giving the elderly person an interest a feeling of belonging and most important, of not being a burden, is essential in rehabilitation work. Activity of both the mind and body is to be encouraged and with this end in view the Harrow Old People's Welfare Committee are actively pursuing the idea of opening a workshop for the elderly in premises in Palmerston Road, Wealdstone. Advisory Clinics for the Elderly. In November 1962 the local Area Health Committee considered a report on Advisory Clinics for the Elderly. It was felt that these clinics could serve a useful purpose and it was decided to open such a clinic on an experimental basis at the Broadway Clinic, Wealdstone. The clinic provides general advice to elderly people on healthy living, including personal health problems, diet, accident prevention and social welfare. The health visitors see the old folk to discuss with them their multifarious problems and try and suggest ways and means for their solution. Cases are referred by health visitors, welfare officers and it is hoped that general practitioners will refer any of their cases whom they feel we might be able to help. A medical officer carries out a medical examination but no medical treatment. Any person found or thought to be in need of treatment is referred to their own doctor. Medicines are not dispensed by the clinic. The clinic opened in July 1963 with one session each week at the Broadway Clinic. The whole approach to this clinic is one of informality. Each person is welcomed by the health visitor and the initial friendly but at the same time information-seeking chat over a cup of tea, is used to explain the purpose of the clinic and also elicit relative details of the individual's circumstances, worries, phobias and general difficulties, etc. Recording of height and weight followed by testing of urine and vision serve as an introduction to an interview with a medical examination by the doctor. Since its inception 62 persons have attended the clinic. The majority were women (51) and of these thirty-five (35) were widows, eight (8) married and eight (8) single. The following is a summary of the advice given at the clinic: Referred to General Practitioner 7 „ Dentist 2 „ Chiropodist 12 „ Optician 4 „ Women's Voluntary Service 2 „ Citizens Advice Bureau 1 Advised about diet 15 Reassurance about state of health 19 43 The good response to follow-up attendances at the clinic seems to strengthen a general comment that the elderly appreciate this type of service. The main advantage such a clinic offers is an unhurried atmosphere with plenty of time to listen and to examine. Old people cannot be hurried. It is considered that the mere act of talking over their problems with a sympathetic listener was of value, just as the mere act of a medical examination was, itself, of some therapeutic value. Generally speaking, prevention is better than cure and so our aim with the elderly should be to maintain them active, interested and useful members of the community. It is hoped that Advisory Clinics of this type will help in trying to achieve this end. (H) LABORATORY FACILITIES The examination of clinical material of public health significance is carried our free of cost to the patient and doctor at the Central Public Health Laboratory, Colindale Avenue, London, N.W.10., (Telephone No. Colindale 7041). The clinical material is collected each day by a van sent by the laboratory calling about mid-day at the Harrow Hospital and at Kynaston Court. The following is a summary of the examination of material from this district carried out during the year:— Nose and Throat Swabs 115 Faeces 311 Sputum 8 Others 13 (I) AMBULANCE SERVICE The Accident and Sick Removal Branches of the service have now been integrated and all vehicles and operational personnel are based primarily in one of the ten depots. Number 6 depot is at Imperial Drive, Rayners Lane, and Number 5, the County Headquarters for the Ambulance Service is at The Mall, Kenton, (Telephone No. Dryden 0251). Each depot has a small number of "satellite" stations at which some of the ambulances and crews reserved for accidents and emergencies will be located. Movement of all ambulances will be governed by an ambulance control system based on the G.P.O. telephone system. Anyone requiring an ambulance for an accident or an emergency will use the 999 or other appropriate telephone system and be connected immediately to a control which will direct the nearest available ambulance to attend. HEALTH EDUCATION The Department's Health Education programme for 1963 included 89 talks on subjects related to the work of the Health Department and participation in Exhibitions including the one organised at the Council's Delegate Conference. 44 In support of Home Safety Year promoted by the Royal Society for the Prevention of Accidents, the Health Department at the 1963 Conference featured "Safety in the Home" as its main feature and eleven of the 89 talks that were given also dealt with this subject. Many people do not realise that accidents in the home are the highest cause of accidental deaths exceeding even those resulting from road accidents. Approximately 60 per cent of these deaths are due to falls, mostly to people over 60 years of age, the second highest cause being poisoning followed by burns and scalds, suffocation and choking. Of the other 78 talks that were given the subject matters covered the work of all sections of the Health Department and were given either by the Health Visitors or by Mr. D. J. Anderton, one of the Public Health Inspectors. The audiences represented all sections of the Community ranging f rom pupils at schools and the staff of local stores to Darby and Joan Clubs. All Organisations in the district were invited to take advantage of the facilities available and the response was encouraging for apart from their health education value they play an important part in the public relations work of the Local Authority. In May 1963 a "Smoking and Health" Campaign was arranged in co-operation with the Education Committee and the Central Council for Health Education, whose mobile unit spent a week in Harrow. The Campaign was concentrated mainly on the Grammar and Secondary Schools and during the week ten sessions were held in the Schools to selected groups of varying ages totalling 1,500 pupils. The children were obviously interested in the subject and one was impressed with the standard of the questions arising from the discussions which always followed the talks. It is difficult to assess the optimum age at which to put the facts before young people in order to achieve maximum impact, but there is evidence to suggest that many children do commence cigarette smoking at an alarmingly early age. There were also open sessions for the general public the response to which can only be described as apathetic. Indeed at one such session on a Saturday morning in the centre of Harrow not one member of the public attended. This only goes to strengthen the views expressed last year that anti-smoking propaganda should be concentrated on the young person before the habit is acquired. Adults will have to make up their own minds as to their course of action, but it is to be hoped that they will help in the general campaign of discouraging young people from starting the habit. The importance of health education cannot be placed on too high a level. It is hoped that in the new borough health establishment a section will be set up to deal with this important facet of a health department's work. 45 SANITARY CIRCUMSTANCES OF THE AREA WATER SUPPLY Apart from a small area in the extreme south-west part of the district which is supplied by the Rickmansworth and Uxbridge Valley Water Company, the Borough is supplied by the Colne Valley Water Company. Nearly all the water supplied by them is obtained from a series of wells that are fed by gathering grounds in the Chilterns. The supply has been satisfactory in quantity and quality and no adverse sample reports were received. The following is a copy of the result of the chemical analysis of a sample submitted for examination in December:— CHEMICAL RESULTS IN PARTS PER MILLION Appearance: Bright with a few particles Colour Nil pH 7.2 Electric Conductivity 460 Chlorine present as Chloride 42 Hardness: Total 205 Nitrate Nitrogen 5.1 Ammoniacal Nitrogen 0.000 Albuminoid Nitrogen 0.026 Metals-Iron, Zinc, Copper and Lead: —Absent Turbidity less than 3 Odour Nil Free Carbon Dioxide 17 Dissolved Solids dried at 180°C 310 Alkalinity as Calcium Carbonate 125 Carbonate 125 non-carbonate 80 Nitrite Nitrogen Absent Oxygen Absorbed 0.25 Residual Chlorine Absent "This sample is practically clear and bright in appearance, neutral in reaction and free from iron and other metals. The water is hard in character but not unduly so, it contains no excess of mineral constituents md it is of very satisfactory organic quality. From the aspect of the chemical analysis these results are indicative of a pure and wholesome water suitable for drinking and domestic purposes". DRAINAGE AND SEWAGE DISPOSAL The soil sewage from the Borough flows to the West Middlesex Drainage Works at Mogden as it has done since 1936 when the last of the five disposal works in the area went out of use. There are still, however, a few properties in the northern part of the district from which the sewage is treated in small disposal plants, otherwise all the properties within the Borough are connected to the main drainage system. Surface water is disposed of by way of separate sewers that discharge into local water courses. There are five of these; the River Pinn; the Yeading Brook; the Kenton Brook; the Wealdstone Brook and the Edgware Brook. 46 The rate of flow in these water courses varies with the amount of rain fall and during sudden storms they may have to carry very large volumes of water, while during drought the flow may be reduced to a mere trickle. One of the problems arising from these water courses is the pollution that is caused by foul water being diverted into the surface water drains of properties which often happens when waste pipes from sinks, baths and lavatory basins are connected to rain water down pipes. Many such waste pipes were found and dealt with during the year. PUBLIC CLEANSING The cleansing services are under the administration and control of the Borough Surveyor. The weekly collection service provided in the district is undertaken by direct labour and involves the handling of over 82,000 bins. There was no change in the method of disposal during the year, the collected refuse being conveyed to Harefield where it was disposed of by tipping. SWIMMING BATHS There are two open-air swimming baths in the district, one at Charles Crescent, Honeybun Estate, Harrow, and the other at Christchurch Avenue, Wealdstone. The former, constructed in 1923, measures 165 feet by seventyfive feet, with a depth of seven feet to three feet six inches. The water, after being filtered, is treated by chlorination. Dressing accommodation, shower and foot baths and sanitary conveniences are provided. The Wealdstone bath, constructed in 1934, measures 165 feet by seventy-five feet, with a depth of eight feet six inches to two feet six inches; in addition, there is a shallow semi-circular beginners' pool. Suitable dressing accommodation, with shower and foot baths, and sanitary conveniences, are provided. The water is treated by passing through filters and is then chlorinated by the break-point method. The duration of the turn-over varies according to the extent the baths are used, but it is at least once a day, and at busy times is every eight hours. Daily tests are carried out for the presence of free chlorine and to determine the pH value. In addition, samples of bath water are submitted for bacteriological examination. During the year 14 samples were submitted the results were all satisfactory. 47 DISPOSAL OF THE DEAD There were no changes during the year in the provisions for the burial of the dead. Mortuary. The mortuary for the district is situated at Peel Road and is under the care of a full-time mortuary attendant, Mr. C. Russell. During the year 333 post-mortem examinations were undertaken and inquests were held on 68. The arrangements with the Borough of Wembley whereby when their mortuary is out of use bodies are received in Harrow and viceversa again worked very satisfactorily. Plans for a mortuary keeper's residence adjacent to the mortuary were submitted during the year and approved by the appropriate committees. It is hoped work will commence on this project early in 1964. STATISTICAL SUMMARY PART I Inspections Made and Conditions Found HOUSING Visits (i) On complaint of dampness or other housing defects 1,064 (ii) On complaint of other nuisances 685 (iii) Routine inspections 521 (iv) Revisits arising from defects found 3,111 (v) Surveys under S.159 Housing Act, 1957 108 CONDITIONS FOUND (i) Number of dwellings or other premises where defects were found 1,431 (ii) Number of cases of overcrowding revealed 8 PUBLIC HEALTH Visits (i) On complaint or request 248 (ii) Routine inspection of premises 908 (iii) Revisits arising from defects found 1,002 (iv) Surveys arising from Rats or Mice complaints 1,568 (v) Inspection of Factories 144 (vi) Inspection of Outworkers' Premises 170 (vii) Inspection of Cinemas and Places of Entertainment 58 (viii) Inspection of Licensed Premises 136 (ix) Visits under Shops Acts 1,086 (x) Sunday observations—Shops Acts 14 (xi) Observations made for Smoke Nuisances 128 (xii) Surveys under Clean Air Act 7,691 (xiii) Pet Shops 23 48 FOOD HYGIENE Visits (i) Slaughterhouses 641 (ii) Butchers' shops 280 (iii) Cowsheds 7 (iv) Dairies 42 (v) Fish Shops 86 (vi) Bakehouses 80 (vii) Cafes and Restaurants 257 (viii) Ice Cream Premises 189 (ix) Provision Merchants 321 (x) Greengrocers 268 (xi) Other Food Premises 241 COMPLAINTS RECEIVED Summary Accumulations of refuse 201 Animals causing a nuisance 18 Dampness and housing defects 182 Drains and sewers—choked 93 —defective 45 Dustbins defective 18 Flooding—Gardens 22 Vermin 12 Insect infestations 62 Overcrowding, alleged 14 Smoke nuisances 17 Watercourse 12 Other complaints (wasps' nests, defective fences) 516 Food unfit (excluding requests received from shops to visit and inspect food) 42 NOTICES SERVED Under Housing Act, 1957 Statutory Notices served under S.9 requiring execution of 2 repair work Dwellings reported under SS.16/17 as being unfit for human habitation 15 Dwellings reported under S.18 (closing orders) 2 Informal notices served under S.9 12 49 Under Public Health Act, 1936: Statutory Notices under:— (i) S.24—work to a public sewer 125 (ii) S.39—repair or renewal of drains 18 (iii) S.45—repair or renewal of defective water closets 3 (iv) S.56—undrained or badly drained yard area — (v) S.75—renewal of a dustbin 2 (vi) S.93—abatement of a nuisance 14 (vii) Informal notices served 1,781 ACTION TAKEN Following Housing Act Notices: (i) S.9 Housing Act, 1957—dwelling rendered fit— (a) By owners — (b) By local authority in default of owners — (ii) S.16/17 Housing Act, 1957, Demolition Order made — (iii) S.18 Housing Act, 1957, Closing Order made 8 (iv) Dwellings rendered fit by owners after receipt of informal notice 7 (v) S.28 Housing Act, Closing Order converted to Demolition Order — Following Public Health Act Notices: (i) S.24—Public sewers repaired 114 (ii) S.39— (a) By owners 4 (b) By local authority in default of owners 11 (iii) S.45— (a) By owners 2 (b) By local authority in default of owners 1 (iv) S.56— (a) By owners — (b) By local authority in default of owners — (v) S.75— (a) By owners 1 (b) By local authority in default of owners 1 (c) By occupier — (vi) S.93—Nuisances abated 10 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice 1,126 Following action under Clean Air Act—S.12(2): Number of notices 36 Complied with by owners 21 50 SUMMARY PROCEEDINGS On three occasions application was made to the Courts for Abatement Orders and in each of these cases the Order was granted. Action taken under Section 27 of the Public Health Act, 1961, in respect of conditions at 79 High Street, Edgware, gave rise to a case of rather unusual interest. In addition to the Public Health aspect, Town Planning and road improvement interests were also involved. The owners, in fact, appealed against the Notice served upon them under Section 27 which called for the demolition of a dilapidated and worn out structure. The Magistrates after hearing the Solicitors appearing for the Council and for the owners visited the site and then decided that the case should be adjourned. A second hearing was also adjourned and though at the end of the year the structure was still standing redevelopment of the site during 1964 which will entail the removal of the dilapidated structure seemed possible. Court action was also taken in respect of three cases involving contraventions of the Food and Drugs Act. Fines were imposed in each of these cases. In another case taken under the Shops Act where a shopkeeper failed to provide suitable means of heating, action was taken and a fine of £20 was imposed. HOUSING Today there is no area within the Borough where large numbers of unfit properties exist. This is indeed a very satisfactory state of affairs. During the year some old properties which could not be made fit at a reasonable cost were reported upon and the Council dealt with these under the provisions of the Housing Acts relating to Closing or Demolition Orders. It is inevitable that of the 60,000 dwellings in the area a number will become beyond repair each year and lost as housing units. During the year some progress was made in clearing unfit dwellings and more would have been possible if the supply of replacement houses had been greater. For years the demand for new houses has exceeded the supply and because of this the housing of families from unfit properties has been delayed, in some cases for more than seven years. The need for a constant supply of new houses within the financial means of the families displaced from unfit houses will remain a matter of importance and it is hoped that during 1964 and 1965 sufficient housing units will become available to ensure that all families from dwellings which are the subject of Closing or Demolition Orders will be rehoused within a reasonable period of an Order being made. 51 The following is a summary of the position at the end of the year:— (i) Number of Closing Orders made during 1963 8 (ii) Number of properties in respect of which action preliminary to the making of a Closing Order was taken 8 (iii) Number of properties represented for action in the Clearance provision of the Housing Acts 7 (iv) Number of unfit properties demolished during the year 6 (v) Number of Closing Orders determined 9 (vi) Number of families rehoused from properties the subject of either Clearance Closing or Demolition Orders 20 (vii) Number of unfit properties occupied 31.12.63 either chased, or being purchased by the Council or the subject of Clearance Closing or Demolition Orders 46 The eight properties made the subject of Closing Orders were 259-271 Pinner Road, 90 Rickmansworth Road. The six demolished were 34-42 Palmerston Road and 2 Stanmore Hill. Overcrowding. On the 1st January 1963 the number of known cases of Statutory Overcrowding in the Borough was twenty-five. During the year eight new cases were added to the Register and over the same period fourteen were removed, the number of cases on the 1st January 1964 being nineteen. This figure has only been improved upon once, namely, during 1941 when the number of cases on the register was 17. Overcrowding was first defined by the Housing Act 1935 and since the date on which this Act came into force 2,454 cases of Statutory Overcrowding have been abated. Of the fourteen that were abated during the year five were the result of re-housing by the Council. CERTIFICATES OF DISREPAIR The following is a summary of the applications received for Certificates of Disrepair under the Rent Act:— Number of applications for Certificates of Disrepair 81 Number of Undertakings accepted from owners 43 Number of Certificates cancelled upon application 3 Number of applications for a Certificate as to the remedying of defects 25 52 The number of applications for Certificates of Disrepair continues to be small in relation to the number of controlled houses in the district and most of the applications received are from the tenants of property 25 to 30 years old where active tenant associations are able to advise on the preparation of Notices of defects. Very few applications are received from the tenants of older property. The defects most frequently listed concern external decorations, fittings, pavements and fences. In many cases inadequate description of defects by the tenant has resulted in difficulty in preparing subsequent documents. The operation of the Act has resulted in improved maintenance of controlled houses but many tenants do not take advantage of the provisions relating to the remedying of defects owing to the difficulty they have in understanding the procedure to be followed. SUPERVISION OF OTHER PREMISES During the year visits were made to factories, hotels, clubs, schools, and places of entertainment. Many of these visits were the result of requests for advice in connection with specific problems, others were of a routine nature and some followed the receipt of complaints. The general standard of maintenance and hygiene found in all but a very few cases was good and there is no doubt that standards tend to rise as improved materials and labour saving devices become available. Only by comparison with premises that have become outmoded and approaching a stage when either demolition or modernising is essential can the extent and effect of the changing standards be assessed. The licensed premises of today is one example. The modern or reconditioned House with its air-conditioned and temperature controlled cellar and well appointed public rooms is far removed from the public house of the early 1900's with its poorly lit cellar and ornate and heavy furnishings. Similarly with some of the schools, and for comparison here one might refer on the one hand, to The Bridge or Vaughan Road Schools and on the other, to any of recent construction. The former have served and are still serving the district well, but with toilet accommodation (without hand washing facilities), sited distant from the class rooms and in structures typical ot the period during which they were built, they fall far short of the easily cleansed, well lit and well appointed structures of today. It is for the ever improving standards that all who work in the public health field of prevention must strive. I think it was said at a recent conference of Cleansing Superintendents that "If an ancient Briton were reincarnated and returned to this country he would recognise the method of refuse collection used in some places as the one operating when he was previously on earth". 53 Many who have seen the dustbin compounds of some of our schools containing 15-20 often mis-shapen, lidless, dustbins may feel there is perhaps a modicum of truth in this statement. However, action was taken during the year to deal with these compounds and it is hoped that during 1964 most of the bins in use will be replaced by bulk containers. The introduction by the Council during 1958 of a bulk container service represented a major step forward and is an important aid to environmental hygiene. The value of the use of these containers cannot be over-estimated and I hope everything possible will be done to extend this service. Other premises visited during the year included pet shops, riding establishments and the premises of Barbers and Hairdressers. All were found to be satisfactory and in the majority a high standard of cleanliness was being maintained. Where it was necessary to draw attention to any matter this was done, but in no instance was it necessary to report any contravention to the Public Health Committee. Factories The Medical Officer of Health by Section 153 (i) of the Factories Act 1961 is required in his Annual Report to the Council to furnish in a set form prescribed particulars about the factories in the district. Part I of the Act 1. Inspections for purposes of provisions as to health:— Premises Number on Register Number of Inspections Written Notices Occupiers Prosecuted (1) (2) (3) (4) (5) (i) Factories in which Sections 1, 2,3,4 and 6 are to be enforced by Local Authorities 53 10 – – (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 401 201 7 – (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers premises) 32 33 2 – Total 486 244 9 – 54 2. Cases in which defects were found:— Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector (1) (2) (3) (4) (5) (6) Want of cleanliness (S.l) 2 1 1 — — Overcrowding (S.2) — — — — — Unreasonable temperature (S.3.) — — — — — Inadequate ventilation (S.4) — — — — — Ineffective drainage of floors (S.6) – – – – – Sanitary Conveniences (S.7) (a) Insufficient — — — — — (b) Unsuitable or defective 6 6 — — — (c) Not separate for sexes 4 1 – 2 — Other offences against the Act (not including offences relating to Outwork) 8 1 2 – — Total 20 9 3 2 — Part VIII of the Act Outwork Particulars of outworkers as required by Sections 133 and 134 of the Act are as follows:— Nature of Work No. on August list Wearing Apparel 143 Curtains and furniture hangings 2 Artificial Flowers 1 Paper Bags 1 Paper boxes and other receptacles 1 Brush-making 5 Stuffed toys 2 Christmas stocking 1 Lamp shades 3 159 55 There was very little change during the year in the pattern of the industrial work undertaken in the Borough and no new factory estates were established. At most of the factories in the district less than fifty persons are engaged and at only three are more than 500 employed. Two hundred and forty-four visits were made to factories in the Borough and twenty contraventions of those sections of the Factory Act for which the Local Authority is responsible were found. Information obtained about matters the concern of H.M. Inspector of Factories was passed to him and in turn his Department reported to the Local Authority any matters noted during his visits to local factories. Shops. At the end of the year there were 2,326 shops on the Register, thirtysix fewer than at the end of the previous year. This reduction was partly due to a number of shop premises being vacated for redevelopment purposes. By comparison with the figures given in the last report of the various types of shops in the Borough the main differences are an increase in the number of shops trading in Radios, Televisions, Electrical and Musical Goods and a decrease in the number trading in various food stuffs, chiefly grocery. The number of visits for the purpose of administering the Shops Act was 1,086. Evening and Sunday observations were also made and the following is a summary of the contraventions noted:— Closing Hours of Shops. Failing to close for weekly half-day 3 Failing to display alternative half-day notice 8 Failing to observe weekly half-day closing orders 4 Serving customers with non-exempted goods after hours of closing 7 Failing to display mixed trade notices 39 Failing to close on Sunday 2 Serving customers with non-exempted goods on Sunday 6 Conditions of Employment. Assistants employed on weekly half-holiday 3 Assistants not allowed proper interval for meals 1 Employment of young persons in excess of permitted hours 3 Failing to keep records of Sunday employment 3 Health and Safety. Failing to provide seats for female assistants 1 Unsatisfactory sanitary accommodation 22 Unsatisfactory washing facilities 11 Absence of or insufficient heating 9 Premises in need of cleansing 12 56 Warnings were given in respect of these matters and also in 117 other cases of failing to exhibit notices required by the Shops Act. One trader was summoned for failing to provide the means for maintaining a reasonable temperature in the shop, and at the end of the year proceedings were pending against another trader for failing to comply with a local Closing Order. In the main, however, traders co-operated in complying with the requirements of the Shops Acts and seldom was it necessary for a case to be referred to the Courts. At shops where oil heaters and fire guards were sold, these appliances and fittings were examined to ensure that as regards construction they complied with the Oil Heaters' Regulations 1962 and the Heating Appliances (Fireguards) Regulations 1953. All examined were satisfactory. New appliances now present little difficulty as manufacturers appear to be meeting the requirements of the Regulations but second hand appliances are sometimes offered for sale and these require close scrutiny. Environmental Hygiene. The dumping of refuse and unwanted household articles in accommodation and service roads and on parcels of undeveloped land continued throughout the year and gave rise to many complaints. That these were justified cannot be questioned for the evidence of this selfish unneighbourly and unhygienic practice was to be seen throughout the Borough. No Ward was immune and in each from time to time could be found the discarded bottle, tin, tank, cistern, mattress, cardboard carton, box, metal frame, pile of garden waste or household article. The slovenly and thoughtless habits from which this dumping springs are a matter of serious concern for they reflect the standards of persona! and general hygiene on which the health of the district and nation depends. Further, these rubbish deposits provide conditions conducive to the breeding of flies, mosquitoes, rats and other vermin and therefore present a challenge to the public health worker and indeed to all who appreciate cleanliness and strive for improved standards of living. Unfortunately there is no simple solution to this problem of dumping. Health education undoubtedly has a part to play and numerous ideas and suggestions could be put forward that might help, for example the establishment of centres where garden waste and unwanted bulky articles could be received but until Local Authorities are able to adopt a more generous attitude to the removal of refuse it appears dumping will continue. I would like to see all the refuse a household produces taken without charge by the Local Authority. I would also like to see more retuse removed from business premises and the sweeping by the Council of all service roads. Far too much trade waste is disposed of by burning in small yards or in bins that are placed in service roads. Far too much is retained in boxes in the hope that it will be taken at a convenient time by one or other of the carriers calling to deliver goods. Rubbish, Old Redding Abandoned Car, South Harrow 57 Refuse encourages rats, burning creates bad feeling among neighbours and litter begets litter and generally lowers standards. The urgent public health need at the moment is to make the public litter and refuse conscious. Comparing the general complaints received during the year with those of ten, twenty or thirty years ago a marked change in the general pattern is to be found. Few are received today about verminous persons or verminous premises—these were common in the 1930s. Few complaints are received about the condition of dustbins whereas in earlier years a steady stream of complaints reached the Department about these fittings. Fewer complaints are received about overcrowding but much more is heard of the dwelling in multiple occupation, of ants, rats, squirrels and pigeons and of foreign matter in food stuff. Rats and Mice. The number of complaints received about rats and mice was 1,568. Of these 1,441 were in respect of infestations at private dwellings. Business and agricultural premises were involved in the other 127. No major infestations were found, though evidence of conditions likely to lead to the build-up of a serious reservoir of rats was found at the Council's Newton Farm Site. This was dealt with and arrangements were made for the area to receive treatment from a Servicing Company at quarterly intervals. The situation here at the end of the year was satisfactory. The Council's Rodent Operatives undertook the treatment necessary for rats at 1,482 premises and for mice at a further 86. The work necessitated over 5,200 visits being made. In addition to the work arising from the complaints received, test baiting was carried out along the water courses in the district and at other points affording cover and likely to harbour vermin. Many of the complaints investigated and dealt with were associated with the depositing of unwanted material particularly behind sheds and coal hunkers and in the nooks and crannies that are to be found in most gardens. The material was often discarded garden or household articles which together with garden debris and litter provided excellent cover and suitable nesting grounds for rodents while ample food is nearly always to be found in the gardens of the many who "willy nilly" scatter food scraps for the birds. There is little doubt that there would be a marked reduction in the rodent population of the district if undeveloped sites, hedgerows, ditches and gardens were kept free of litter and debris and if more thought and care were exercised by well meaning bird lovers. 58 It is the disposal of debris that gives rise to the most difficult of these problems and it would help if all who have any unwanted material to get rid of would dispose of it through the services that are available and not allow it to remain where it could provide cover and a possible breeding ground for rats and mice or flies. The bird lovers too could help by placing any food put out for the birds on a bird table or roof out of reach of the rats or mice. Pigeons. There was a marked increase in the number of complaints about the fouling of gutters, footways and buildings by these birds and there is no doubt that the nuisance caused by pigeons in the Borough is now considerable. Early in the year action was taken through a firm of specialists to deal with the pigeons that for many years have roosted under the railway bridges in South Harrow. Between 300 and 400 were taken and though in this area the position improved, there are signs that it is now beginning to build up again. Wealdstone, Rayners Lane, North Harrow and parts of the centre of Harrow, are the areas from which most of the complaints are received. Section 74 of the Public Health Act, 1961, empowers Local Authorities to "take steps for the purpose of abating or mitigating any nuisance, annoyance or damage caused by the congregation on any built up area of housedoves, pigeons or of starlings or sparrows. The Local Authority may take reasonable steps to seize or destroy, or sell or otherwise dispose of any doves or pigeons which in their belief have no owner". Further action to deal with this problem is to be taken during the coming year. Wasps. Complaints about wasps received during the year totalled 453 and in respect of the majority of these the work of destroying the nest was undertaken by the Department. There were occasions when by reasons o the numbers to be treated there was a delay of several days before the complaints could be dealt with and as in previous years when this has occurred householders were given the addresses of firms prepared to undertake work of this kind. The year was in fact for Harrow an average one for wasps; the largest number of complaints ever received being in 1959 which followed a record low of 111 during 1958. The figure 1960, 1961 and 1962 being 647, 450 and 244 respectively. 59 CLEAN AIR Smoke Control. During December it looked as though the progress and the efforts that had been made by Local Authorities with their Smoke Control Area Programme was to be bedevilled by a shortage of open fire coke. Few people would have forecast at the time of the Beaver Committee on Atmospheric Pollution that during 1963 there would be a shortage of this fuel but in parts of the country this is the position today. In December 1963 the Minister of Power issued a White Paper "Domestic Fuel Supplies and the Clean Air Policy". This White Paper was followed by the Minister of Housing and Local Government issuing Circular 69/63 which it was pleasing to find emphasised the Government's intention to encourage and facilitate vigorous action against urban smoke and confirmed that future supplies of solid smokeless fuel would be adequate to meet the demands of those householders in areas covered by confirmed smoke control orders. Clean air is vital to the health and well-being of all people and in spite of the temporary setback arising from the dwindling supplies of open fire coke it would be a tragedy if the work of creating smoke control areas did not proceed. It will, and in fact the end of the year saw the planning of the changes necessary to meet the changing fuel situation. In my annual report for 1962 I expressed the hope that 1963 would see the whole of Roxeth and Roxbourne Wards covered by operative smoke control orders. This objective was achieved though it was necessary to ask the Minister of Housing and Local Government to make a Suspension Order in respect of Council owned houses, where it was found that the work involved in the adaptation of the fire grates could not be completed by the date the order became operative, namely 1st November. During the year three smoke control orders became operative bringing the total to six. The area covered at the end of the year being 1,043 acres embracing 8,999 dwellings and 384 other premises. The shaded area on the map below indicates the areas covered by Orders Nod. 1-6 and the hatched section to areas covered by Orders that will 60 come into operation during 1964. A summary of the position at the end of the year is as follows:— SMOKE CONTROL ORDERS—31st DECEMBER, 1963 ORDER NUMBER 1 2 3 4 5 *6 7 Date of operation 1/9/61 1/9/62 1/11/62 1/7/63 1/10/63 1/11/63 1/7/64 Totals Private Dwellings— Ante Act 1,981 744 1,009 1,518 1,642 935 1,367 9,196 Post Act — 46 — — 53 — 11 110 Corporation Dwellings— Ante Act 198 272 60 41 2 306 — 879 Post Act — 57 — — — 135 — 192 Area in Acres 225 105 132 208 212 161 176 1,219 Applications for Grant Approved 711 233 397 494 684 316 42 2,877 Notices Served (Sec. 12) 29 9 5 10 4 — — 57 Grant Claims settled 698 219 360 409 357 89 — 2,132 Total cost of work £12,091 £3,238 £5,066 £8,045 £6,404 £2,059 — £36,903 Grant Paid £6.896 £1,580 £2,180 £2,836 £3,279 £589 — £17,360 *N.B.—The Council owned dwellings in the No. 6 Order are affected by the Harrow (Suspension of Smoke Control) Order, 1963. 61 It was pointed out in the report for 1962 that householders on an average spent on adaptation about double the amount of money they received by way of Grant and it will be seen from the above figures that this trend continues. Industrial Premises. During May the Minister of Housing and Local Government issued a memorandum on chimney heights for industrial plants. This contained the long awaited official recommendations on the height at which flue gases can be discharged into the atmosphere to give an acceptable amount of pollution at ground level. The issue of this guide was welcomed by all who have to make recommendations in respect of Section 10 of the Clean Air Act 1956 on plans submitted for new boiler house installations. A shortcoming of the Clean Air Act in respect of chimney heights is that while Section 10 gives some control over new structures there is no control over the discharge of flue gases into an existing chimney or over plant where the management decide at a later date to use an alternative fuel. In July a temporary exemption permitted by Section 2 of the Clean Air Act 1956 which allowed as a defence against prosecution for the emission of dark smoke due to the inability to remedy faulty buildings and equipment came to an end. Industrialists in the district known to be using old types of plant were advised prior to July of the position and (luring the early months of the year two coal fired plants changed over to oil burning. NATIONAL SURVEY OF AIR POLLUTION The four Harrow Stations supplying information to the Warren Spring Laboratory of the Department of Scientific and Industrial Research for the National Survey have continued in operation. Station No. 1 at the offices of the Health Department, Harrow Weald is in an area of light development on the edge of the Green Belt, Station No. 2 is situated at a factory in Wealdstone in a heavily developed area including dwelling houses and industrial premises, Station No. 3 is at a school in Roxeth in a residential area subject to Smoke Control Orders and Station No. 4 is at a school in a similar area in Stanmore which is not smoke controlled. Some difficulty has been experienced in obtaining the necessary Minimum of 21 valid daily readings in each period of 28 days, particularly at holiday times and it has been decided to install at least one 8 port air sampling device which automatically carries out the eight-day sequence of changing re-agent bottles and filter papers. The highest sulphur dioxide concentrations have been at Station No. 2 with a particularly high peak during February of 1,178 micrograms per cubic meter and an average daily figure for six months of 600. 62 This was the highest month for sulphur dioxide for all Stations, No. 4 having an average reading of 329, No. 1 of 298 and No. 3 of 275. The highest daily reading of smoke was at No. 4 in January—815 micrograms per cubic meter. The highest daily average concentrations were in February No. 2 being 211, No. 4 203 and No. 1 159 and No. 3,108. The Stations have in a general way maintained this order in degree of pollution throughout the year with the summer levels of sulphur dioxide at 126 for No. 2, 57 for No. 4 and 54 No. 1. No average figures have been obtainable for No. 3 between March and October but the available figures point to a rate of the order of 40. July smoke concentrations of 22 at No. 2, 16 at No. 4 and No. 1 were the lowest recorded for the year. It is interesting to learn from the Warren Spring Laboratory that as a result of the information supplied by the co-operating authorities it is now possible to forecast with reasonable accuracy the levels of pollution in a given area from such basic information as population, geographical situation and amount of industry. The thanks of the department are once more due to the pupils and teachers at the two schools and the factory laboratory staff for their invaluable assistance in operating three of the stations. THE INSPECTION AND SUPERVISION OF FOOD On the 1st October the Meat Inspection Regulations 1963, came into operation, replacing the Public Health (Meat) Regulations 1924-1952. The main provisions of the Regulations deal with:— (i) The movement from slaughterhouses of the carcases oi animals slaughtered for sale for human consumption. (ii) The marking of carcases inspected and found fit for human consumption. (iii) Method of inspection. Inspection of Meat. There was a slight reduction in the number of animals killed at the three slaughterhouses in Harrow the total for 1963 being 6,616, compared with 7,347 in 1962. Of these 5,506 were killed at 46 High Street, Wealdstone, 425 at 7 Northolt Road and 685 at 87 Stanmore Hill. For the first time all the cattle killed in Harrow were found free from tuberculosis, compared with the three years preceeding the war when the average percentage affected with tuberculosis was 23.7% in cows and 12.6% in cattle other than cows. MEAT INSPECTION 63 Whilst there has been a general decline due to improved husbandry and feeding in the post war years the present clean bill is due to the compulsory terberculin testing of all milk producing herds. The incidence of tuberculosis in pigs has also declined from a pre war percentage of 8.1% to 1.96% in 1963, again due to improved husbandry and scientific feeding although the pre war figure may also be associated with the practice of feeding the strippings and skimmed milk from the cows to the pigs. Again in 1963 all tuberculosis in pigs was localised in the head, whereas before the war the disease was far more wide spread in the animal, necessitating the condemnation of an average of six whole carcases per annum due to generalized infection. Cysticercus Bovis in cattle, a parasite which can cause tape worm in man if not destroyed by adequate heat treatment, was isolated in 17 beasts, an incidence of 1.42%. In two cases the condition was generalized resulting in the total condemnation of the carcases, and in nine cases the lesion was viable, necessitating the treatment of the carcases by extreme refrigeration. This treatment can result in considerable financial loss to the owner, though at most markets it is possible to insure against the condition. The carcase of one other beast was condemned due to bruising after injury. Two pig carcases were condemned due to (i) chronic inflammation and (ii) multiple abscesses; and two sheep carcases condemned due to (i) emaciation and oedema and (ii) sceptic pneumonia. One calf which arrived in a moribund state was also condemned. The incidence of other diseases in cattle was 16.5% compared with 19.7% pre war, due mostly to the parasitic or abscessed condition of the liver. In pigs, however, the incidence of other diseases and conditions has increased from a pre war figure of 4.1% to 12.6% in 1963, due mainly to such respiratory conditions as pneumonia, pleurisy and congestion. aver percentage of other diseases in sheep was 5.5% compared with an age of 1.6% before the war, the most common disease in both cases being parasitic infections of the liver and lungs. 64 The following is a summary of the return to the Ministry of the post mortem examination of the animals in slaughterhouses:— Cattle Excluding Cows Cows Calves Sheep and Lambs Pigs Horses Number killed 1,201 Nil 404 3,171 1.840 – Number inspected 1,201 Nil 404 3,171 1,840 – All diseases except Tuberculosis and Cysticeri— Whole carcases condemned 1 – 1 2 2 – Carcases of which some part or organ was condemned 194 – 4 174 232 – Percentage of the number inspected affected with disease other than tuberculosis and cysticerci 16.5% Nil 1.0% 5.5% 12.6% – Tuberculosis only Whole carcases condemned – – – – – – Carcases of which some part or organ was condemned – – – – 36 – Percentage of the number inspected affected with tuberculosis – – – – 1.96% – Cysticercosis Carcases of which some part or organ was condemned 17 – – – – – Carcases submitted to treatment by refrigeration 11 – – – – – Generalised and totally condemned 2 — — — — – 65 MILK Production. There are five dairy farms in the district. At four of these tuberculin tested milk is produced and at the fifth the milk is sent to a wholesaler for processing. Two of the farms are in Pinner, two in Harrow Weald and one in Harrow. Pasteurising Establishments. Two dairies in the Borough are licensed for the pasteurising of milk. Namely Messrs. Hall & Sons of Pinner Park Farm and Messrs. J. H. Brazier of Kenton Lane. Licences to pasteurise milk have been held by these two firms for many years and though the licensing authority is the County Council, both establishments were visited from time to time by the Public Health Inspectors. Sampling. During the year 27 samples were taken of milk produced or retailed in the district. All were satisfactory. Milk Bottles. In my annual report for 1962 I was able to report that the number of complaints about milk bottles, namely 15, was the lowest for many years. The number of complaints received during 1963 was 14. Eight of these were about dirty or damaged bottles and six about the presence of foreign matter. The mis-used bottle and the one hoarded for weeks without being rinsed, are the cause of endless trouble to the dairyman and they give rise to problems that are not easily resolved. The non-returnable container is perhaps the only real answer to this bottle problem and earlier in the year the supplying of milk in one-third pint cartons was introduced as an experiment at two schools in the Borough. It was a partial success and the of cartons was in fact extended to other schools. Some of these schools speak well of this method of supplying milk whereas others find it less acceptable. The containers are hygienic and their use reduces considerably the possibility of dirt or foreign matter being present. 1 would like in connection with the introduction of cartoned milk to schools, to record my appreciation of the co-operation received from the head teachers and staff of Pinner County School and the Pinner Junior School for the help and assistance they rendered during the initial stages of the carton experiment. It will be interesting to learn of the decisions that are finally taken. During the year it was unfortunately necessary on many occasions to write to the Dairy Companies about the stacking of empty milk bottles on the highway. The efforts that were made to stop this met with some success. and I am hoping this very undesirable practice will soon be a thing of the past. 66 ICE CREAM No change occurred in the number of premises registered for the manufacture of ice cream, though during the year one manufacturer transferred his business from High Street, Wealdstone, to Pinner Road. Harrow. The number of premises registered at the end of the year being two. There was, however, a marked increase in the number of vehicles operating in the district that were equipped for the making of soft ice cream. These are specially equipped and most are of modern design and well maintained. The majority of retailers, however, continued to sell prepacked ice cream. During the year twelve samples of pre-packed ice cream, 26 of soft ice cream and 40 of loose ice cream were submitted for examination. Of these 78 samples 55 were reported as satisfactory, and the remaining 23 failed to reach the standards required. In each of these cases follow up action was taken and ultimately further samples were submitted to the Colindale Laboratory. OTHER FOODS AND FOOD HYGIENE Food shops were visited regularly as a routine and though the calls made upon the services of the Public Health Inspectors resulted in a longer interval than is desirable occurring between visits, the general standard of cleanliness in most food shops remained high. There were lapses on the part of a few traders and it was necessary to remind these of the provisions and requirements of the Food and Drugs Act, but overall the year was one of steady progress. Many factors have assisted in securing the standards that are enjoyed today not the least being the ever increasing interest of the public in clean food. Over the years every opportunity has been taken of talking at meetings of Women's Organisations on this and allied subjects and the part the shopping public now play in the raising of standards is an extremely important one. Then improved types of material which are not only pleasing in appearance but easily cleansed have helped. Likewise the wider use of the refrigerated display cabinet and the pre-packing of the food stuffs found on sale in the modern self-service shop. All, however, is not on the credit side. Far too many members of the public still take dogs into food shops. Many shoppers still smoke over open food stuffs. Supplies being delivered to shops are still left on the highway far too long before being taken into the premises, and many greengrocers remain reluctant to raise the height of goods on display at forecourts above the minimum 18". Then much still remains to be done about the condition of many delivery vehicles, particularly those in which meat is conveyed. The cleanliness of yards and the disposal of waste are Pinner Fair 1963 67 still matters of concern. Nevertheless progress continues to be made and this in spite of the staff shortages and the many other problems that are experienced by food traders. Complaints. There was a slight fall in the quantities of food stuff found unfit and destroyed by the Department during the year, whilst the complaints about unsound food stuff or of the presence of foreign matter fell from 54 for 1962 to 39. Of these 39, 19 were about bread or bakehouse confectionery, eight about meat products, nine about tinned or packeted foods. The other three involved beverages and fruit. The investigating of complaints about food stuff is time absorbing but often rewarding in that it enables action to be taken to prevent a repetition. As a result of a complaint, the existence of old stock is sometimes found, and in consequence removed from sale, and enquiries often result in the traders introducing improved methods of stock rotation. Of the complaints received statutory action was taken in respect of three which involved foreign matter being found in bread. OPEN AIR TRADING The Middlesex County Council Act, 1950, requires that a person retailing food from a cart, barrow or other vehicle, shall be registered with the Local Authority and that the storage premises used by him shall also be registered. The number registered at the end of the year was 69. Most of the hawkers who are registered retail greengrocery on established rounds and their supervision presents little difficulty. Problems sometimes arise with the trader who commences trading without applying for registration, and one of the difficulties he is likely to encounter is the finding of suitable storage accommodation in areas zoned for business purposes under own Planning. This particular difficulty is a very real one and the day not be far distant when Local Authorities will undertake the provision of properly equipped centres for these traders. Such centres would facilitate the maintenance of standards of hygiene and with accommodation provided in relation to the size of the area served, it would help to limit the number operating in a particular district. As with shops the standard of the mobile unit has risen, but even sot there are problems with open air trading. Examples of open air trading are to be seen annually at Pinner Fair, where during 1963 between 40 and 50 nicies or stalls were to be found retailing food stuff in one form or another. 68 INFECTIOUS AND OTHER DISEASES PREVALENCE OF NOTIFIABLE INFECTIOUS DISEASES (other than Tuberculosis) TABLE 1. Disease Und. 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65 + yrs. Unknown Total Scarlet Fever 11 44 5 1 1 1 — _ — 63 Pneumonia Primary — 4 4 2 2 — 4 3 3 9 11 1 46 Pneumonia Influenzal — — 1 3 2 — 3 5 2 1 9 — lb Diphtheria — Dysentery — 6 7 4 1 3 4 1 — 1 — 11 Erysipelas — 3 i — 6 Meningococcal Infection - - Puerperal Pyrexia — — — 1 1 2 — — — — 1 Ophthalmia Neonatorum 2 - - - - - - - - - - - - Poliomyelitis, Paralytic - - - - - - - - - - - - - Poliomyelitis, non-paralytic - - - - - - - - - - - — - Encephalitis Infective - - - - - - - - - - - — Measles 32 934 799 53 15 2 5 2 1 2 li 1868 Whooping Cough 14 44 31 10 — 1 1 3 — 1 — 105 Paratyphoid Fever — 2 Typhoid Fever — — — — — 1 1 — — — — — Food Poisoning 1 — 1 — — 2 2 — 3 2 1 — 2 Malaria - - - - - - - - - - - - 12 THE CONTROL OF INFECTIOUS DISEASES The various steps taken in the control of communicable disease include:— (a) Notification. (b) Enquiries by the staff of the department at the home, school, place of work or institution. (c) Aids to diagnosis, such as the Public Health Laboratory Service, or the obtaining of a second medical opinion. (d) Isolation either at home or in hospital. (e) Exclusion of contacts from their work, especially in the case o those in close contact with susceptible young children or patien s in a ward, or those handling food or drink. (/) Exclusion of carriers of enteric (Typhoid, Paratyphoid) fever, and dysentery from any work involving handling food or drm for human consumption. (g) Exclusion from places of assembly. (h) Disinfection. (/) Cleansing. (j) Destruction of articles of food. (k) Immunisation. (/) Propaganda. 69 DIPHTHERIA There were no cases of this disease, but, or course, no complacency is permissible in the prevention of the condition. There is a generation of young mothers which, because of the successful campaign against diphtheria initiated twenty years ago, has no first-hand knowledge of its ravages. Further, diphtheria, unlike poliomyelitis, is a killer rather than a crippler. Like so much else in public health, constant vigilance is essential to ensure an adequately immunised child population. During the year 2,888 were immunised for the first time and booster doses were given to 1,067 children. SCARLET FEVER Scarlet fever these days is not clearly demarcated from acute tonsillitis. Any case of acute tonsillitis presenting with ear symptoms should be regarded as a potential cause of scarlet fever, and the urine should be examined to exclude the possibility of kidney involvement. SMALLPOX In 1963 the Ministry of Health issued Circular 16/63 about International Certificates of Vaccination against smallpox. The Public Health Committee of the Council of Europe has sought to improve the special arrangements which aim to facilitate international travel with special reference to smallpox. Valid International Certificates of Vaccination against smallpox are now required by national health administrations from travellers arriving from local infected areas and from "endemic areas", the latter to be defined as consisting of African, Asia, the Americas (excluding Canada and the United States of America). This general definition of "endemic areas" is recommended to replace the various definitions, differing from country to country, which have previously been employed. The new procedure to be adopted for passengers from locally infected areas or from the "defined" areas has been approved by the Ministry of Health. Passengers who do not possess valid International Certificates or o not show sufficient evidence of protection by a previous attack of smallpox, will be offered vaccination and unless they are in transit, placed under surveillance for fourteen days. During the year 1,107 primary vaccinations and 515 re-vaccinations were carried out. POLIOMYELITIS No cases were notified during the year 1963. TABLE II Number of persons who have received Second injection SALK vaccine Third dose ORAL vaccine Children born in 1963 59 286 Children born in 1962 298 1.390 Children born in 1961 109 288 Children and young persons born 1943-1960 59 309 Young persons born 1933-1942 55 180 Others 114 226 Totals 694 2,679 Number of persons given reinforcing dose of SALK vaccine .. 1,765 Number of persons given reinforcing dose of ORAL vaccine .. 1,983 WHOOPING COUGH During the year 105 cases of whooping cough were notified. It is difficult to know whether these were all true cases of the disease as normally the diagnosis is made symptomatically and not confirmed bacteriologically. Recently it has been noted that other viruses can cause similar symptoms of whooping cough and yet have no evidence of infection with the actual whooping cough virus. The degree of immunity given by whooping cough vaccine is in the order of 80%, and in the remaining 20% a mild form of the disease would probably occur—not in itself a bad thing as the subsequent immunity wi be of a high degree. It is now suggested that agents other than whoopm? cough virus can produce symptoms resembling whooping cough, an unless confirmed by laboratory investigation the actual numbers o notifications of cases of whooping cough may not give the true picture o the disease in a particular district. Immunisation. 2,846 primary immunisations and 725 "booster" doses were given during the year. The importance of the "booster" at 18 months is being emphasised. 70 71 ENTERIC FEVER In 1963 the public image of Switzerland as one of the "clean" holiday places in Europe was marred by the outbreak of typhoid fever in the winter sports resort of Zermatt. The outbreak occurred at the height of the season and being a water-borne infection resulted in many cases. Many of these were holiday makers from other countries and their return home either with the disease or incubating it caused much work for many health departments. About 45 cases were reported in England and Wales (one Harrow resident was involved). Normal routine investigations were instituted and all contacts cleared. Circular letters were sent to proprietors of all food handling establishments in the Borough asking them to seek advice from the Health Department should any of their staff have been in Zermatt during the danger period. About 4 million of the United Kingdom population booked holidays abroad in 1963 and about 84 per cent of them travelled in Europe. These figures show that there is a not inconsiderable proportion of the population at risk and in these circumstances immunisation with T.A.B. vaccine before the projected holiday should be regarded as the best form of insurance against this particular illness. Of the four cases of typhoid and paratyphoid notified during the year, ihree contracted the disease from abroad (one in Zermatt). The lady mentioned in previous reports, who was excluded from engaging in her work as a cook, still remains a carrier. DYSENTERY AND FOOD POISONING All cases are followed up by the Department to try and trace sources of infection. Control of these diseases lies in the hands of the public themselves. Simple routine hygiene measures are all that are required yet seem so difficult to obtain. MEASLES The usual periodic rise in measles occurred in 1963, with 1868 Mifications compared with 719 in 1962. As about 5°/0 of cases develop one or other of the recognised complications of the disease an effective vaccinewould be a worthwhile advance. There is hope that such a vaccin will be available soon. TUBERCULOSIS The following table gives the age and sex distribution both of persons were resident in the district when it was recognised that they were 72 suffering from tuberculosis, and of those who moved into the district already suffering from the disease:— Age Group Primary Notification Brought to notice other than on a Form "A" Pulmonary NonPulmonary Pulmonary NonPulmonary M F M F M F M F Under 1 — — 1 - - 1-4 — 1 — - - 5-9 — — — 1 - - 10-14 I 1 — 1 - — 15-19 2 1 1 — - - — 20-24 4 2 2 1 4 4 - — 25-34 5 8 — — 7 8 1 1 35-44 4 2 — 1 6 6 - — 45-54 5 2 — 2 2 3 - — 55-64 12 5 2 2 1 3 — 65 and over 5 4 —• 1 3 — Totals 38 26 5 7 25 25 1 1 Register. The Tuberculosis Register is a compilation of the names of those persons in the district who are suffering from the disease or have recently suffered from it. The names of the newly notified are added to it and entries are made of those persons who have moved into the district suffering from tuberculosis. Names are deleted on the removal of persons from the district or on death, or recovery, an accepted standard of recovery being a lapse of five years in the pulmonary cases and three years in non-pulmonary cases from the date the disease was arrested. The following is a summary of the changes which have taken place in the register during the year:— Pulmonary Non-Pulmonary Male Female Male Female No. on register, January 1st, 1963 1,139 948 116 145 No. of new cases added 38 26 5 7 No. of cases other than on a Form "A" 25 25 1 1 No. of cases restored to register 1 1 - - No. of cases removed 98 81 7 7 No. on register December 31st, 1963 1,105 919 115 146 73 Details of cases removed from register: Pulmonary Non-Pulmonary Male Female Male Female Left District 26 32 1 3 Deaths 26 2 — — Recovered 44 35 6 3 De-notified — — — Lost Sight Of 2 12 1 Deaths Tuberculosis caused the death of five local residents, all male. No children died of the disease. Prevention The early recognition of infection in a person is of paramount importance and in this context the work of the chest clinics and the Mass X-ray Unit must be mentioned. It should be more widely known that there is available at the Central Middlesex Hospital, Park Royal, N.W.10, a permanent Mass X-ray Unit, open between 9-5 on Mondays to Fridays, and 9-12 on Saturdays. Here any person over fourteen years can attend without appointment or medical note and without the payment of a fee. In addition, the Chest Clinic at Station Road, Harrow, and Edgware General Hospital provide ready facilities for the examination of all patients referred on suspicion of some chest trouble by hospital departments and also by their own doctors. In addition, of course, the clinics undertake the routine examination and re-examination of contacts, especially family contacts of a known case. Here one would like to record appreciation and grateful thanks to Dr. Grenville-Mathers and Dr. Trenchard and their respective staffs at the Harrow and Edgware Chest Clinics, for their co-operation, help and advice so willingly given at all times. The school medical and nursing staff continue to play their part in controlling this infection. 1. Tuberculin Testing of School Entrants is done at some of the schools. 295 children were given the jelly test and 691 were tested by heaf gun. 19 positive reactors were found, but all of these, who were X-rayed, were free from disease. The testing of school entrants is of doubtful value in case finding and consideration is being given to stopping this procedure and using the staff in more fruitful pursuits. 2. Examination of Contacts. Whenever a case is notified either n a pupil or a teacher, or other member of school staff, the question of the need for epidemiological investigation in the school is discussed with the 74 staff of the appropriate chest clinic. During the year two cases of primary tuberculosis were reported in children attending schools in the Borough. All staff and class contacts were investigated with negative results. 3. B.C.G. Inoculation. This procedure, which was started here in 1957, has continued to function satisfactorily. The following is a summary of the work done in 1963:— Type of School Ato. of Pupils Eligible No. of Acceptance Negative Reactors Positive Reactors Secondary Modern 1,202 840 757 59 Secondary Grammar 787 625 578 41 Independent 490 397 354 26 Special 11 10 6 1 Total 2,490 1,872 1,695 127 (2,752) (2,113) (1,729) (241) For comparison, the final figures for 1962 are shown in brackets. Of the negative reactors, 1,688 were given B.C.G. The acceptance rate was 75-2% and the percentage of positive reactors was just under 7%. It is a routine practice at the Harrow Chest Clinic to offer X-ray examination to the domiciliary contacts of those children found to be tuberculin positive. SOME NON-NOTIFIABLE INFECTIONS German Measles. The well known connection between German Measles in pregnant women and congenital defects in their babies inevitably leads during an epidemic of German Measles to some understandable anxiety in the prospective mothers. In this connection, two points may be stressed:— 1 ■ Any female child who is suspected of having German Measles should have medical confirmation of this and if the diagnosis is confirmed some record should be made by the parent of this fact for future reference. Too many female children give a history ot possible or probable German Measles where no medical confirmation has been obtained. 2. It should be remembered that the administration of gammaglobulin to a mother in the early months of pregnancy where there is a risk of contracting German Measles only protects her for three weeks at the most. 75 INFLUENZA Immunisation. The present position regarding this is that while the protection conferred by immunisation is of brief duration (about 3-6 months) there is a case for immunising certain groups of the population in whom a contact of influenza might aggravate their disability or prove fatal. Such groups include:— (a) Chronic Lung disease, e.g. chronic bronchitis, asthma, bronchiectasis, pulmonary tuberculosis. (b) Chronic heart disease. (c) Chronic kidney disease. (d) Diabetes and possibly other endocrine disorders. The only type of vaccine recommended is an inactivated influenza A+B Saline vaccine, and it should be given during the early part of the autumn. TETANUS The "first aid" prevention of tetanus is usually by the administration of anti-tetanic serum. This is known to have certain disadvantages, whereas the prophylactic use of tetanus toxoid either separately, or in the combined form ("Triple" vaccine or Quadrillin) has no similar disadvantages. Ideally, if a child known to be protected with tetanus toxoid sustained an injury, all that should be necessary would be the administration of a booster dose of tetanus toxoid. Unfortunately, too often, the immunisation state of the child is unknown, at the time of the accident, and anti-tetanic serum has to be given in the absence of this information. 2,997 children were given a primary course of immunisation against tetanus and 890 were given a booster. QUADRUPLE VACCINE TRIAL During 1963 the Public Health Laboratory Service organised a trial in eight centres in England and Wales to compare quadruple vaccine, Salk and Sabin vaccine in their effect on the excretion of poliovirus after a challenge dose of live attenuated poliovirus. The total number of children required to take part was 240 and some 70 to 80 children were required from the County of Middlesex. This was spread over the ten health areas in the County and meant that six children in Harrow took part in the trial. The proposed trial was carried out in children aged between six months and two years who had not been immunised against poliomyelitis or pertussis. One group of the children was given Quadrillin vaccine, another group Salk vaccine and a third Sabin vaccine, and a fourth trial group was not given poliovirus but was given a pertussis vaccine. The vaccines were given in three doses at intervals of one month. The four groups of children were given a challenge dose of living attenuated Poliovirus type 1 three months after the last dose of vaccine and poliovirus excretion was then investigated for six weeks.