REPORT ON THE HEALTH OF THE Borough of Lambeth DURING THE YEAR 1948 (92nd Annual Report) BY A. G. G. THOMPSON, M.A., M.D., B.C., D.P.H. Medical Officer of Health London: Truslove & Bray, Ltd. Printers and Bookbinders West Norwood, S.E.27 2 Borough of Lambeth Public Health Committee (Appointed by the Council on the 9th November, 1948) HIS WORSHIP THE MAYOR (Mr. Councillor J. W. Simpson, A.Inst.L.M., J.P.) Ex-Officio Aldermen: Mrs. Alderman E. S. Barnes, J.P. Mr. „ G. K. Rettie Councillors : Mr. Councillor T. Cleasby (Chairman) Mrs. „ A. W. Collins „ „ A. Coward, B.A. I. C. England Mr. „ A. W. Fisher Mrs. „ C. E. Hall (Vice-Chairman) „ „ M. M. O'Connell „ „ F. L. Payne Dr. ,, H. J. Powell, M.R.C.S., L.R.C.P., L.M.S.S.A., L.C.C. Mr. „ R. C. Mellish. „ J. H. Waller „ „ G. Woodgate, J.P. 3 To the Mayor, Aldermen and Councillors of the Metropolitan Borough of Lambeth. Your Worship, Ladies and Gentlemen, I have the honour to present to you the 92nd Annual Report on the health of the Borough of Lambeth. In 1857 the work of the Medical Officer of Health, William Odling, M.B., M.R.C.P., F.R.S., and two inspectors of nuisances, who were the entire staff of the Public Health Department, was recorded on two of the pages of a 27-page Annual Report of the Proceedings of the Vestry of Lambeth. By the time George Puckle, M.D. (1863-71) was appointed Medical Officer of Health the report had been enlarged to nine pages, recording the nuisances abated and the births, deaths and epidemic diseases in the year. M. J. McCormack, M.B. (1871-76) succeeded George Puckle and was followed by Archer Farr (1876-81), Firth Groves (1881-83) and H. Walter Verdon, M.D., F.R.C.S. (1883-1894). The Annual Report for 1894 had by this time grown to a 112-page document, but still confined to vital statistics, epidemic diseases and the improvement of environmental conditions. It was not until my predecessor in office, Joseph Priestley, B.A., M.D. (1895-1927) had been Medical Officer of Health for a number of years that any expansion of the Council's Public Health activities was extended to the personal health services. It was in 1899 that the bacteriological laboratory was set up, and utilised no doubt with grave misgivings at first by the medical profession. The first of the direct personal services was the milk depot established in 1905, which supplied pasteurised diluted cows' milk suited to the needs of infants of various ages, mainly in the Guardians' Hospital of St. Mary's, Brook Drive. This was followed after considerable debate in the Council by the temporary appointment for one year of a " female health visitor " at £80 per annum, who started on 1st January, 1906. From those two small ventures grew the Lambeth Maternity and Child Welfare scheme, which had at one time the equivalent of fifteen welfare centres, a maternity home and, later, nine nurseries. The scheme was closely linked with almost all the large hospitals in London, and rightly took much of the credit for the reduction of infantile mortality from 127 per 1,000 live births to the present rate of 27 for 1948. The whole of the Council's Maternity and Child Welfare scheme was handed over, together with the administrative staff, as a going concern on the 5th July, the appointed day, to the County Council, while the two tuberculosis dispensaries were curiously divided between the County Council and the South Western and South 4 Eastern Metropolitan Hospital Boards. With these services went the whole of the files and records, so that it is not a practical possibility to report upon the activities of the Council's scheme for the first part of the year before the appointed day. After the appointed day the County Council were fortunately able to arrange accommodation in the Town Hall for much of the transferred staff, which is a great convenience to the inhabitants of all but the most northern part of the district who might otherwise be forced to make their inquiries in person to the Divisional office in Brook Drive. This has made the task of day-to-day administration of the transferred services by your Medical Officer of Health on behalf of the County Council much easier. The report will be found, therefore, to deal only with the environmental services, as these are the only matters with the exception of epidemic disease for which the Council now have any responsibility. Broadly, the effect of the National Health Service Act, 1946, has been to take from the local authorities all the work connected with hospitals, and in effect to nationalise that side of the work, to take from the local sanitary authorities all the personal services of preventive medicine and hand them to the major local authorities, the County Councils and County Borough Councils, renaming them Local Health Authorities for the purpose and to leave only the environmental services with the local sanitary authorities. Unhappily for Public Health, of the 80 sections of the new Act, a mere twelve deal with preventive medicine, and they are dwarfed between the two giants for disease treatment, the Hospital and Specialist Services on the one hand, and the General Practitioner and ancillary services on the other, with the handicap and burden of having the duty of providing among other matters for the nursing and other requirements for cases from both hospitals and general practitioner nursed at home. In times of stress obviously preventive medicine staff will be used to supplement curative nursing staff for whose services weekly payments in advance have been made by patients who have up till now shown every intention of getting value for their money. It seems unlikely that the art of preventive medicine which was raised to such heights in the war, particularly in Burma, will be able to hold its true place in promoting the welfare of the people until the swing of the pendulum brings prevention to the foreground to take its rightful place in front of that which treatment of disease new occupies so prominently. The health of the borough as indicated by the statistics to be found in the report has not suffered in the least as the result of the transfer of services which, considering the extent of the change, is 5 a good augury for the future. The population has increased by roughly 3,000, and at 226,600 is well above the number 215,000 envisaged in the County of London Plan. Both the birth rate and the death rate have fallen, maternal mortality is down almost to vanishing point at 0.23, while the infantile mortality at 27, shows in dramatic fashion how times have changed since the "temporary female health visitor " was appointed in 1906. Great changes always cast additional burdens upon the shoulders of those responsible, and the staff of the Public Health Department responded cheerfully to the challenge. My best thanks are again due to them as well as to the other chief officers, to the Public Health Committee, and to many other members of the Council. I am, Mr. Mayor, Ladies and Gentlemen, Your obedient Servant, (Signed) A. G. G. THOMPSON. July, 1949 6 STAFF OF THE PUBLIC HEALTH DEPARTMENT AT 31st DECEMBER, 1948 MEDICAL OFFICER OF HEALTH A. G. G. THOMPSON, M.A., M.D., B.C. (Cantab), D.P.H. PUBLIC ANALYST (Part Time) A. H. MITCHELL MUTER, F.I.C., F.C.S. ACTING CHIEF ADMINISTRATIVE ASSISTANT H. P. WRIGHT CLERICAL STAFF A. W. Bayley, E. F. Mannerson, G. M. Conlon, N. Jupp, Mrs. G. Hopkins, Mrs. M. Partridge, V. W. Edgar, J. Ellis, Mrs. I. Warton SANITARY INSPECTORS (a) District Inspectors : S. G. Ford, Cert. S.I.E.B. (Meat and Other Foods) J. Bowers, Cert. S.I.E.B. (Meat and Other Foods and Smoke). J. Holland, Cert. S.I.E.B. (Meat and Other Foods) S. G. Starling, „ ,, „ „ J. Smith, „ „ „ ,, T. Lloyd, „ „ „ „ R. G. Cutler, Cert. S.I.E.B. H. F. Bryan, „ „ A. E. White, „ „ „ „ J. Baillie, „ „ „ „ *A. E. French, „ „ „ „ *E. E. Morgan, * Seconded for Re-housing. (b) Food Inspectors: S. Bradley, Cert. S.I.E.B. ,, „ C. W. Idle, „ „ „ „ (c) Housing Inspectors: B. Good, Cert. S.I.E.B. „ „ F. J. Heffield, (id) Rodent Officer : S. F. Heal, Cert. S.I.E.B. „ „ (e) Women Inspectors : Miss L. E. Auger, Cert. S.I.E.B. S.C.M., H.V.Cert. Miss A. F. Crombie, „ „ „ 7 DISINFECTING STATION Wanless Road, Loughborough Junction, S.E.5. Superintendent: H. Wrigley GENERAL ASSISTANT H. Piggott Assistant Rodent Officer: W. Deamer Rodent Operative : R. N. Redstone 8 STATISTICS AND SOCIAL CONDITIONS Summary of Vital and Mortal Statistics, etc. (The comparable figures for the previous year appear in brackets) Area of Borough.—4,083 statute acres (inclusive of land and inland water, but exclusive of tidal water and foreshore), divided into 4 Registration Sub-Districts, 4 Parliamentary Divisions, and 12 Wards. The Parliamentary Divisions and Registration Sub-Districts have been adjusted so that they and the Wards are co-terminus. Population—estimated, 1948—226,600 (223,670). Density—55.5 (54.78) persons per statute acre (inclusive of land and inland water, but exclusive of tidal water and foreshore.) Births (corrected)—4,311 (5,166). Birth rate per 1,000 estimated resident population corrected 19.02 (23.10). Deaths (collected)—2,508 (2,917). Death rate per 1,000 estimated resident population, 11.07 (13.04). Maternal mortality (corrected) per 1,000 total births (live and still), 0.23 (1.51). Infantile mortality, 27 (32). Zymotic Death-rate (corrected)—0.13 (0.14) per 1,000 population (total zymotic deaths, 29 (33) ). Marriages. Marriage rate per 1,000 population, 9.66 (10.41). Rateable Value at 1st April, 1948—£2,080,399 (£2,218,284) Sum represented by 1d. rate—£8,901 (£8,662). Comparable rates for England, and Wales and London:— Emeland and Wales London Birth rate 17.9 (20.5) 20.1 (22.7) Death rate 10.8 (12.0) 11.6 (12.8) Infantile mortality 34 (41) 31 (37) Puerperal causes 1.02 (1.17) not available 9 Vital Statistics The population of the Borough of Lambeth for the year 1948 has been estimated by the Registrar General to be 226,600, which is greater by 2,930 than the official estimated population of 1947. The following table shows both actual numbers and the percentages of total deaths in the various age groups. It is of interest to note that the number of deaths in the age period 65 and over was more than 62 per cent. of the total deaths. The prolongation of life brings into greater prominence the difficulties facing old people who have lost their near at hand relatives and friends and are all alone in the world. Their numbers are still increasing year by year and their problems likewise. The principal causes of death were heart disease which claimed 707 or 28.19 per cent. of the total deaths, and cancer 488 or 19.46 per cent., and influenza, bronchitis and pneumonia 308 or 12.28 per cent. All ages 0-1 1-5 5-15 15-45 45-65 65 and over 2,508 118 29 12 198 585 1,566 100 per cent. 4.70 per cent. 1.16 per cent. 0.48 per cent. 7.89 per cent. 23.33 per cent. 62.44 per cent. During the year the number of births corrected by inward and outward transfers was 4,311, giving a corrected birth rate of 19.02, compared with 23.10 in 1947, a decrease of 4.08 per 1,000 population. Maternal Mortality The maternal mortality is expressed as the number of deaths attributed to puerperal and post-abortive sepsis and other maternal causes for each 1,000 live births. Maternal deaths numbered 1, giving a rate of 0.23, compared with 1.51 in 1947. Causes of, and Ages at, Death (Corrected) During the Year 1948 Mortality 13.04 (12.87) Causes of Death Ages—Both Sexes Totals Under 1 year 1 and under 5 years 5 and under 15 years 15 and under 45 years 45 and under 65 years 65 and upwards M. F. 1. Typhoid and Paratyphoid - - - - - — 2. Cerebro-spinal Fever 1 2 — — 1 1 1 4 3. Scarlet Fever - - - - - - - - 4. Whooping Cough 2 — — — — — 2 - 5. Diphtheria — 2 — — - 23 1 1 6. Tuberculosis, respiratory system 1 — — 64 40 28 78 50 7. Other Tuberculosis — — 2 3 - 2 3 4 8. Syphilitic diseases — — - 1 10 4 10 5 9. Influenza 1 — - 2 1 10 11 3 10. Measles 2 2 — - - - 2 2 11. Ac. Poliomyelitis and Polioencephalitis — — — - - — — - 12. Ac. Infectious Encephalitis(Lethargic) - — 1 - 3 — 3 1 13. Cancer, Buccal Cavity and Oesophagus (M.) — — — 5 18 27 21 29 Uterus (F.) 14. Cancer, Stomach and Duodenum — — — 3 28 56 49 38 At 15. Cancer, Breast — — — 8 15 20 - 43 16. Cancer, all other sites — 4 — 13 126 165 189 119 17. Diabetes — — — 1 3 8 2 10 18. Cerebral Vascular Lesions — — — 4 44 190 190 129 19. Heart Disease - - - 24 163 580 349 358 20. Other Circulatory Diseases - - - 5 35 76 61 55 21. Bronchitis 5 1 2 3 35 131 126 51 22. Pneumonia 15 6 1 4 22 69 126 54 23. Other respiratory diseases - - - - 15 11 63 11 24. Ulcer, Stomach and Duodenum - - - 5 14 24 25 18 25. Diarrhoea (under 2 years) 20 1 - - - - 8 13 26. Appendicitis - 1 - 1 1 2 4 1 27. Other Digestive diseases - 2 - 2 12 28 27 17 28. Nephritis - - 1 6 11 28 23 23 29. Puerperal and Post Abortive Sepsis - - - - - - - - 30. Other Maternal Causes - - - 1 - - - 1 31. Premature Birth 23 - - - - - 13 1 32. Congenital Malformations, Birth Injury, Infantile diseases 42 - 1 2 3 4 37 10 33. Suicide - - - 7 9 11 17 15 34. Road Traffic Accidents - 1 1 3 6 5 15 10 35. Other Violent Causes 4 2 - 12 7 24 21 1 36. All other causes 2 5 3 19 23 67 55 64 Total All Causes 118 29 12 198 585 1,563 1,340 1,168 10 11 12 Birth-rates, Civilian Death-rates, Analysis of Mortality and Case rates for certain Infectious Diseases in the year 1948 Provisional Figures based on Weekly and Quarterly Returns England and Wales 126 C.Bs. and Great Towns including London 148 Smaller Towns Resident Population, 25,00050,000 at 1931 census London Administrative County Lambeth * Rates per 1,000 Civilian Population : — Live Births 17.9† 20.0 19.2 20.1 19.0 Still Births 0.42† 0.52 0.43 0.39 0.34 Deaths: All Causes 10.8† 11.6 10.7 11.6 11.07 Typhoid and Paratyphoid 0.00 0.00 0.00 0.00 — Pneumonia 0.41 0.38 0.36 0.54 0.51 Whooping Cough 0.02 0.02 0.02 0.01 0.00 Diphtheria 0.00 0.00 0.00 0.01 0.00 Influenza 0.03 0.03 0.04 0.02 0.06 Smallpox 0.00 0.00 0.00 - - Tuberculosis 0.51 0.59 0.46 0.63 0.56 Acute Poliomyelitis and Polioencephalitis 0.01 0.01 0.01 0.00 - Deaths under 1 year of age Rates per 1,000 Live Births:— 341 39 32 31 27 Deaths from Diarrhoea and Enteritis under 2 years of age 3.3 4.5 2.1 2.4 4 9 * A dash (—) signifies that there were no deaths, † Rates per 1,000 total population. ‡ Per 1,000 related births. 13 Sanitary Circumstances of the Area Sanitary Inspectors. Total number of inspections 13,068 Total number of reinspections 34,272 Total number of intimation notices served 7,390 Total number of nuisance notices served 2,430 Women Sanitary Inspectors. Total number of visits and inspections (factories, workplaces, infectious disease, etc.) 2,455 Total number of revisits 256 Total number of intimation notices served 99 Workshops in which defects were found 141 The difficulties encountered by the owners of property were eased to some extent by the relaxation on the 1st July of the need to obtain building licences for works estimated to cost under £100 for each dwelling, replacing the previous limit of £2 a month for each dwelling. Materials and labour have also generally been less scarce, although certain things like zinc sheeting are still almost unobtainable. The cost of repairs, however, is out of proportion to the general rise in the cost-of-living, a pre-war £60-70 repair now requiring an expenditure of £200 and more. The fact that rents are controlled at pre-war prices is putting a severe, sometimes intolerable, strain upon owners of property, particularly upon those whose savings for old age have been invested in a few small houses or cottages and who now find their meagre incomes after taxation swallowed up by the excessive cost of repairs. Many premises are still being patched and patched again which are really beyond repair, owing to the great need to conserve anything which does in any measure relieve the strained housing position. New homes are rising slowly, and only 455 were erected during the year, which go such a little way among the fourteen to fifteen thousand applicants still waiting for homes of their own. It is fortunate that there have been no severe weather strains cast upon the old property, because much of it seems to be held together by the mere fact of being occupied, and excessive stress might well tip the scale in many instances. 14 Scabies and Verminous Persons Cleansing Centre. At the end of the war the Council agreed, in principle, to adapt the disused mortuary at Wanless Road for use as a cleansing station owing to the increased demand for facilities which had been, and still are, met. through the goodwill of the adjoining Boroughs of Southwark and Battersea, whose premises are placed at the disposal of Lambeth residents. The service at both is free to the individual, the Lambeth Council defraying the expense. A total of 630 persons were treated at the cleansing station and given 950 treatments, compared with 1,076 persons treated in the previous year. There has again been a noticeable fall in the number of cases of scabies notified, 125, compared with 310 in 1947, 758 in 1946 and 851 in 1945. More settled conditions of life and modern treatments have both conduced to this end. The continued reduction in the incidence of both scabies and head lice makes the adaptation of the mortuary less necessary, and as the treatment of scabies is really now as much a matter for either the regional hospital board or the local executive council as for the borough council, the adaptation may well be postponed indefinitely. National Assistance Act, 1948 Section 47. This section replaces section 224, Public Health (London) Act, 1936, and alters slightly the powers under which a Local Authority may obtain an order in court for the compulsory removal and detention in hospital or other suitable institution of persons in need of care and attention. Whereas it was necessary to obtain the permission of the County Council for admission to a municipal hospital, now the consent of either the South Eastern or South Western Metropolitan Regional Hospital Board must be obtained for a hospital bed, depending upon which side of the dividing line the address of the person happens to be, whereas if no therapeutic treatment is needed but only institutional care and attention is required, the County Council are the authority whose duty it is to provide a bed. It is in either event the duty of the County Council to take reasonable steps to prevent loss or damage to the movable property of the person removed, and in general the legal requirements are more involved than they were before the appointed day. During the year one case was removed under section 224, and after the appointed day another under section 47. 15 Section 50. Under this section it is the duty of the borough council to make arrangements for the burial or cremation of the body of any person who has died or been found dead in their area and for whom no suitable arrangements are being made. The council may recover the cost from the estate, but in many cases the assets are so small that the cost falls almost entirely upon the rates. Some, however, die possessed of assets which more than cover the cost of the funeral, and of these particulars are forwarded to the Treasury Solicitor. All furniture and personal effects are stored until authority is obtained for their disposal. The work entailed in making all the funeral arrangements, in collecting the effects, and claiming on the insurance policies, is considerable, but, fortunately, the winter season was mild and the number of bodies was only 70 up to the end of the year, males 55, females 12 and stillborn 3. Of these 41 resided outside the district but died in a hospital, an institution or elsewhere in Lambeth. The cost to the Council was about £536, which will be reduced when the effects have been realised. Fortunately, this work has been greatly reduced since the 9th March, 1949, by a Ministry circular which enables the regional hospital boards and the County Council to arrange for the burials of the bodies of all persons dying in their hospitals or institutions which are reasonably straightforward cases; where, however, the cost of burial is not leadily recoverable from the person liable, the borough council assume all responsibility for the disposal of the body and the recovery of the expenditure. Rat Infestation During the year 1948, 826 complaints have been investigated. Of these, 572 were found to be brown (common) rats, 26 black (ship) rats, 102 mice, and 126 were found to be not justified; 1,130 baitings were carried out, and in 116 cases defective or disused drains were found to be the cause of infestations and were dealt with by the Borough Engineer and the Sanitary Inspectors. One major infestation has been completely cleared after having been treated for many years by various ratting companies. No other major infestations have come to light during the year. There has been a further reduction in the number of black rat infestations, and in no case has the infestation been of a serious character. This type of rat is still confined to the northern end of the Borough. Once again, two separate sewer treatments with poison have been carried out by the Borough Engineer's department. The Borough Engineer's staff have continued to be most helpful 16 in the examination of sewer and suspected defective drainage connexions, and many disused connexions have been sealed. The examination of sewers and sewer connexions has involved close co-operation with the staff of the Borough Engineer's department, and the success attained in the never-ceasing campaign against rats has been due in no small measure to the cordial relationship which has existed for many years between the staffs of the two departments. Rehousing and Overcrowding 2,744 cases were examined and reports sent to the County Council with copies to the Borough Council's rehousing department. Of this number, 811 Orange forms (overcrowding) were forwarded to the County Council and 264 preferential forms on medical grounds. For the Council's housing department priority recommendations numbered 99 and no preference 123. Information upon 83 cases was forwarded to other districts. Cases not overcrowded and without need for preference numbered 790, deferred cases for which no immediate grounds for giving preference was possible were 111. The 164 remaining cases were those in which no change in circumstances was discovered on revisiting. As a result of these activities the County Council rehoused during the year 258 Orange form and 41 preferential cases. Inspection and Supervision of Food This part of the report deals with the work carried out by the Food Inspectors under The Food and Drugs Act, 1938, The Public Health (Meat) Regulations, 1924, The Milk (Special Designations) Regulations, 1936-1946, and The Ice Cream (Heat Treatment., etc.), Regulations, 1947. 1. Sampling of Food and Drugs. (a) For chemical analysis. Number procured formally 211 Number procured informally 1,764 Of the 211 formal samples, 191 were of milk, 5 of which were adulterated (representing 2.6 per cent. of the number of formal milk samples procured). 17 Six samples were the subject of legal proceedings, particulars of which are set out below. Table 1 Sample No. Subject of Prosecution Nature of offence Result of Prosecution Fines Costs £ s. d. £ s. d. 15 Milk 9 per cent. added water Summons withdrawn on account of death of defendant 29 Milk 21 per cent. added water Convicted 2 0 0 3 3 0 33 Milk 11 per cent. added water Convicted 12 12 0 4 0 0 62 Zinc Ointment 17 per cent. deficient in zinc oxide Convicted 3 0 0 5 5 0 78 Milk 5 per cent. added water Convicted 5 0 0 3 3 0 216 Milk 8 per cent. added water Convicted 5 0 0 2 2 0 (b) For bacteriological and other examinations. The following tables show the number and types of samples submitted for bacteriological and other examinations:— Table 2 Bacteriological Examinations Ice Cream and Ice Cream Mix 161 *Egg Albumen 2 *Icing Sugar 1 *Fondant 1 *Jam 1 *Castor Sugar 1 *Fish 1 *Wedding Cake 2 *Meat Gelatine 2 *Hors d'oeuvre 1 *Salad Cream 1 *Cider 1 *Cream, Synthetic 1 *Cream Doughnut 1 *Piping Bag 1 *Marshmallow 1 *Rabbit, Canned 1 *Faeces 3 Spam 2 Milk Bottle Rinsings 2 Milk 1 Total 188 18 With regard to Table 2, the articles marked with an asterisk were suspected to have caused food poisoning. In the case of two of the foods set out above (wedding cake and cream doughnuts) organisms likely to cause food poisoning were isolated. The outbreak of food poisoning which resulted from the consumption of the cream doughnuts, affected 93 people and is fully described in the following report which is extracted from the Minutes of the Council. Food Poisoning: Bacillus Aertrycke Infection. The following report, which has been submitted to us by the Medical Officer of Health, indicates the ease with which infection can be widely spread in a community by lack of attention to the maintenance of the ordinary standards of cleanliness:— On the 18th May last, a report was received that four inmates of St. Giles' Hospital were suffering from food poisoning, the suspected source of the infection being cream buns purchased at a local baker and confectioner's shop on the 15th May. Samples of synthetic cream were taken for bacteriological examination, but there was nothing to indicate whether this was from the same batch as that sold on the previous Saturday. No access could be gained to the home address of the patients, as they were all ill in hospital and so no other line of inquiry could be opened. On the 19th May two children in the Belgrave Hospital were reported to have eaten ice lollies on the 15th May, and to have been taken ill the same evening. Inquiry disclosed that these children, however, had also eaten cream buns from the confectioner implicated, and that the third child in the family who had not been affected ate an ice lolly but no cream bun, which was a valuable indication that the direction in which inquiries were being pursued was the right ore. There was no history oi sickness or diarrhoea among the staff employed by the baker. A piping bag and further samples were taken for examination from the baker with the object of checking the possible sources of infection. On the 19th May and following days, thirty-four cases were notified by medical practitioners in Lambeth, thirty-six cases by other persons, and twenty-three cases were reported to have occurred outside the district, making a total of ninety-three. In every case the food incriminated was synthetic cream in buns, eclairs and similar articles purchased from the one confectioner on the 15th May and eaten either that day or a day or so after. On the 20th May bacillus aertryche was isolated from the sample of cream taken on the 18th May, so further inquiries were then 19 made at the bakery, when it was learned that one of the staff had been absent from work since the week-end suffering from an illness similar to the cases of food poisoning already notified. It was thought likely that he might have been the origin of the infection, but as a precaution, samples of excreta from all the other bakery staff were obtained for bacteriological examination. This was fortunate, as bacillus aertrycke was isolated from one of these samples. Meantime both St. Giles' and Belgrave Hospitals reported that the same organism had been found in the stools of the patients nursed there. The baket was asked to suspend his employee until certified fit to return. The bacteriological reports upon the piping bag and samples of cream taken on the 19th were received on the 24th May, in which the bag was shown to be infected and was therefore presumably the one used on the 15th May to fill the cream buns and eclairs. Samples of other ingredients used in the bakery were all found free from the infection. The deductions which can safely and logically be drawn are that the faecal carrier of bacillus aertrycke employed in the bakery infected the synthetic cream which conveyed the infection to the ninety-three cases of food poisoning. In order to limit and, if possible, prevent a second crop of infections, information of the outbreak was sent to the medical officers of health of other districts. Information was obtained in Lambeth that some of the victims were themselves engaged in various food distributive trades, handling food for human consumption. Employers were advised to stand these off work until ceitified by their doctors to be fit to return to duty with safety to others. The incubation period varied from seven to over sixty hours and the duration of illness from seven to fourteen days. There were fortunately no deaths, but the more severe cases were completely prostrated in the early days, and the measure of the misery and anxiety to the relatives as well as to the sick can be better imagined than assessed. Bacillus aertrycke used to be associated almost exclusively with duck eggs at one time, but with the great increase in communal feeding during the war years and since, it has been proved again and again to be the cause of food poisoning outbreaks behaving like bacillus paratyphosus B, which has been in the past responsible for innumerable outbreaks caused by lack of ordinary cleanliness in the preparation of food for others by carriers who are seldom aware of their condition until proved to be the originators of an epidemic. The Public Health (Infectious Diseases) Regulations, 1927, empower a local authority to forbid an employer to permit a carrier of enteric or dysentery to work in a business which entails the 20 handling by him of food for human consumption. There is no similar legal authority to enable the like measures to be taken against a carrier of bacillus aertrycke or other salmonella organism. The Medical Officer of Health has suggested to us that some such power should be available, and that the Minister of Health should be approached to that effect. He is of opinion, however, that greater success would follow if the public conscience were awakened to the extreme laxity which exists almost everywhere in connexion with the various food trades. In some of the United States of America and notably in Guildford in this country the trades concerned have put their own house in order by adopting a high standard of cleanliness in restaurants and cafes, and maintaining that standard in order to qualify for the appropriate certificate to hold it. Customers were soon educated to avoid all establishments which could not or did not qualify, and there is no reason why there should not be a much wider application of this movement towards what is no more than a reasonable standard of cleanliness; nothing impossible is asked of the ordinary employee, nothing even difficult, but it would entail a routine washing drill and some education of both staff and public in the simple elements of hygiene. We concur in this opinion and have asked the Medical Officer of Health to prepare a scheme for Lambeth upon which we will submit a further report in due course. With regard to the extension of the powers conferred upon the Council by the Public Health (Infectious Diseases) Regulations to carriers of bacillus aertrycke or other salmonella organism, we strongly support the suggestion of the Medical Officer of Health, and accordingly recommend— That the Minister of Health be asked to extend the powers conferred upon the Council by the Public Health (Infectious Diseases) Regulations to cover carriers of bacillus aertrycke or other salmonella organism, and that the Metropolitan Boroughs' Standing Joint Committee be asked to support the Council in this request. Adopted Following the outbreak of food poisoning consultations were held with representatives of food traders' organisations in the borough with the object of preventing similar outbreaks in the future. By the end of the year matters were well advanced, and a report had been prepared which provided a basis for founding an association for promoting the hygienic handling of food. In the appendix will be found copies of the Articles of the Lambeth Clean Food Association, of the certificate issued, and of the code of practice to which all applicants must subscribe. 21 There have been few applicants so far, mainly because the statutory obligations defined in section 13, Food and Drugs Act, 1938, only came into force on the 1st October, 1939, after the outbreak of war so that there was little time for tradesmen to digest and appreciate the effect of the section, while it has been out of the question during and since the war to make the alterations. Improvements are expensive, labour materials and licences difficult to obtain, so that it is readily understandable how few businesses are, in fact, ready for an application to be made. Conditions are everywhere steadily improving, but there is still much to be done. The general public can help by insisting upon a high standard of cleanliness, and employers and employees can do their part, even with unsatisfactory conditions and surroundings, by taking a greater pride in always being scrupulously clean. Table 3 Milk Type of Test Samples. No. procured No. passing test No. failing to pass test Methylene Blue 49 46 3 Phosphatase 43 43 Nil 2. Inspection of Food. (a) At the slaughterhouse. 154 pigs. (b) At shops, stores and factories. Large quantities of food of all varieties. As a result of these inspections the following amounts of food were surrendered as unfit for human consumption and unsound food certificates were issued. (i) At the slaughterhouse. Tons cwts. qrs. lb. Pig carcases and organs — 1 2 27 (ii) At shops, stores and factories. Fresh meat, fish, poultry, vegetables, prepared and canned foods 42 9 — — Wedding cake weighing 7f lb. unfit for human consumption was seized and taken before a justice, who made an order for condemnation and destruction. In appropriate cases the unsound food was disposed of for animal feeding either through the Salvage Division of the Ministry of Food or this Council's Salvage Scheme, including the Zoological Gardens. 22 Home Office Table Factories, and Other Premises. 1.—Inspections for purposes of provisions as to health Including inspections made by Sanitary Inspectors. Premises Number of Inspections Written Notices Occupiers prosecuted (1) (2) (3) (4) Factories : With mechanical power 330 28 - Without mechanical power 157 10 - Other Premises under the Act (including works of building and engineering construction but not including outworkers' premises) 61 4 Total 548 42 - 2.—Defects Found Particulars Number of Defects Number of defects in respect of which prosecutions were instituted Found Remedied Referred to H.M. Inspector (1) (2) (3) (4) (5) Want of cleanliness (S. 1) 69 51 — — Overcrowding (S. 2) 1 1 — — Unreasonable temperature (S. 3) 1 1 Inadequate ventilation (S. 4) 1 1 — — Ineffective drainage of floors (S. 6) — - Sanitary Conveniences (S. 7) : Insufficient 1 1 — — Unsuitable or defective 68 45 — — Not separate for sexes 3 2 — — Other offences (Not including offences relating to Home Work or offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers) Order, 1921, and re-enacted in the Third Schedule to the Factories Act, 1937) 48 30 Total 192 132 — — 23 Outwork in Unwholesome Premises Nature of Work Instances Notices served Prosecutions (1) (2) (3) (4) Wearing Apparel— Making, etc. 97 - - Cleaning and washing - - - Household linen 3 - - Lace, lace curtains and nets — - - Curtains and furniture hangings — - - Furniture and upholstery — - - Electro-plate — - - File making — - - Brass and brass articles — - - Fur pulling — - - Cables and chains — - - Anchors and grapnels — - - Cart gear — - - Locks, latches and keys — - - Umbrellas, etc. - - - Artificial flowers 2 - - Nets, other than wire nets - - Tents - - - Sacks — - - Racquet and tennis balls — - - Paper, etc., boxes, paper bags 29 - - Brush making — - - Pea picking — - - Feather sorting ... ... — - - Carding, etc., of buttons, etc. 2 - - Stuffed toys - - — Basket making — - - Chocolates and sweetmeats — - - Cosaques, Christmas crackers, Christmas stockings, etc. 4 Textile weaving — - - Lampshades 28 - - Fancy articles, pin cushions, milk bottle covers, etc. - Stringing cotton bags — - — Pot scourers — - - Total 165 — — 24 Water Section 95, Public Health (London) Act, 1936 The number of new dwellings for which applications were received for certificates that a proper and sufficient supply of water had been installed was 455, relating to 140 dwellings erected by the Borough Council, 226 by the County Council, and 89 by private enterprise. The water supply for the area is provided almost entirely by the Metropolitan Water Board, but there are a few deep wells of which some supply water for purposes other than human consumption, while in a few cases the supply is used for potable purposes both for drinking on the premises as well as for the manufacture of beverages and for similar trade purposes. In these latter cases a comprehensive examination of the supply both bacteriological as well as chemical is made every three months at least, which is deemed sufficient for ample warning of any serious changes to be observed before there is danger to health. Prevalence and Control Over Infectious and Other Diseases The mortality from infectious disease was again comparatively insignificant, scarlet fever, 0, diphtheria 2, measles 4, and whooping cough 2. Measles is much less of a danger to life than it was between the wars. Whooping cough on the other hand seems to retain much of its virulence, the deaths in the ten years 1928-37 averaging 23.4 every year, highest 58 in 1929, and lowest, 2 in 1930. The accompanying chart shows the incidence of diphtheria since 1895, and shows that the dramatic fall began in 1939 before the outbreak of war and at least two years before the national scheme for immunisation had had time to be effective. The rate to which the incidence rose in 1942 might, however, have been much higher but for the success of the national campaign. The two deaths recorded were from faucial diphtheria, and the ages two years and four years. Measles has been notified in Lambeth since 1917, and the chart shows the extraordinary regularity with which epidemics occurred every other year up to 1939-40, and then when black-out conditions and the crowding caused by war might well have been expected to exact a heavier toll than usual the expected epidemic failed to appear for some reason which has not been explained. Now that the disease is getting into its stride again the chart indicates that, instead of a two-year there is a three-year cycle, but it would seem that the epidemics are spread over two years instead of beginning and ending in one calendar year. Although the incidence shows little change over the years, apart from the break in the early war period, the case mortality has fallen considerably. DIPHTHERIA INCIDENCE PER 1000 POPULATION (Lambeth) 25 Tuberculosis Notifications received during the year ended 31 st December, 1948 Respiratory 344 (339) Non-respiratory 25 (34) Deaths certified 135 (152) The notifications per 1,000 population for the past six years (1943-8) have been 2.21, 2.28, 2.24, 1.16, 1.68, 1.63. Notifications received during the Year ended 31st December, 1948 Scarlet Fever 371 (331) Diphtheria 46 (73) Erysipelas 57 (32) Puerperal Fever 2 (4) Puerperal Pyrexia 19 (28) Cerebro-spinal Fever 8 (14) Ophthalmia Neonatorum 12 (11) Measles 2,250 (875) Whooping Cough 590 ( 615) Primary Pneumonia 65 ( 64) Influenzal Pneumonia 17 ( 31) Malaria 5 ( 4) Dysentery 9 (8) Food Poisoning 57 ( 32) Anthrax — ( -) Scabies 125 ( 310) Typhoid 2 (2) Paratyphoid 3 ( -) Polio-Myelitis 7 ( 68) Polio-Encephalitis — (2) Encephalitis Lethargica — (1) 26 England and Wales 126 C.Bs. and Great Towns including London 148 Smaller Towns Resident Population, 25,00050,000 at 1931 census London Administrative County Lambeth Kates per 1,000 Civilian Population:— Notifications : Typhoid Fever 0.01 0.00 0.01 0.00 0.01 Paratyphoid Fever 0.01 0.01 0.01 0.01 0.01 Cerebro Spinal Fever 0.03 0.03 0.02 0.03 0.04 Scarlet Fever 1.73 1.90 1.82 1.37 1.64 Whooping Cough 3.42 3.51 3.31 3.13 2.60 Diphtheria 0.08 0.10 0.09 0.10 0.20 Erysipelas 0.21 0.23 0.21 0.22 0.25 Smallpox — — — — — Measles 9.34 9.75 8.84 9.17 9.93 Pneumonia 0.73 0.84 0.60 0.57 0 36 Rates per 1,000 Total Births (Live and Still):— (a) Notifications:— Puerperal Fever 6.89 8.90 4.71 0 61 0.46 Puerperal Pyrexia 7 34* 4.33 *Including Puerperal Fever. 27 Disinfecting Department 2,936 rooms and 7,569 articles of bedding were disinfected during the year, among them being the rooms and articles used by the 329 cases of various forms of infectious disease taken to hospital; 516 certificates of disinfection were issued, and 187 library books dealt with from the 8,669 premises visited during the year. The clean van was used regularly for the delivery of stores to the day nurseries. 28 APPENDIX LAMBETH CLEAN FOOD ASSOCIATION FORM OF APPLICATION by a person wishing to become a member of the LAMBETH CLEAN FOOD ASSOCIATION To the Medical Officer of Health, Lambeth Town Hall, Brixton Hill, S.W.2. I (BLOCK CAPITALS) being engaged in the business of hereby apply to have my name entered in the register of members of the Lambeth Clean Food Association in respect of the following premises I undertake to comply with the Articles of Association of the Lambeth Clean Food Association, a copy of which has been supplied to me. Signature of Applicant Date 29 LAMBETH CLEAN FOOD ASSOCIATION ARTICLES OF ASSOCIATION 1.An Association, to be called "The Lambeth Clean Food Association," shall be formed of persons who— (a) Having undertaken to comply with the Articles of Association, are retail food traders and their employees carrying on business within the Borough of Lambeth. (b) Are Members or Officers of the Lambeth Borough Council nominated by the Council. 2. The Association shall meet in February in each year and at such other times as may be decided by the Executive Committee, who shall give not less than 14 days' notice except in emergency. 3. The objects of the Association shall be— (a) To promote clean methods of handling food among persons engaged in the food trades in Lambeth. (b) To encourage the observance of all statutory standards of food hygiene. (c) To urge all food traders in Lambeth to become members. 4. An Executive Committee of the Lambeth Clean Food Association shall be formed of 19 members of the Association, as follows:— (a) Twelve representatives composed of at least one member from each food trade or group of food trades. (b) Two representatives of food trade employees. (c) Three members of the Lambeth Borough Council. (d) The Mayor of Lambeth. (e) The Medical Officer of Health for the Borough of Lambeth. The Committee shall have powers to co-opt additional members at any time and Members shall retire annually, but shall be eligible for re-election at the Annual General Meeting of the Association. 5. The duties of the Executive Committee shall include the following:— To consider applications for membership of the Association. To authorise the issue of Clean Food Certificates. To refuse or withdraw Clean Food Certificates. To keep a Register of Members. To report to the Association at the Annual and other meetings, and there shall be referred to the Committee all matters which concern the Association. 30 6. Each application for membership of the Lambeth Clean Food Association shall be:— (a) Accompanied by an undertaking by the applicant that he will comply with the Code of Practice set out in these articles, and that he will hold himself responsible for seeing that any person who handles food on his behalf in respect of the premises to which the application relates is made aware of the contents of the Code of Practice. (b) The subject of a report by the Medical Officer of Health. The report shall state whether or not the premises comply with the requirements of the Food and Drugs Act, 1938, and any Regulation, Order or By-law in force in the district and shall include the results of any bacteriological or other examinations made by him or on his behalf. (c) Submitted together with the undertaking and report of the Medical Officer of Health to a meeting of the Executive Committee who shall, if the conditions of membership are complied with, forthwith enter the name of the applicant in the Register of Members, and issue to the retailer one Clean Food Certificate in respect of the premises to which the application relates. In any other case the application and the issue of a Clean Food Certificate shall be deferred until the requirements of the Association are satisfied. 7. It shall be the duty of the Medical Officer of Health to report, and any other member of the Association may report, to the Executive Committee any breach by a member of the Articles of Association. On receipt of such a report or upon any complaint about a member, the Committee shall cause investigation to be made, and if as a result they are of the opinion that membership of any member should be determined and the Clean Food Certificate withdrawn, the member shall be invited to attend the meeting of the Executive Committee at which the matter will be discussed. If the member does not show cause to the satisfaction of the Committee why the membership should not be determined and the Clean Food Certificate withdrawn, then the Committee shall delete the member's name from the Register of Members and withdraw the Clean Food Certificate which was issued to him. 8. Applications for membership shall be made to the Medical Officer of Health in writing. It shall be a condition of membership that::— (i) An application shall be accompanied by an undertaking by the applicant that he will comply with the Code of 31 Practice set out in these conditions, and that he will hold himself responsible for seeing that any person who handles food on his behalf in respect of premises to which the application relates is made aware of the contents of the Code of Practice as follows :— Code of Practice. The Management shall provide all reasonable facilities for the personal cleanliness of their staff, and shall encourage and, as far as possible, ensure that all persons employed in the preparation, distribution and handling of foodstuffs on their premises shall do so in a hygienic manner and comply with the undermentioned rules. (a) Hands and finger nails shall be scrubbed clean before commencing work, and after every visit to a sanitary convenience, and as often as necessary. (b) Overalls shall be changed as frequently as necessary to maintain a clean appearance. (c) Smoking during the preparation of foodstuffs and handling and distribution of unprotected foodstuffs is prohibited. (d) Premises, fixtures, fittings, utensils, etc., including vehicles, for which the management or individual employee is responsible, shall be kept clean at all times. (e) Employees shall undertake to do everything possible to support the efforts of employers in preparing, handling and distributing food in a thoroughly clean and hygienic manner. (f) Employees shall immediately notify their employer if they are in an infectious condition or have been in contact with infectious disease. (g) A copy of this Code of Practice shall be handed to each employee and another copy shall be exhibited on the premises for the information of all concerned in the handling or distribution of food. (h) A copy of any certificate in respect of a bacteriological examination carried out by the Council shall be exhibited for the information of the staff. (i) Where separate cloakroom accommodation is provided, no food shall be prepared or stored in it. (j) It shall be the duty of the management to notify the Medical Officer of Health of any infestation of the premises by rats, mice, cockroaches, or other vermin. (ii) The premises to which the application relates shall comply with the requirements of the Food and Drugs Act, 1938, and any relevant Regulation, Order or By-law in force in the district. 32 (iii) The result of any bacteriological or other examination of cultures from persons employed in food handling or from utensils used in the preparation or distribution of food shall be reported to the Committee by the Medical Officer of Health. (iv) A Clean Food Certificate may be displayed only on premises to which the Certificate relates. The Clean Food Certificate shall remain the property of the Lambeth Clean Food Association, and no person is entitled to hold or display a Clean Food Certificate unless he is a member of the Association. 9. No article of the Association shall be altered or rescinded nor shall any new article be made except on a report submitted by the Committee to the Association. The foregoing Articles were adopted at a meeting of representatives of the Food Traders' Associations on the 5th day of January, 1949. (Signed) J. W. Simpson, Chairman. Lambeth Clean Food Association This is to Certify that of is enrolled as a member of the LAMBETH CLEAN FOOD ASSOCIATION. The Public are assured that the holder of this Certificate has taken all reasonable precautions to safeguard against contamination all food sold or exposed for sale in this establishment. This Certificate is exhibited in order that purchasers may be aware that all food has been handled in accordance with the code of practice adopted by the trade and under conditions which satisfy the requirements of the Food and Drugs Act, 1938. ISSUED BY LAMBETH CLEAN FOOD ASSOCIATION Dated this day Nineteen hundred and Chairman Medical Officer of Health This Certificate is the Property of the Lambeth Clean Food Association FACSIMILE of clean food badge 33 INDEX page Births 12 Burials 15 Clean Food 28 Committee 2 Deaths 10 Disinfection 27 Factories 22 Food Inspection 16 Food Poisoning 18 Infectious Diseases 24 Maternal Mortality 9 Milk 21 Mortality Analysis 12 Outworkers 23 Overcrowding 16 Rats 15 Removal to Hospital 14 Sanitary Circumstances 13 Scabies 14 Staff 6 Statistics 8 Tuberculosis 25 Water 24