LIBRARY BOROUGH OF HEND0N ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH A N D SCHOOL MEDICAL OFFICER FOR THE YEAR 1940 A. FAIRGRIEVE ADMSON, M. D. , D. P. H. , Medical Officer of Health, School Medical Officer and Medical Superintendent of the Isolation Hospital. ANNUAL REPORT OF THE MEDICAL 0FFICER OF HEALTH FOR THE YEAR 1940 Mr. Mayer, Ladies and Gentlemen, I have the honour to submit my Eleventh Annual Report, which in accordance with the instructions of the Ministry oF Health is an interim report and deals only with matters which can be regarded as new or likely to affect the public health. No effort has therefore been made to review in detail the various social services, although I am happy to state that these are functioning to full capacity, GENERAL HEALTH CONDITIONS. Excepting for casualties consequent upon enemy action, no effect was seen in the first complete year of war on the health condition of the population which could reasonably be attributed to war conditions. The incidence of the tain infectious diseases remained low, particularly in the case of Diphtheria, of which only 70 oases were notified compared with 150 in the previous year. On the ether hand, Cerebrospinal Fever, a disease which becomes more prevalent under war conditions, showed an increase, 16 cases being notified as against 5 in 1939. Conditions as regards essential food supplies continued to be satisfactory, rationing was not severe and there was no scarcity of unrationed foodstuffs, the only restriction in obtaining foods being economio as there had been a steady increase in prices. The Council continued the policy of providing accessory foods at the Health Centres and revised its economic scale in conformity with the increased cost of living, for the free provision of additional nourishment and for the reduction and remission of the fees for the various services. In the latter part of the year the Education Committee approved a scheme for the provision of solid meals to children recommended by the Medical Officer of Health. V - • T. ' :'v : m.!;{ . • . -v' f . . . •" ' ' ■ ' ; ■ ■ , 2. Against this optimistic outlook, however, must be placed the fact that the infantile mortality rose from the very low figure of 34 per 1000 live births to 54, this latter rate being only slightly under that of the country generally, which was 55. It must however be pointed out that the rate for Hendon has for a number of years been remarkably low. An investigation into the cause of this increase showed that the majority of the deaths occurred within the first three months of life and that they were mainly due to respiratory diseases. They were spread fairly evenly throughout the year so that no single factor could be held responsible, such as shelter life or the overcrowding which took place from families using their ground floor rooms for sleeping accommodation once bombing had commenced, although such conditions are obviously adverse factors. MIGRATION INTO THE AREA. In the Spring the threat of the enemy over-running certain of the small European countries necessitated provision being made for the reception of foreign refugees. The Middlesex County Council were the responsible Authority with, of course, the co-operation of Local Authorities within the County. Arrangements for billeting were made by the Chief Billeting Officer but it was felt that each refugee should be examined because of the risk of the importation of infectious diseases, many of the refugees coming from countries in which the public health standards are not so high as in this country. Moreover, these refugees had been living under the threat of war for a considerable period, with a likely lowering of general standards and it was also almost inevitable that arrangements would have to be made for hospital treatment of various conditions. Altogether about 250 refugees were received in this area but no serious infectious conditions were, in fact, found and I am glad to say that the Chief Billeting Officer was able to arrange for the refugees to be accommodated in private billets almost at once, thereby obviating the necessity of their living communally in halls, etc. , where any infectious conditions which might exist would be likely to spread. . '•••" ..•••-• • • I • I- ' 3. WATER SUPPLIES. An obvious danger exists when bombing takes place of damage to water mains by enemy action with a lowering of the pressure and if at the same time nearby sewers are also damaged, there may be a percolation into the water mains. This, of course, would be liable to be followed by outbreaks of gastro-intestinal disorders and possibly by infections of the typhoid group. The Metropolitan Water Board and the Colne Valley Water Company were approached as to the methods they were employing to reduce this danger to a minimum. These consisted of preventing any water to which the slightest suspicion was attached from entering supply, sampling at the time of an incident and in the event of proven damage to any water main, careful continuous flushing, chlorination and sampling after repair, before the water was allowed to re-enter supply. In addition pamphlets were prepared for the information of the public and these, in this Borough, were distributed through the local wardens Association. The safeguards adopted by the water Companies are very comprehensive and have so far proved effective. IMMUNISATION AGAINST DIPHTHERIA. This continued to be provided free of charge and further steps were taken to draw the attention of the public to the desirability of having their children immunised. After consideration of Ministry of Health Memorandum 170/Med, the Council approved (l) the advocating of diphtheria immunisation on the birthday letters sent to all children attending the Child Welfare Centres on their first birthday, (2) offering immunisation to all entrants to public elementary schools, and (3) offering an additional dose of prophylactic agent to children entering school if primary immunisation had been carried out in early infancy. ^he figures for immunisation are set out in the following Table:- Successfully immunised 592 No. under treatment 319 If one may be permitted to anticipate at this stage, the year 1941 saw a marked increase in immunisation due largely, I believe, to B. B. C. 4. broadcasts. There is little doubt in my mind that these broadcasts are the most effective means of arresting public attention, and if followed up locally result in considerable increases in the number of parents prepared to have their children immunised. IMMUNISATION AGAINST ORGANISMS OF THE TYPHOID GROUP. Consideration was given to the advisability of mass inoculation and while this was not considered necessary at the present stage, facilities were provided so that any one applying for this protective immunisation could obtain it. A recommendation was, however, made to the Council, that members of the Fire Brigade should have their particular attention drawn to this form of immunisation. This group was selected as the nature of their duties in this and other areas might result in their drinking water which had become contaminated. The Council decided to extend this by offering immunisation to all members of the Civil Defence personnel. IMMUNISATION AGAINST TETANUS INFECTION. This was not considered, necessary, as arrangements are already in existence for all casualties due to enemy action to receive protection by an injection of anti-tetanic serum. PUBLIC AIR RAID SHELTERS. Danger was anticipated to health from the use of public air raid shelters, especially as excessive bombing necessitated their use for much longer periods than was originally anticipated, many being used as dormitories. The diseases most likely to become prevalent are those which are spread by droplet infection, that is, infection carried from person to person in the act of speaking, laughing, etc. Such diseases are influenza, the common cold, tuberculosis, and many of the acute diseases of childhood. Another risk was that of the spread of verminous conditions and scabies, As regards the risk of droplet infection the only real precaution is adequate ventilation and the prevention of overcrowding. A scheme of visiting was put in hand by the Council's Medical and Sanitary staff and as a result of this many improvements in detail for the comfort of shelterers were, I believe made. 5. In addition notices were prepared for the guidance of the public, Events, however, proved that at no time were the shelters used to their full capacity, most people prefering to remain in their own houses or to use private shelters of the Anderson or other type. I am glad to say that up to the end of the year none of the dangers anticipated had, in fact supervened. SANITARY SERVICES. Tn my Report of last year I recorded how these services had been adversely affected by the outbreak of war, and the employment of Sanitary Inspectors on Civil Defence duties. with the exception of two of these Inspectors - the one seconded for Civil Defence duties, and the other employed still in this work - the others have been released, and a temporary Inspector has been provided in place of the one seconded. Inspection and supervision have been resumed. The following were the main developments during the year:- SLAUGHTERHOUSES Pursuant to the requirements of the Food and Drugs Act, 1938 the Council gave consideration to application for the licensing of three slaughterhouses which before the coming into operation of this Act were registered with the Local Authority, and had been in uninterrupted use for many years; and to applications for the renewal of two existing licences. The five licences were granted. As the Ministry of Food have not taken possession, under the Defence (General) Regulations, 1939, of any of these slaughterhouses none has been used since the Livestock (Restrictions on Slaughtering) Order, 1940 came into operation on January 15th, FOOD. In the earlier part of the year the qualify of some imported butchers meat and bacon was the cause of complaint both by the trade and the purchasing public; and although examination showed much of the meat to be of a quality inferior to that normally sold in the district, and also not up to a standard a purchaser would expect to buy at a controlled price, the question of fitness for food for human consumption was rendered more difficult by the absence from some carcases of the vital organs, A marked improvement in quality followed that period. During the latter months enemy bombing was responsible for the extensive damage to shopping centres. At all shops or other places where any article of food was sold or prepared for sale, which were damaged however slight the damage, an inspection of every article was conducted for the purpose of withdrawing from sale any food - canned, glassed, package or loose, contaminated by glass or other injurious substances to such an extent as to render them unfit for human consumption. 6. This work was much facilitated at premises in the occupation of most butchers, fishmongers and dairymen whose practice it is at the end of the day to place the more perishable foodstuffs in refrigerators or similar appliances. To enable tradesmen to continue supplying rationed foods to their registered customers without undue delay, these commodities were, wherever practicable, the first to be examined, and detailed lists of food condemned were forwarded to the Food Executive Officer who in turn arranged for replacement. In one night practically all food, premises in Golders Green and Temple Fortune were so damaged. Other shopping centres affected at various times were, Central Kendon, west Hendon, Cricklewood, Colindale Avenue, Fill Hill (part), Edgware (part), and Burnt Oak. The services of the Inspectorial staff at times were employed fully in this work; work rendered the more difficult by chaotic conditions. 256 premises were inspected, and include 73 Grocers, Provisions Merchants etc., 33 Butchers, 29 fruiterers and Greengrocers, 19 Bakers, 14 Dairymen, 5 fishmongers and 83 Miscellaneous - (restaurants, confectioners, etc.) These figures do not include revisits which in many instances extended over periods of several days. with the considerable amount of food dealt with the loss, owing to condemnation, was unimportant. ARMY BILLETING-, Billeting in privately-owned property was not as extensive as last year, although close contact was maintained between the Military Authorities and the Public Health Department, and disinfection after illness or disinfestation after verminous complaints was undertaken. HENDON EMERGENCY AND ISOLATION HOSPITAL. The Hospital continued in its dual capacity as an infectious diseases hospital, in which there was a provision of 36 beds available for the treatment of infectious diseases and 170 Emergency Medical Services beds, for the accommodation of air raid casualties, service and civilian sick and for transferred cases from the London Hospitals. The Hospital was one of the many London institutions which suffered damage during the year as the result of air raids. In September three high explosive bombs fell on the Hospital premises, the first demolished one side of Block I, which was fortunately almost empty at the time, one patient only being injured. The second bomb struck the Cubicle Block, unfortunately resulting in the death of 5 children and putting the whole Block temporarily out of commission. Six Cubicles were subsequently repaired and put into use for the treatment of patients, 4 more which were beyond repair for the use of patients were restored to an extent which enabled them to be used for storage and other purposes. A delayed 7; action bomb also fell in the grounds near the Lodge and exploding later damaged the Lodge and the two staff cotages adjoining. These sustained further damage from mother bomb which fell close to them a few weeks later. It was found possible to repair the cottages but the Lodge could not be made habitable. The structional damage to the Hospital necessitated the re-allocation of beds as between the infectious disease section of the Hospital and the Emergency Medical Services, and the accomodation at the end of the year was disposed of as follows:- Block 1 (Diphtheria) 10 beds " 2 (Scarlet Fever) 25 " " 4 (Cubicle cases) 6 " 41 Block 3 E.M.S. beds 20 " 5 " " 60 " 6 " " 60 140 181 The loss of 10 out of 16 Cubicles was serious from the point of view of the efficient functioning of the infectious disease side of the Hospital. The provision of adequate Cubicle accommodation is at all times highly desirable but under war conditions their need is accentuated, partly because admission is sought for diseases such as measles and whooping cough, which, under peace conditions are adequately nursed at home. In war time, however, this cannot be so effectively carried out as the family may have to resort to public shelters during air raids, or crowd together in a single room and also with the calling up of men and the entrance of women to industry, there may be no adult left at home to look after the sick child. Representations are therefore being made for the re-establishment of the cubicle accommodation. There follows a Table which gives the admissions to the infectious disease side of the hospital during the year, from which it will be seen that 140 cases of Scarlet Fever were nursed at home, The Council appreciated the difficulty which would inevitably occur due to the shortage of isolation accommodation in the County generally and in June sought permission from the Ministry of Health to meet the medical fees for domiciliary attendance on such cases; this proposal, however, was not approved. 8. PERCENTAGE OF CASES REMOVED TO HENDON ISOLATION HOSPITAL. Disease Notified TOTAL Cases Removed To Home Treatment Cases Percentage of cases removed to Hendon Isolation Hospital. Hendon Isoln. Hoap. Other Hospitals Council's arrangements Private arrangements Scarlet Fever 306 123 41 2 140 40.2 % Diphtheria 70 46 19 4 1 65.7 % Erysipelas 40 3 2 3 32 7.5 % Cerebro-spinal meningitis 16 2 1 12 1 12.5 % Anterior poliomyelitis 2 1 - 1 - 50.0 % Typhoid Fever 4 2 - 2 - 50.0 % Although the treatment of Emergency Medical Services cases is not primarily the responsibility of this Council, the following facts regarding the admission to Emergency Medical Services beds will be of interest. 61 air raid casualties were admitted, of which one case was dead on arrival, while another, which arrived in a moribund condition, died shortly afterwards. Of these cases, 54 were discharged (12 of them within 24 hours of admission leading 5 air raid casualties in hospital at the end of the year. The Emergency Medical Services section was also concerned with the treatment of 288 cases transferred from the Central London and other hospitals, and 111 services patients,. MATERNITY AND CHILD WELFARE. Three Health Centres which had been used 3ince the commencement of the war solely as First id Posts were re-opened in January as Health Centres and have since continued to act in a dual capacity. In June it was possible to re-establish the Child Welfare Centre held weekly at Frith Manor School, woodside Park; this had been abandoned since the outbreak of war owing to lack of accommodation, Despite a certain amount of emigration of the population the Health Centres continued to be well attended and over 50,000 attendances were made at the Child Welfare sessions. 9. Contrary to expectations the health of the toddler was not much affected by war conditions. There was no serious epidemic and no real hardship in the food rationing. In July the Government scheme for the provision of milk at cheap rates bo expectant and nursing mothers and young children and the revision of the Council's economic scale for supplying accessories, such as cod liver oil find other vitamin containing foods did much towards supplying any deficiencies in diet. After the bombing began, however, many of the children spent considerable periods of time in shelters or in the shelter rooms in their own homes, In other oases young children and babies had to do the best they could to sleep with lights burning in vitiated and anything but a quiet atmosphere. Certain of the children were bound to suffer from these conditions and this was shown by such symptoms as irritability, loss of appetite, etc. Many of these cases were found to be the reflection of parental anxieties. where the parents showed confidence and self possession in the presence of the children the latter did not lose their sense of security; they slept through a great deal of noise and accepted the conditions as being unavoidable. The position as regards the children under one year of age was not so favourable and reference has been made in a previous section to the increase in infantile mortality. The cause of this is largely speculative; it was distributed fairly evenly throughout the year and therefore did not point to shelter life or overcrowded sleeping conditions as being the main factor, but pre-natal conditions may have had some influence. The ante-natal mother is undoubtedly more affected by war conditions than any other civilian, as she has the double anxiety for her own immediate future and the welfare of her family, There may also have been a certain deficiency in her physiological requirements in protein, iron, calcium and the vitamins; for a diet sufficient for the individual may have proved inadequate for the double purpose of nourishing the mother and at the same time building up a healthy baby. Above all other foods milk contains the largest percentage of the elements required and the Government scheme for the provision of milk at reduced prices was based on e. realisation of this fact, and should milk supplies become seriously restricted every step should be taken to 10. ensure that the expectant mother is provided with a generous supply. The ante-natal clinics continued to be well attended, 1033 mothers being supervised during their pregnancy. It may be of interest to note that 305 births were successfully conducted by the Council's Fidwives and 142 by the Watling & District Nursing Association under the arrangement made with the Borough Council, I should like to take this opportunity of thanking the voluntary workers at the Child welfare Sessions for their continued interest and assistance and also the Civil Defence personnel at these Health Centres who have been of considerable assistance and took a keen interest in the varying activities. school judical services. By the beginning of 1940 it was possible to re-establish the School Medical Services practically to their full capacity, the only exception being that of the orthoptic treatment of squint, and this was re-established in April. The difficulties occasioned by staff changes made it appear at one time that come curtailment of the School Medical Services would become inevitable. This was envisaged in Board of Education Circular 1523 - I am glad to say, however, that this eventuality never actually occurred and it was possible to maintain a complete service throughout the year, Arrangements with the Middlesex County Council for the medical examination and treatment of visual and dental defects for children attending secondary schools was continued, the number of children being increased by those attending at the Hendon Technical Institute, In addition it was possible to persuade the bounty Council to agree to certain other forms of treatment where this was considered necessary by the examining doctor. The outbreak of war gave rise to the apprehension that an increasing cost of living and the subsequent rationing of certain foodstuffs might result in a lowering of the nutritional standard of the children,. For this reason Doctors, Health Visitors and Teachers were asked to be on the look-out for any deterioration which might take place. This was followed in June by an ad hoc Nutritional Survey of all the children then attending the elementary schools, with the following results:- 11. Number of Children CLASSIFICATION. Surveyed. Normal Slightly Sub-normal Bad Sub-normal 10,781 9618 765 322 76 89.21% 7.10% 2.99% .70% As a result of this survey 368 children were recommended for a mid-day meal, the nutritional classification of these children being as follows:- Normal Slightly Sub-normal Bad TOTAL sub-normal 2 127 102 57 368 It can he generally said that so far there is no evidence that a deterioration is taking place but the Council have, in view of the exceptional circumstances of the times, decided to inaugurate a scheme for the provision of solid moalc for- snob public elementary school children as are selected by the Medical Officer of Health and also to extend the Milk in School Scheme to cover holiday periods. In my opinion, however, it would he of great public health value if the provison of meals in schools could he extended to nil children attending school and continue in peace time. CASUALTY SERVICES. These services had not had a chance of proving themselves under war conditions until August, nevertheless every endeavour was made to maintain as high a degree of efficiency as possible by constant exercises, training in first aid and other subjects. One of the greatest obstacles to the creation of a really efficient service was the frequent changes in personnel necessitating new recruitment and a constant repetition of training. Thi3 was, of course, not local but was taking place throughout the country generally and it was realised by all who hnd administrative responsibility that it was creating difficulties in establishing a really adequate and efficient service. Fortunately an order was ultimately made reserving male personnel who can now only transfer to other occupations at the discretion of local controllers, and this legislation was eventually applied to female personnel. I believe it will he generally admitted that the services not only here but throughout the country have functioned extremely well, despite 12. the numerous handicaps which were imposed on those who were responsible for building up these services from their beginnings. STAFF, The following changes in staff took place during the year:Resignations. (Full-time Officers) Medical Staff. Dr. K. S. Stalker, Resident Medical Officer, Isolation Hospital - resigned on account of ill health. Dr. K, M. Bodkin, Assistant Medical Officer of Health - resigned upon her appointment as Assistant Medical Officer to the Birmingham Education Committee. Dr. J. N. Morris, Assistant Medical Officer of Health - resigned on his appointment to the Harrow Urban District Council. Part time Officers. Mr. J. H. Seddon, Orthopaedic Surgeon - appointed Nuffield Professor of Orthopaedics at Oxford University. In addition Dr, J. M. MacLennan was, at the request of the Ministry of Health, seconded for duty as a Regional Medical Officer. Mr. J. G. Milner, F. R. C. S. , Ophthalmic Surgeon, and the following members of the clerical staff, .joined H. M. Forces: - Mr. B. F. Higham. Mr. R. Betteridge. Mr. A. B. Reynolds. Mr. R. Penteney. Appointments. Dr. M. F. Coveney, Assistant Medical Officer of Health. Dr. J. Gastrell-Lewis, Assistant Medical Officer of Health. Mr. W. H. Gordon, part-time Ophthalmic Surgeon. Mr. J. H. Cholmeley, part-time Orthopaedic Surgeon. These changes in staff occurred at a time when the social services were being fully re-established and additional work and responsibility inherent in a war time public health administration were being undertaken. It will be evident that this could only have been accomplished by the loyal co-operation of the remaining members of the staff who have been quite unselfish in their devotion to duty and have undertaken the additional work and responsibilities with enthusiasm mid I would like 13. to take this opportunity of expressing my gratitude for the spirit which they have shown throughout. In conclusion I wish to thank the Members of the Council for their help and encouragement during a difficult year. I have the honour to be, Mr. Mayor, Ladies and Gentlemen, Your obedient servant, A. FAIRGRIEVE ADAMSON, Medical Officer of Health. '