??? AC441 (1)LEYTON Borough of Lepton. HEALTH REPORT FOR THE YEAR 1954. ANDREW W. FORREST, M.A., M.D., Ch.B., D.P.H., Medical Officer of Health, Borough of Leyton, Area Medical Officer, County of Essex. CONTENTS Pages r. Index 2 2. Opening Remarks 11 3. Vital Statistics 21 4. Special Reports— Our Daily Bread 24 The Water We Drink 25 The Air We Breathe 28 Housing 32 Old People Living at Home 42 Thiourea 45 Leptospiral Jaundice 46 Hygiene in Catering Establishments 48 Town Hall Canteen 51 Public Health Offices 55 Sanitary Inspectors—Staff 57 Scheme for the Recruitment and Training of Student Sanitary Inspectors 63 Rodent Control 75 5. Infectious Diseases 65 6. General Provision of Health Services in the Area 69 7. Sanitary Circumstances of the Area 72 8. National Health Service Act, 1946, Part III 103 9. School Health Services 131 2 INDEX Page Acreage 9 Air We Breathe, The 28 Ambulance Services 122 Ante-natal Clinics 103 Area Health Sub-Committee 4 Atmospheric Pollution 100 Aural Clinic 144 Bacteriological Examinations 89 B.C.G. Vaccination 119 Birth Notifications 103 Birth Rate 21 Birth Registrations 103 Births, Illegitimate 21 Births, Institutions 115 Births, Inward Transferable 115 Burial of the Dead 71 Business and Industrial Establishments, Inspection of 95 Care Association 127 Care of Mothers and Young Children 103 Chemical Analysis 87 Chest Clinic 117 Child Guidance Clinic 154 Child Welfare Clinics 105 Chiropody 122 Clinics Ante-Natal 103 Aural 144 Chest 117 Child Guidance 154 Child Welfare 105 Chiropody 122 Minor Ailment 140 Ophthalmic 141 Orthopaedic 143 Orthoptic 141 Post-Natal 107 Scabies 70 Speech Therapy 154 Clinic Sessions 108 Committees 4 Convalescent Home Treatment 124 Day Nurseries 113 Death, Causes of 22 Death Rate 21 Defective Vision 140 Dental Treatment 141 Diphtheria 66 Diphtheria Immunisation 118 Diseases of Animals, Acts and Orders 99 Disinfestations 81 Distribution of Welfare Foods 106 Domestic Help Service 129 Domiciliary Midwives 115 Dysentery 66 Education, Leyton Committee for 5 Encephalitis 66 Erysipelas 66 Page Expectant Mothers, Mass Radiography of 105 Extra Nourishment 126 Factories Acts, 1937/48 83 Foetal Mortality 112 Food, Clean 90 Food Condemned 90 Food Poisoning 66 Food Premises 83 Food and Drugs Act, 1938 90 Foot Clinic 122 Fowl Pest 99 Funeral Arrangements 71 Gas and Air Analgesia 114 General Practitioner and the Health Visitor 117 Handicapped Pupils 144 Harrow Green E.S.N. School 147 Health Centres 103 Health Education 124 Health Services, General provision of 69 Health Visiting 116 Home Nursing 117 Hospitals 70 Housing 32 Housing Development, Future 34 Housing Statistics 72 Hygiene in Catering Establishments 48 Ice Cream 85 Ice Lollies 85 Immunisation 118 Infant Mortality 112 Infectious Diseases 65 Introduction 11 Knotts Green Special School 148 Laboratory Facilities 70 Lectures 124 Legal Proceedings 92 Leptospiral Jaundice 46 Leyton Corporation Act, 1950 95 Mass Radiography 125 Maternal Mortality 109 Maternity Nursing 114 Maternity Outfits 114 Meals in School 151 Measles 66 Medical Aid 114 Medical Examination of Staff 130 Medical Research 160 Meningococcal Infection 66 Meteorological Conditions 10 Midwifery 114 Milk Inspections 89 Minor Ailment Clinics 140 3 Page Mortuary 71 National Assistance Act, 1948 (Sections 47 and 50) 71 National Blood Transfusion Service 71 National Health Service Act, 1946 (Part III) 103 Neo-Natal Mortality 112 Notices, Sanitary 74 Notification of Births 103 Notification of Infectious Diseases 65 Nursery and Child Minders Regulation Act, 1948 131 Nursing Homes 70 Occupational Therapy 129 Office Accommodation 55 Old People Living at Home 42 Open Air Shelters 126 Ophthalmic Clinic 141 Ophthalmia Neonatorum 66 Oral Hygiene 143 Orthodontic Treatment 143 Orthopaedic Clinic 143 Orthoptic Clinic 141 Our Daily Bread 24 Paratyphoid Fever 66 Pemphigus Neonatorum 66 Pet Animals Act, 1951 96 Pneumonia 66 Poliomyelitis 67 Population 9 Post-Natal Clinic 107 Premature Infants 107 Prevention of Food Poisoning in School Canteens 151 Public Health Committee 4 Puerperal Pyrexia 67 Rag Flock Act, 1951 97 Rateable Value 9 Rehabilitation 126 Remedial reading classes 149 Research Work 160 Rodent Control 75 Routine Medical Inspection 139 Page Sanitary Circumstances of the Area 72 Sanitary Inspection 72 Samples for Analysis 84 Scabies Clinic 70 Scarlet Fever 67 School Dental Service 141 School Health Service 131 Shop Window Displays 124 Shops Act, 1950 91 Sick Room Equipment 127 Smallpox 67 Smoke Abatement 100 Smokeless Zones 31 Social Conditions 9 Speech Therapy 154 Staff 6 Staff, Medical Examinations 130 Statistics, Vital 21 Student Sanitary Inspectors 63 Thiourea 45 Town Hall, Basement Kitchen 53 Town Hall Canteen 51 Tuberculosis 67 B.C.G. Immunisation 119 Care Association 127 Chest Clinic 117 Deaths 69 Extra Nourishment 126 Mass Radiography 125 Notifications 67 Occupational Therapy 129 Open Air Shelters 126 Rehabilitation 126 Typhoid Fever 67 Uncleanliness 140 Vaccination 118 Vital Statistics 21 Water We Drink, The 25 Welfare Foods, Distribution of 106 Whooping Cough 67 Whooping Cough Immunisation 119 4 PUBLIC HEALTH COMMITTEE 1954-55 The Worshipful Mayor—Councillor C. J. Mills, j.p. (ex-officio) Chairman Councillor H. E. Martin Vice-Chairman Councillor F. W. Marshall Alderman G. S. Flack „ E. A. Rigg Councillor W. A. Cross „ Miss V. D. Gostling „ W. Hook, m.p.s. „ W. A. Sanders „ J. D. Watson F. W. Wigg Leyton Health Area Sub-Committee of the Health Committee of the Essex County Council 1954-55 Chairman : Councillor Mrs. A. M. M. Burrell Vice-Chairman : Councillor T. C. Messenger Representatives of Essex County Council County Aldermen : Mrs. M. Ball (ex-officio) (Chairman, County Health Committee) F. D. Smith, J.P. (Resigned, 19th October, 1954) County Councillors : H. Burton Mrs. F. E. Cochrane C. F. H. Green (ex-officio) (Vice-Chairman, County Health Committee) W. H. Herridge F. R. Richards Representatives of Leyton Borough Council Aldermen : Mrs. J. Hammond, o.b.e., j.p. Mrs. R. King Councillors : J. A. E. Collins Miss V. D. Gostling E. W. R. Harding W. Hook, m.p.s. F. W. Marshall P. A. Parry 5 Mrs. E. V. Pearson W. H. Sanders C. B. Underwood, j.p. J. J. Walsh J. D. Watson Representative of Local Medical Committee Dr. J. F. B. Hill Representative of Hospital Management Committee Alderman The Lady McEntee, j.p. Representative of Executive Council for Essex (Vacancy) Representatives of Voluntary Organisations Mrs. A. M. Clewer (Leyton, Wanstead and Woodford Care Association) G. A. Dicker, Esq. (Leyton, Wanstead and Woodford Care Association) Mrs. E. Gardner (British Red Cross Society) Mrs. A. E. Sampson (St. John Ambulance Brigade) LEYTON COMMITTEE FOR EDUCATION 1954-55 The Worshipful Mayor—Councillor C. J. Mills, j.p. [ex officio) Chairman : Councillor J. J. Walsh Vice-Chairman : Councillor A. L. Chamberlain Representative Members (Leyton Borough Council) Aldermen : A. E. Bechervaise A. W. Bourne Mrs. J. Hammond, o.b.e., j.p. Mrs. R. King Councillors : F. J. Abbott, j.p. Mrs. D. E. Barker Miss V. D. Gostling W. J. Low F. W. Marshall Mrs. E. V. Pearson G. W. A. Robinson S. G. Shepherd, j.p. J. D. Watson Co-optative Members J. Fairfax C. Hicks F. C. Holbrook L. F. Quilter M. Rayner L. W. Turp Nominated Members County Councillors : E. C. Hardy P. S. Powell 6 OFFICERS OF THE HEALTH SERVICES LEYTON BOROUGH COUNCIL Medical Officer of Health Borough School Medical Officer and Area Medical Officer (Essex County Council) Andrew Walker Forrest, m.a., m.d., Ch.b., d.p.h. Deputy Medical Officer of Health Deputy Borough School Medical Officer and Assistant County Medical Officer (Essex County Council) Mary Lyle Gilchrist, m.d., Ch.b., d.p.h. Senior Sanitary Inspector B. J. Ashcroft, m.s.i.a., m.inst.B.e. a, b, c, d Deputy Senior Sanitary Inspector R. A. Reeves, m.s.i.a. a, b Sanitary Inspectors A. E. Barnes a, b J. Clarke (Resigned 5.8.54) a, b P. W. Edwards, m.s.i.a. a, b D. J. Davies (from 8.2.54) a, b, c G. D. John, m.s.i.a. (Resigned 1.10.54) a C. Pomfret, m.s.i.a., a.r.s.i. a, b, c C. Broomfield (from 8.2.54 to 31.7.54) a, b a. Certificate of the Royal Sanitary Institute and Sanitary Inspector's Examination Joint Board. b. Royal Sanitary Institute—Meat and Food Inspector's Certificate. c. Royal Sanitary Institute—Smoke Inspector's Certificate. d. Gold Medallist—Ollett Trust Competition. Public Analysts G. Taylor, f.r.i.c. j. h. hamence, m.sc., Ph.D., f.r.i.c. Chief Clerk *W. D. Softley Clerical Staff N. Gray J. Burtt Mrs. V. Hatwell L. Williams T. Crute Miss A. L. List (from 20.7.54) ESSEX COUNTY COUNCIL Assistant County Medical Officers *Mary L. Gilchrist, m.d., Ch.B., d.p.h. Samuel C. Lovell, m.r.c.s., l.r.c.p. * Part-time. 7 Ethel R. Emslie, m.d., ch.b., d.p.h., d.c.h. Elsie Lilian Peet, b.Ch. *Anne S. Clark, m.d., B.Ch. *Rachel Jacobs, m.d., d.obst., r.c.o.g. Specialist Part-time Medical Officers. (Regional Hospital Board Appointments) Ophthalmologist A. Logan Adam, m.r.c.s., l.r.c.p., m.b., b.s., d.o.m.s. Orthopaedic Surgeon H. A. Oatley, m.b., b.s., f.r.c.s. Aural Surgeon M. Sharif, m.b., b.s., d.l.o. (from 1.1.54 to 10.11.54) Area Dental Officer A. E. Hall, l.d.s. (Liverpool) Dental Officers *rs. V. A. Wolf, l.d.s., r.c.s. (from 25.8.54) *Mr. D. E. Robinson, l.d.s., r.c.s. (from 1.12.54) *Mr. D. G. Gould, l.d.s., r.c.s (from 3.8.54) *Mr. S. T. Lowe, b.d.s., l.d.s., r.c.s. (from 3.2.54) *Mrs. D. M. Powell, l.r.c.p., l.r.c.s., l.r.f.p.s., l.d.s., r.c.s. *C. Shamash, b.d.s., l.d.s., r.c.s. *Mr. P. G. Arnold, l.d.s., b.d.s. *Mr. P. J. Pearce, b.d.s. *Mr. G. M. Ritchie, l.d.s., r.c.s. *Miss S. Rogart, l.d.s., r.c.s. *Mr. T. D. H. Millar, l.d.s., r.c.s. Non-Medical Supervisor of Midwives Miss E. M. Wearn a, b, c, e Midwives Miss E. Daines a, b Mrs. C. L. Wackett a, b Superintendent Health Visitor Miss E. M. Franklin a, b, c Health Visitors!School Nurses Miss L. Acton Mrs. I. M. Adamson (Resigned 30.4.54) Miss I. D. Appledore Miss M. J. Charters (Resigned 13.8.54) Mrs. D. E. Chatfield Miss E. O. Corby Miss G. W. Craddock Miss J. M. Denman Miss R. M. Edward Miss C. B. Ferguson * Part-time. a, b, d a, b a a a, c a, b, c a, c a, b, c Miss B. D. Jukes (from 5.7.54) Miss B. King Miss K. M. Munday Miss M. H. Roger Mrs. M. Sims Mrs. J. H. Souter Miss O. Phillips (from 10.8.54) Miss K. M. Rayment (from 10.8.54) a, c a, c, d a, c a, b, c a, b a, b, c a, c a, c 8 Tuberculosis Visitors Miss C. G. Teale a, b, c, e Mrs. L. M. Abbott a, f Matrons of Day Nurseries Knotts Green Day Nursery— Mrs. E. M. White a, d Ellingham Road Day Nursery— Mrs. D. M. M cStay a, b (a) S.R.N. (d) S.R.F.N. (b) S.C.M. (e) Q.N. (c) H.V.Cert. (f) T.A. Cert. Orthoptist Mrs. K. S. Box, s.r.n., s.c.m., d.b.o. (Regional Hospital Board Appointment) Speech Therapist Miss M. E. Tippett Chiropodists Chief : J. C. O'Brien, m.ch.s. Others : Miss J. M. Hunter, m.ch.s. D. D. Waters, m.ch.s. S. A. Wightman, M.ch.s. *R. Sadowski, M.ch.s. *G. E. Fenn, M.ch.s. *G. V. Ledger, M.ch.s. Domestic Help Organiser Mrs. E. M. Saxby Oral Hygienist Miss J. Watts Dental Attendants Mrs. D. Blundell Miss E. Corcoran Miss A. I. Warren *Mrs. Ayres *Mrs. Ferris Clinic Clerks Miss F. C. Cheetham Mrs. L. Neville Miss E. Nichols (Foot Clinic) Mrs. J. Price Chief Administration Assistant W. D. Sofdey * Part-time. 9 Administrative and Clerical Staff F. C. Ware E. R. Price L. G. Goodbun G. A. Thurlow E. Lamb A. Keeys Miss E. Beckley Mrs. F. Wright Miss R. Carrington G. Whitehouse (H.M. Forces 13.3.54) Miss B. G. Johnson (from 20.4.54) Distribution—Welfare Foods Mrs. D. Gray *Mrs. H. Coleman * Part-time. STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area in Acres 2,594 Population (Census 1951) 105,978 Population (Registrar-General's Estimate, 1954) 103,100 Number of private householders (Census 1951) 34,720 Number of structurally separate dwellings occupied (Census 1951) 27,134 Number of rooms occupied (Census 1951) i37j763 Number of persons per room (Census 1951) 0.75 Number of dwellings occupied by one private household ... 20,012 Number of dwellings occupied by two private households ... 6,728 Number of dwellings occupied by three or more private households 394 Assessable Value for General Rate purposes (1954/55) £782,902 Sum represented by a Penny Rate for General Rate purposes (1954/55) £3>200 10 METEOROLOGICAL CONDITIONS, 1954 Summary of Temperature, Rainfall and Sunshine Records These figures—supplied by the Director of the Meteorological Office of the Air Ministry—summarise the official records of temperature, rainfall and sunshine made at Kew Observatory during the year 1954. January. Coldest since 1947. Frequent frosts. Snow and sleet on 10 days. Sunshine above average. February. Coldest since 1947. Snow and sleet on seven days. Rainfall above average. Sunshine a little below average. March. Cold spells. Rather wet. April. Driest since 1938. Absolute drought 7th~30th. Rainfall a quarter of average. Half the month's rain fell on first day. Sunshine above average, the tenth consecutive sunny April. May. Rather wet. Sunshine about three-quarters of average. June. Wettest June since 1905. Rainfall nearly twice average. Dull, less than three-quarters average sunshine. July. Coolest July since 1922. Dull. Rainfall above average. August. Coolest since 1946. Dullest since 1948. Rainy. September. First sunny month since April. Very warm on 1st ; warmest day of the year. Rainfall below average. October. First warm month of the year. Only two warmer Octobers on record. Sunshine about average. November. Wet ; rather mild. December. Unusually mild. Sunshine above average. Easter (16th-igth April.) Sunniest Good Friday since 1946, and sunniest Easter Monday since 1924. Whitsun {5th-qth June.) Wettest Whitsun since records available. August Week-end (31 st July—2nd August.) Dullest since records available. Coolest since 1930. Christmas (24th-27th December.) Driest for six years. 11 TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF LEY TON Mr. Mayor, Ladies and Gentlemen, I have the honour to submit this my twenty-seventh Annual Report on the health, sanitary circumstances and vital statistics of the Borough of Leyton during the year 1954. The Report also contains information regarding the health services administered by Leyton Health Area Subcommittee and Leyton Committee for Education on behalf of Essex County Council. The Annual Report of a Medical Officer of Health contains of necessity much information in the form of figures and dry facts required by Central and Local Government Departments, and such information makes dull reading. But in the body of the Report there are extracts from many special reports submitted by me during the year to the Council, and it is hoped that they will be found to contain general observations on aspects of the public health services which are of sufficient current interest to merit special attention. Meteorological. From the meteorological point of view 1954 will be remembered as an exceptionally dull, cold and wet year—the worst since 1941 and the worst summer since 1890, with a marked deficiency of sunshine from May to August (inclusive). In spite of these adverse climatic conditions the year was a relatively healthy one in which endemic infectious diseases were at a low ebb. Vital Statistics. From the vital statistics it will be seen that the gradual but progressive decline in the population since 1949 still continues. The birth rate, which reached its post-war maximum in 1947, has now declined almost to the level of the lowest pre-war figure. Before relinquishing my official appointment I had hoped to be able to furnish an account of my stewardship in the form of an historical survey showing the great expansion that took place in Leyton's health services during the 11 years before the outbreak of war, the growth and decay of the civil defence and other emergency medical services during the six war years, and the post-war changes brought about by the Education Act, 1944 and the National Health Service Act, 1946. Unfortunately there is available neither the time nor the space for such a survey, and in the meantime all I can do is to compare a few salient vital statistics to-day with those in my first Annual Report to your Council some 27 years ago. Infectious Diseases. Since 1928 the annual number of persons notified to be suffering from tuberculosis has fallen from 180 to 77, and there has been a very marked reduction in the annual number of deaths from tuberculosis—from 97 in 1928 to 11 in 1954 (i.e., to nearly a ninth part of what it was). 12 In my first year (1928) in Leyton, there were notified 346 cases of diphtheria, of whom 18 died. In 1954, as in each of the previous five years, not only has no Leyton resident died from diphtheria, but no case has even been notified. The last death from diphtheria occurred in Leyton in 1947. These are but two of the many signs of improvement in the public health. In my Annual Report for 1950 I included facts and figures showing the great reduction in deaths from infectious diseases. Those of us who remember the high death and disability rates of the so-called common infectious diseases but a generation ago can at least claim that our efforts have been successful—so successful that many former fever hospitals have now been closed altogether and many others allocated for other purposes. Three Prime Necessities of Life. The food we eat, the water we drink, and the air we breathe are three fundamental requirements on which our bodies depend for health ; and ideally all three should be pure and unadulterated. Some idea may be obtained of the extent to which our food is adulterated by reference to a report on " Our Daily Bread " (page 24). In recent years there has been a great increase in the practice of spraying growing crops, fruit and stored food with chemicals to prevent or discourage weeds and insect pests ; and constant vigilance is required to ensure that such chemical fungicides should not be allowed to contaminate our food in harmful concentrations. An example of such contamination of oranges sold in the Borough is to be found in a report on " Thiourea " (page 45). The control of our drinking water supply, the prevention of pollution of its source, and the dangers to which it is exposed by the great recent increase in the use of synthetic detergents are matters dealt with in a report on " The Water We Drink " (page 25). " The Air We Breathe " is the tide given to a report on atmospheric pollution (page 28), one of the most serious and urgent public health problems of our day and generation—at least to dwellers in large towns. Housing. There is no activity of a local authority more conducive to family health and happiness than the efficient administration by the Council of its duties and responsibilities in housing—the abatement of unsanitary conditions in the home, the demolition and clearance of slums, and the provision of dwellings complying with modern standards of fitness and decency. Any attempt to clear slums without adequate provision of dwellings for dispossessed families can have but one result—increased overcrowding, which is a greater menace to health and happiness than is the slum. For that reason it is definitely laid down in the Housing Acts that action involving clearance-area procedure can be undertaken only if the authority can provide in advance accommodation for persons who will be displaced by the clearance. Looking back on Leyton's record in slum clearance during my tenure of office the most disappointing feature has been the inability of the Council as local sanitary authority to carry out its full statutory responsibilities in the clearance of slum areas owing to the persistent failure of the Council as 13 local housing authority to make provision in advance for the re-housing of families to be displaced. This failure has generally been attributed to a state of affairs known locally as " the present acute shortage of houses in Leyton " ; but as there is evidence that the shortage has been in existence since 1920—a period of 34 years—it can no longer be regarded as " acute or even as " sub-acute It should therefore be recognised as a " chronic " disability which cannot be expected to respond to palliative treatment and requires a radical major operation. On pages 32 to 34 I submit a brief historical survey of Leyton's progress in slum clearance and housing development since the end of the first world war ; and on pages 34 to 41 there is a comprehensive joint report by the Chief Sanitary Inspector and me on future housing development. This latter report is one in the preparation of which we devoted much time and thought, and it is hoped that it will be found useful by those responsible for deciding the policy to be pursued by the Council in respect of the procedure outiined in the new Housing Repairs and Rents Act and other Government Circulars issued during the year. Clean Food. During 1953 (the last year for which complete records are available) the number of recorded cases of food poisoning in the country was 50 per cent, higher than in the previous year. In addition, food poisoning is responsible for a substantial amount of sickness and loss of working time which is never recorded. The remedy is largely in the hands of those who prepare, cook and serve food ; for there are still far too many caterers and food handlers who combine deplorable standards of hygiene with an attitude of indifference to the needs of the public they claim to serve. During reccr.t years the three responsible Government Departments (the Ministries of Health, of Education and of Food) have been actively engaged in a Clean Food Campaign, in pursuit of which they have been enlisting the help of the Medical Officer of Health and his Sanitary staff to ensure not only that official inspection of catering establishments is fully and effectively carried out, but also that the necessary measures are taken to prevent the risk of food poisoning. In order that the responsible health officers may be able to educate dirty food handlers by setting them a good example it is hoped that the Council will lend official encouragement by adopting in their municipal catering arrangements the methods and appliances advocated by their officers to outside caterers. Extracts from special reports submitted during the year are to be found on pages 48 to 51 and on pages 151 to 153. Sanitary Circumstances. Since his appointment two years ago, Mr. Ashcroft (Chief Sanitary Inspector) has been able to effect substantial re-organisation of the work of the department for which he is responsible—and that in face of very serious depletion of the staff during the year under review. Given the necessary staff and support, his valuable knowledge and experience in all aspects of housing should be of great value to the Council in the planning and execution of its scheme of future housing development in the Borough. 14 Whereas Mr. Ashcroft, in his capacity as Chief Sanitary Inspector, has been responsible for the section of this Report dealing with Sanitary Circumstances (pages 72 to 102), there will be found much information of a sanitary or environmental nature in my special reports (pages 24 to 64) to the Council. Staff—Sanitary Inspectors. As long ago as 1932 I found it necessary to report to your Council that, if their work is to bear fruit, the sanitary inspectors must receive adequate encouragement and support from the sanitary authority ; but with the passage of time I have never felt that, however industrious and efficient they may have been, they have enjoyed the complete confidence of the Council. The value of their services to the public may be gauged from the fact that their appointments cannot be terminated without the consent of the Ministry of Health, and that half the cost of sanitary inspectors' salaries is contributed by the Central Government via the County Council. During the year under review some very important additional duties have been placed on sanitary inspectors, and many local authorities have not been slow to appreciate that the appointment of an adequate number of well qualified and experienced inspectors is a sound financial investment. They have therefore taken steps either to increase their staff, or at least to retain existing staff by the only means available in a community subject to the law of supply and demand (i.e., by offering higher salaries or additional emoluments). In the short period of six months three capable and well qualified young inspectors left your previously inadequate staff in order to take up higher paid appointments in other areas ; and, with a staff numerically half of what it should be, it has been impossible to operate a comprehensive sanitary service, to undertake the detailed surveys of areas for re-development, or to take full advantage of the Council's powers in connection with clearance areas. Rats. Through the centuries rats have spread fear and famine, plague and pestilence with varying intensity. Their proverbial fecundity and cunning have defeated all attempts at their extermination, and the provision of the wherewithal for their subsistence is a severe drain on the public purse. As long as sewers and drains in Leyton are as defective as they are now we are fighting a losing battle in our efforts to keep rats out of surface properties. Short of complete renewal or rehabilitation of our drainage and sewerage system there is no solution to our rat problem ; and the best we can hope to achieve is to keep surface infestation as low as possible by constant vigilance and organised attack. As in so many branches of public health activity and preventive medicine (e.g., disease prevention), there is little or nothing to show for our efforts as long as things are going well. It is only when disaster overtakes us that prevention becomes " news 15 On pages 46 to 47 there are shown the results of a special investigation into the incidence of leptospiral infection in some 32 live rats caught in various parts of the Borough ; and an interesting by-product of this work was the sidelight it has shed on the presence and habits of the black or " ship " rat. County Health Services (National Health Service Act—Part IH). On " the appointed day " (5th July, 1948) all health services within the province of the then new National Service Act (Part III)—including the services formerly administered by Leyton Corporation as the local Maternity and Child Welfare Authority—were transferred to Essex County Council. Fortunately for the continuity of the services, the County Council delegated most of the administration to local Health Area Sub-Committees and most of the day-to-day work to the existing local staff. It was, of course, inevitable that during the early days of transition there should have occurred " teething troubles " of many kinds. That such difficulties were satisfactorily resolved was due in some measure to the understanding manner in which they were handled by the County Council and its staff; but much of the credit for the smoothness of the change in administration was undoubtedly due to the active and informed interest—in all aspects of the work of the department and its staff—taken by Councillor Mrs. A. M. M. Burrell, E.C.C., who has officiated as Chairman of Leyton Health Area Sub-Committee during the difficult years since its initiation in 1948. The infantile mortality rate is the lowest ever recorded, and will be found to compare very favourably with that of any other town in the country. In 1929—the first whole year of my service in Leyton—the infantile mortality rate (i.e., the number of deaths of infants under one year of age per 1,000 births) was 57.77 ; and in the year under review the rate has fallen to 14.61—the lowest ever recorded. In other words, there has been effected during these 26 years a saving of more than 43 lives during their first year among every 1,000 children born. In addition to the great saving of infant lives, there has been brought about a corresponding decrease in sickness and incapacity among the children who survive ; for the diseases that kill some children can be reckoned to cripple and injure many others. The fact that the lowest infantile mortality rate ever recorded in Leyton occurred during a year of adverse climatic conditions substantiates the view that such factors play but a small part in the deaths of infants. Leaving aside the influence of heredity, a child's health and happiness depend primarily on the ability of the mother to discharge her maternal functions. The neo-natal mortality rate (i.e., number of deaths of children in the first 28 days of life per 1,000 births) has fallen from 24.28 in 1928 to 8.11 in 1954 (i.e., to a third of what it was). In 1928 some 10 Leyton mothers died from causes connected with childbirth ; last year the comparative maternal mortality figure was three. Since 1950 there have been two years in which no Leyton mother died from childbirth. 16 School Health Service. One of the most valuable features of routine medical inspection of pupils in school is the opportunity afforded to parents of being present at the examination and of conferring with the school doctor. At the first routine medical examination (of entrants) over 95 per cent, of parents were present ; but by the time that the third medical examination (of leavers) was reached the number of parents who availed themselves of the invitation to be present had fallen to as low as 30 per cent. Whereas it is natural that mothers should feel their presence is required at the young child's first medical examination, it is equally important that they should be present at the child's final examination, for it is then that the school doctor may be able to supply valuable information and advice. In August there was put into operation a new scheme for the protection against tuberculosis by B.C.G. vaccination of older school children, and full information regarding the arrangements is furnished on pages 158 to 160. Unfortunately the response to the offer of vaccination was much lower than expected, and it is hoped that parents will become more inclined to take advantage of the facilities offered. As the clinical work on which it was based was carried out in connection with the public health services of Leyton Corporation, my Presidential Address of that year to the Society of Medical Officers of Health (Home Counties Branch) was included in my Annual Report for 1936. Now, after the lapse of almost 20 years, I am pleased to be able to include in this Report another Presidential Address—that delivered by my colleague Dr. Mary Gilchrist last year at the beginning of her year of office as the first woman President of the School Health Service Group of the Society of Medical Officers of Health. Although addressed to school doctors, Dr. Gilchrist's paper (see pages 131 to 138) contains much clinical and administrative wisdom based on experience in Leyton schools, and much information of interest to those responsible for educational policy and administration. Acknowledgments. To the long succession of Mayors, Aldermen and Councillors I have served I am grateful for encouragement or support accorded to me, and especially for the helpful interest shown by Chairmen and members of the Committees concerned with the work of the Health Department. It is my privilege to be able to acknowledge the co-operation and collaboration I have received for over a quarter of a century from all persons, organisations and institutions concerned in the promotion of the health and happiness of Leyton residents—doctors and dentists, nurses and midwives, teachers and taught, mothers and children. It is, however, to those with whom I have been most closely associated in my day-to-day work—my colleagues who comprise the staff of Leyton Health Department—that I owe my deepest debt of gratitude. At all times their industry, efficiency and loyalty have been a source of great comfort and inspiration, and I am proud to have had the opportunity of serving the public in their company. 17 Whereas it would be invidious to single out any member of the staff for special mention, it will be appreciated that a voluminous Report such as this requires much concentrated effort and attention to detail. In its preparation I am deeply grateful for the valuable help I have received from Mr. W. D. Sofdey, Chief Administrative Assistant of the Department. I have the honour to be, Mr. Mayor, Ladies and Gendemen. Your obedient Servant. i8 A FEW LANDMARKS IN LEYTON'S PUBLIC HEALTH PROGRESS 1896 Temporary Isolation Hospital opened. 1907 Arrangements for free supply of Diphtheria Anti-toxin to General Medical Practitioners. 1908 Routine Medical Inspection of school children initiated. First School Minor Ailment Clinic held in Town Hall. 1912 First Health Visitor appointed. 1914 Ophthalmic Clinic inaugurated. (Town Hall.) Dental Clinic opened. (Town Hall.) 1915 Notification of Births (Extension) Act. 1917 First Ante-natal Clinic held. (People's Hall, E.n ; September.) First Infant Welfare Clinic. (Town Hall ; February.) Second Ante-natal Clinic held. (People's Hall, E.11 ; May.) 1918 Third Infant Welfare Clinic opened. (Baptist's Church, E.io ; October.) 1919 Arrangements made for municipal supply of milk to Nursing and Expectant Mothers and to Children under 5 years of age. Day Nursery opened at " Wrentham," Church Road, E.io. 1920 Arrangements made for Convalescent Treatment of Nursing Mothers and Babies. 1921 Arrangements for operative treatment of Tonsils and Adenoids at Queen Mary's Hospital. 1925 Arrangements made with Queen Mary's Hospital for Maternity Beds. E.C.C. delegated their powers under Rats and Mice Destruction Act, 1919. 1926 Second Ante-natal Clinic opened. (All Saints' Church Hall, Capworth Street, E.io.) Arrangements for X-ray treatment of Ringworm of Scalp. 1927 Knotts Green Special School opened. Orthopaedic Clinic opened. (Knotts Green Special School.) Artificial Light Clinic opened. (Knotts Green Special School.) Arrangements with Brookfield Hospital for residential Orthopaedic treatment. " Daily News " First Prize of £20 awarded to Leyton for greatest reduction in Neo-natal Mortality rate for districts over 100,000 population. 1928 First Health Week. (Attended by 14,000 people.) Appointment of Consultant Obstetrician. 1929 Second Health Week. (Attended by 13,000 people.) Institution of scheme for provision of Insulin to necessitous persons suffering from Diabetes. First School Camp held. (Epping.) 19 1930 Agreement with L.C.C. for institutional treatment of Ophthalmia Neonatorum. Agreement with Connaught Hospital for two beds for Enteric Fever cases. Routine steam disinfection of bedding discontinued after commoner infectious diseases. Infant Life Protection and Supervision of Foster Mothers becomes responsibility of Leyton Council. Powers and duties under Nursing Home Regulations Act, 1927 delegated to Local Authority by County Council. Ministry of Health made Leyton (Supervision of Midwives) Order, 1930, constituting the Council the local Supervising Authority under the Midwives Acts, 1902-1926. Widespread epidemic of smallpox—138 cases in Leyton. 1931 Home Help Scheme instituted (24 cases dealt with in full year 1932). 1933 Leyton Green Health Services Clinic opened. New Public Mortuary opened. Special investigation into the results of surgical operations for removal of tonsils and adenoids. Establishments for Massage and Special Treatment—Powers and Duties under Part IV of the E.C.C. Act, 1933, vested in Leyton Corporation. 1935 Park House Health Services Clinic opened. First Diphtheria Immunisation Clinic opened. 1936 Squint Clinic opened. Council instituted scheme for provision of meals to Nursing and Expectant Mothers. Foot Clinic opened. Overcrowding Survey under Housing Act, 1936. Presidential Address by M.O.H. to Society of Medical Officers of Health (Home Counties Branch) on " Scarlet Fever and Current Methods of Control 1937 Provision made for medical and dental inspection and treatment of pupils attending County Secondary Schools. Domiciliary Midwifery Service inaugurated. Post-Natal and Gynaecological Clinic instituted. Arrangements for treatment of children at London Child Guidance Clinics. 1938 Special investigation by S.M.O's into the incidence of Hypochromic Anaemia in children. First Aural Clinic held. Special investigation into incidence of Plantar Warts in school children. Heart Clinic opened. 20 1939 Arrangements made with the Mothers Hospital, Clapton, for provision of maternity beds for Leyton Cases. Isolation Hospital closed. Corporation took over responsibility for the administration of Food and Drugs Act, 1938. 1942 Scabies Clinic opened at Ruckholt Central School. Knotts Green Day Nursery opened. July. Ellingham Road Day Nursery opened. August. 1943 Ambulance Service transferred from Harrow Green Fire Station to Auckland Road Garage. 1944 New Education Act. 1945 The County Council became Local Education Authority and delegated the actual school medical service arrangements to the staff of the former Leyton Education Authority. 1946 Health Department Administrative Offices transferred from Town Hall to Sidmouth Road. New Scheme for the supply of Home Helps and Domestic Helps. Survey : Population investigation—Pregnancy and Childbirth. 1947 Outbreak of acute poliomyelitis. Number of births (2,359) highest since 1922. 1948 National Health Service Act, 1946 (Part III) came into operation. 1949 First year in Leyton's history when no case of diphtheria notified. Whooping Cough survey in collaboration with Medical Research Council. Survey : Virus Infection during Pregnancy. 1950 Commencement of Occupational Therapy. Research in connection with Whooping Cough, B.C.G., and House to House Spread of Tuberculosis. 1951 Dawlish Road Health Services Clinic opened (22nd September). 1952 Intensive and fatal London Fog (5th to 9th December). Measles. Most widespread epidemic since figures available (1,630 cases). Survey : Illnesses in first year of Child's Life. 1953 Commencement of facilities for Ante-natal Exercises. 1954 Local Health Authority assumed responsibility for distribution of Welfare Foods supplied by Ministry of Food. Commencement of Mass Radiography for Expectant Mothers. B.C.G. Vaccination available to School Leavers. 21 Vital Statistics Population 103,100 Live Births :— Legitimate Males 618 Females 570 Illegitimate Males 22 Females 22 Totals 1,232 Birth rate per 1,000 of population 11.95 Stillbirths :— Males 13 Females 18 Rate per 1,000 total (live and still) births 24.54 Deaths :— Males 566 Females 567 Totals 1,133 Death Rate per 1,000 10.99 Number of women dying from diseases and accidents of pregnancy and childbirth :— From sepsis 1 From other causes 2 Rate per 1,000 total (live and still) births 2.37 Death rate of infants under one year of age :— All infants per 1,000 live births 14.61 Legitimate infants per 1,000 legitimate live births 14.30 Illegitimate infants per 1,000 illegitimate live births 22.73 The natural increase of population {i.e., excess of births over deaths) was 99. Comparability Factor. To make approximate allowance for the way in which the sex and age distribution of the Borough population differs from that for England and Wales as a whole, the Registrar-General has issued the following comparability factors for Leyton. Area comparability factor for births 0.96 Area comparability factor for deaths 0.91 These factors, when applied to the crude rates, produce the following adjusted rates :— Live births 11.47 Deaths 10.00 Deaths. The Registrar-General's classification of causes of death by sex totals is shown in Table 1 on page 22. The total number of deaths in 1954 (1,133) compares with 2,029* in 1953, the respective death rates per 1,000 population being 10.99 and 19.66. * See note on page 22. 22 TABLE i. Causes of Death as given by the Registrar-General, 1954. Causes of Death Males Females Total 1. Tuberculosis (Respiratory) 7 3 10 2. Other forms of Tuberculosis 1 — 1 3. Syphilitic Disease 2 1 3 4. Diphtheria — — — 5. Whooping Cough — — — 6. Meningococcal Infections — — — 7. Acute Poliomyelitis — — — 8. Measles — — — 9. Other Infective and Parasitic Diseases 3 — 3 10. Malignant Neoplasm—Stomach 19 24 43 11. Malignant Neoplasm—Lung and Bronchus 42 12 54 12. Malignant Neoplasm—Breast — 19 19 13. Malignant Neoplasm—Uterus — 4 4 14. Other Malignant and Lymphatic Neoplasms 45 52 97 15. Leukaemia and Aleukaemia 3 2 5 16. Diabetes 1 5 6 17. Vascular Lesions of Nervous System 71 89 160 18. Coronary Disease, Angina 78 52 130 19. Hypertension with Heart Disease 12 13 25 20. Other Heart Disease 83 140 223 21. Other Circulatory Disease 22 30 52 22. Influenza 1 — 1 23. Pneumonia 27 28 55 24. Bronchitis 56 21 77 25. Other Diseases of Respiratory System 11 3 14 26. Ulcer of Stomach and Duodenum 19 7 26 27. Gastritis, Enteritis and Diarrhoea 2 2 4 28. Nephritis and Nephrosis 8 6 14 29. Hyperplasia of Prostate 4 — 4 30. Pregnancy, Childbirth, Abortion — 3 3 31. Congenital Malformations 4 2 6 32. Other Defined and Ill-defined Diseases 34 37 71 33. Motor Vehicle Accidents 4 3 7 34. All Other Accidents 4 8 12 35. Suicide 3 1 4 36. Homicide — — — Totals, 1954 566 567 1,133 Totals, 1953* 986 1,043 2,029 * In 1953, on the instruction of the Registrar-General, deaths which occurred in Institutions in the Borough were assigned to Leyton, irrespective of the area from which they had been admitted. The effect of this was that an additional 800 deaths (in Langthorne Hospital) were included in the total deaths allocated to Leyton. Without this allocation the death rate would have been 10.92. 23 TABLE 2. Comparative Statistics of Births, Mortality, Etc. LEYTON, 1901-1954. Year Population Births Birth Rate Deaths Death Rate Deaths under 1 year Infantile Death Rate 1901 100,000 2,963 29.63 1,243 12.4 404 136 1902 100,000 3,152 31.52 1,183 11.8 336 106 1903 102,000 3,273 32.08 1,112 10.9 322 99 1904 104,000 3,198 30.07 1,370 13.1 444 138 1905 105,000 3,209 30.05 1,177 ii.2 303 94 1906 108,000 3,344 30.9 1,327 12.2 382 114.5 1907 120,000 3,190 26.6 1,269 10.6 182 86.6 1908 121,200 3,071 25-3 1,185 9.8 242 78.8 1909 121,200 2,979 24.6 1,208 9-9 244 81.9 1910 123,300 3,on 24.4 1,112 9.0 191 63.4 1911 124,736 2,931 23.5 1,473 11.8 327 116.6 1912 126,700 2,797 22.1 1,343 10.6 223 79.7 1913 129,366 2,904 22.4 1,336 10.3 242 83.3 1914 130,847 2,800 21.4 1,363 10.4 219 78.2 1915 124,497 2,655 21.3 1,510 12.1 225 84.7 1916 B132,107* 2,560 19.4 i,47i 12.1 197 76.9 D121,420* 1917 8125,352* 2,005 16.0 1,414 12.6 172 85.8 D112,452* 1918 B125,352* 1,791 14.3 1,723 15.3 161 89.9 D112,452* 1919 B129,062* 2,195 17.0 1,397 11.3 154 70.16 D123,896* 1920 128,832* 3,168 24.6 1,330 10.3 207 65.34 1921 128,432 2,679 20.86 1,290 10.04 182 67.94 1922 131,600 2,416 18.36 1,420 10.79 155 64.16 1923 132,800 2,328 17.53 1,228 9.25 106 45.53 1924 133,500 2,101 15.74 1,325 9.92 no 52.36 1925 132,700 2,091 15.76 1,349 10.16 114 54.51 1926 130,000 2,022 15.55 1,261 9.7 131 64.79 1927 128,920 1,826 14.16 1,322 10.25 80 43.81 1928 130,300 1,853 14.22 1,290 9.90 91 49.10 1929 128,300 1,731 13.49 1,510 11.76 100 57.77 1930 128,300 1,757 13.69 1,222 9.52 81 46.09 1931 128,600 1,812 14.09 1,365 10.61 71 39.18 1932 127,140 1,666 13.10 1,341 10.54 89 53.43 1933 125,700 1,499 11.91 1,468 11.67 76 50.70 1934 123,430 1,454 11.78 1,317 10.67 64 44.02 1935 121,690 1,493 12.26 1,225 10.06 60 40.18 1936 119,900 1,421 11.85 1,272 10.61 74 52.07 1937 il8,ioo 1,420 12.02 1,349 11.42 75 52.81 1938 117,200 1,509 12.87 1,148 9.79 70 46.38 1939 B116,100* 1,499 12.90 1,242 11.21 46 31.65 D110,800* 1940 96,500 1,353 14.02 1,563 16.2 50 39.03 1941 84,790 1,129 13.31 1,142 13.46 37 38.30 1942 86,960 1,452 16.69 1,123 12.91 73 50.27 1943 87,880 1,595 18.14 1,248 14.20 57 35.73 1944 85,440 1,613 18.87 1,285 15.04 68 42.15 1945 87,330 1,474 16.87 1,147 13.13 52 35.27 1946 101,910 2,223 21.81 1,181 11.58 64 28.78 1947 105,550 2,359 22.35 1,278 12.10 78 33.06 1948 106,100 1,810 17.06 1,118 10.53 38 20.99 1949 106,700 1,630 15.27 1,232 II-54 43 26.38 1950 106,600 11,447 13-57 1,134 10.64 29 20.04 1951 104,700 1,311 12.52 1,362 13.00 27 20.59 1952 104,200 1,355 13.00 1,220 11.70 37 27.30 1953 103,200 1,279 12.39 2,029 19.66 30 23.45 1954 103,100 1,232 11.95 1,133 10.99 18 14.61 * Population as estimated for purposes of b, Birth Rate ; d, Death Rate. 24 OUR DAILY BREAD (Report by the Medical Officer of Health—March.) Reference. At the last meeting of the Public Health Committee I was asked for information regarding agene in bread; and as bread forms such a large proportion of the national diet, especially among growing children and the poor, I submit hereunder some information and observations regarding the changes it has undergone during recent years. Extraction. Flour for bread-baking used to be made by grinding wheat between stones and, as no heat was generated in the grinding process, the valuable health-giving properties of the wheat were left in the flour—all except the bran, which was sifted out. But when metallic roller mills came into use for grinding the flour lost a great deal of the valuable vitamins and minerals it used to contain. Before the last war only 70 per cent. of the wheat was made into flour, and most of the valuable extracted residue was sold either for the feeding of animals (cattle, swine and poultry) or to the makers of proprietary foods for the prevention or treatment of vitamin deficiency in human beings. During the war, in the interests of the nation's health, the extraction rate was raised compulsorily to 85 per cent. in National Flour, to which chalk was added. In 1945 a conference convened by the Ministry of Food to advise on post-war bread recorded "the very definite view expressed by the medical and scientific members of the conference that a return to white flour, such as was commonly in use before the war, would be thoroughly bad for the nation's health". Nevertheless in 1950 the extraction rate was lowered to 80 per cent. In 1953 Government control ended, so that bread can again be baked from flour of 70 per cent, extraction, with a corresponding loss to the public of valuable vitamins and minerals. A National Flour of 80 per cent. extraction is still available—subsidised and subject to price control; but the millers contend that the average housewife prefers white bread when she can get it. Bread made from the new white flour is now neither subsidised nor subject to price control; but the subsidy on bread made from National Flour continues. Addition. Of the many chemicals used by millers and bakers to improve the texture and keeping qualities of bread ("improvers"), to replace the valuable vitamins and minerals removed by extraction ("fortifiers"), to replace the lost natural fats (" fat extenders "), to increase the bulk of the loaf (" aeration process ") and to prevent it from going stale too quickly—probably the most objectionable is nitrogen trichloride ("agene"), which began to be added to flour in this country soon after the end of the first World War. Unfortunately no public statement was made at the time of its introduction, and we knew very little about it until the second World War. The purpose of agene is to bleach and "improve" the flour, and to make the loaf larger and more attractive in appearance. 25 In 1946 Sir Edward Mellanby—then Secretary of the Medical Research Council—published the results of experiments in which he showed that growing dogs fed on bread made from agenised flour developed hysteria, and that the fits ceased when the dogs were fed with untreated flour. Later experiments showed that agenised flour produced harmful effects in such animals as monkeys, rabbits and ferrets. In 1949 the use of agene as an "improver" was banned in America. In this country a special committee to consider the matter was set up by the Ministries of Food and Health, the Medical Research Council and the milling industry. Some four years ago our Government decided to ban agene "when an alternative improver is found", but for some reason or other the changeover to the alternative has not yet taken place. In 1950 a Committee under the chairmanship of Sir Wilson Jameson was unable to find evidence that agenised flour was in any way toxic to man; but the man in the street is left to wonder why he should have to feed his growing child on bread which has been proved to be harmful to growing dogs. Statement by Minister of Food. On 21st December, 1954—in response to a question asked in the House of Commons—the Minister of Food made this statement regarding the report of the Committee set up in 1950 under the chairmanship of the Chief Medical Officer of the Ministry of Health. ''The methods of flour improvement which have been examined are agene, chlorine dioxide, potassium bromate, ascorbic acid and an aeration process. "The experiments have confirmed that agene-treated flour, when fed in large quantities, causes fits in dogs and have shown that none of the other improvers tested does the same. Since other methods of flour improvement exist which have not produced these symptoms in animals, the Government are of the opinion that, although no ill-effects in man due to the use of agenised flour have been established, effect should now be given to the decision taken in 1950 to discontinue agene. "In view of this decision, the National Association of British and Irish Millers have agreed to recommend their members to discontinue the use of agene and to give an undertaking that the equipment for treating flour in this way will be removed from their mills by the 31st December, 1955. Some delay is inevitable because new equipment has to be obtained to treat flour by other means. The National Association of Flour Importers have similarly agreed to recommend their members to ensure that no flour treated with agene will be imported by them. "The further investigations undertaken by the Medical Research Council have revealed some differences between the effects on flour of the other methods of improvement, but the effects demonstrated are not sufficient to require the discontinuance of any of the other four improving processes. These methods of flour improvement will continue to be kept under close scrutiny in collaboration with the milling and baking industries.'' THE WATER WE DRINK Its Source. In days gone by all towns had to take their water supply from rivers and streams which had also to act as sewers ; but most have abandoned that method long ago in favour of a piped water supply from a dammed-up valley, in some cases a long way off. London still gets its water supply from the Rivers Thames and Lea, and the Metropolitan Water Board has developed 26 a system of purification which is almost perfect. In course of time it will no doubt again become necessary for large towns to revert to the London system, because the great increase in urban development of rural areas is making it more and more impossible to maintain sources of supply other than those from rivers. The River Lea has its source in Bedfordshire and, as it flows southwards through Hertfordshire, it receives the sewage effluents of a large number of nearby towns and villages. It supplies about a million Greater London households, including those in Leyton, with drinking water; and, as the water is heavily polluted above the intake of the Metropolitan Water Board, the water authority has the tremendous responsibility of operating a system of purification which converts its foul raw material into a drinking water supply which is at least safe, though it may have lost much of its natural sparkle and palatibility. Control of Purity. No public health service is more vulnerable than the public water supply, and none is more exposed to destruction and contamination by hostile attack in time of war. In my Annual Report for 1945 I wrote :— "During the early days of the first London 'blitz' in September, 1940, one was appalled to see fractured water and sewage mains in bomb craters which became filled with a mixture of drinking water and sewage. Such fracture of water mains occurred during almost every heavy air raid, and the Director of Water Examination has reported that during one night over 500 water mains were broken. Sewers were damaged during each air raid, with the inevitable result that untreated sewage was discharged into the river from which the raw water supplies came. Reservoirs were cut off from purification works by the destruction of aqueducts. Bombs fell into filter beds and caused short circuits between filtered and unfiltered water channels. The demand for water to deal with fires necessitated the occasional by-passing of the slow sand filters in order to maintain supplies. Here, surely, were circumstances which might be calculated to cause pollution of water supplies on a scale hitherto unknown. Had the enemy succeeded in stopping or polluting the water supply of one-sixth of the country's population, it would have been a staggering blow worth many military victories. "However, by exercising unremitting attention and supervision, and by the application of special measures designed to shut out sewage from water channels, those in charge of London's water supplies were able to avoid a major calamity to public health and morale. Furthermore, they have achieved the wonderful record of being able to report that not a single case of typhoid fever attributable to the water supply has occurred in London since September, 1939. This is indeed one of the greatest achievements during the war; but, like so much of the work undertaken in the interests of the public health, it has never received the appreciation it deserves because it never allowed to occur the disasters it was designed to prevent." The passage of time has served but to increase my wonder at the achievement of the Metropolitan Water Board during these war years, and the fact that it surmounted all disasters with such complete success that no case of water-borne disease occurred in the area it serves. A truly wonderful achievement. Prevention of River Pollution. Prior to 1951 it had been found that the Rivers Pollution Prevention Acts and various local enactments were quite inadequate to prevent gross pollution of rivers and streams, and great hopes were raised by the replacement of these statutes by the Rivers (Prevention of Pollution) Act, 1951. Optimists, who thought that the fight for clean rivers had then been won, 27 have since been disappointed owing to the protection afforded to those responsible for pollution by trade and industrial effluents, including sewage effluents. Unfortunately few of the effluents discharging into rivers and streams, even above drinking water intakes, comply strictly with the "standards " prescribed in the Act. Synthetic Detergents. During recent years there has been an enormous increase in the use of synthetic detergents for trade and domestic uses, and unfortunately the purification plants at sewage works do not remove all types of detergents. In the upper reaches of the River Lea, well above the intake of the Metropolitan Water Board, the amount of "foaming" of the water has given rise to grave concern; and even if there be found some reliable method of overcoming the foaming, public health officers will naturally wish for some evidence that the presence of detergent in our drinking water is not deleterious to health. The Committee on Synthetic Detergents. In May, 1953, the Minister of Housing and Local Government appointed a Committee "to examine and report on the effects of the increasing use of synthetic detergents and to make any recommendations that seem desirable with particular reference to the public health services." As there is such a keen and widespread public interest in the subject, an Interim Report was published early in 1954, although there still remains much work to be done by the Committee. The reasons for the widespread public interest regarding detergents are because:— (a) they may be the cause of trade dermatitis and other dangers to health; (b) they are believed to cause corrosion of domestic equipment and plumbing; (c) there are reports of excessive foaming at sewage works; and (d) they have given rise to public anxiety for the purity of drinking water drawn from rivers subject to thick layers of foam. The Committee's Interim Report. The Report states that there has been no significant increase in dermatitis since synthetic detergents came into use; and the Committee's advice to housewives is:— (i) Choose the detergent that suits you best. (ii) Do not use more than you need. (iii) Always rinse and dry the hands thoroughly after using detergent. The Committee recognise the possibility that traces of detergent may get into food and drink after washing-up of crockery and in other ways, and they are examining the implications of that possibility; but they have no definite evidence so far of ill-effects to health caused thereby. Nor do they think that corrosion will lead to widespread difficulty if sinks are well rinsed after each washing with detergent. 28 The most serious aspect of the problem is the effect of detergents on sewage works and the disposal of effluents, and it is considered that further research is called for before any single method can be recommended for use. Meanwhile foaming is not considered to be sufficiently serious to justify public alarm, although it may become more troublesome if detergents of the present type should become increasingly used. The Committee sum up in these words:— "Available evidence about the effects of the growing use of synthetic detergents does not justify any immediate alarm in users or in the public health services. There is definitely nuisance at some sewage works however, and there are other and more serious possibilities in relation to the efficiency of sewage treatment, the condition of rivers, and the purity of water supplies. All these matters require and will receive most careful examination." THE AIR WE BREATHE (Report by the Medical Officer of Health—November.) Of the three absolute necessities of life—Food, Water and Air— measures for safeguarding the purity and preventing the contamination of food and water are so far in advance of those applied to the air we breathe that the pollution of the atmosphere may be regarded as the almost unchecked environmental evil of our age. It required the five-day fog of December, 1952, which resulted in the death of over 4,000 people, to awaken the public conscience to the seriousness of the air pollution which has been comparatively neglected for generations. The Disastrous Fog of December, 1952. During a period of five days—from 5th to 9th December, 1952—the Greater London area was enveloped in the thickest smoke-laden fog within living memory. In February, 1953 I submitted to the Public Health Committee a special report entitled' Fog and 'Flu—Some Facts and Figures', and in the following month some additional statistical and graphical information in the form of a second special report entitled' The Winter of 1952-53', from which the following is a quotation. 'The man-made fog of three months ago was no new phenomenon; nor can it be regarded as a pestilence caused by an agent against which we have no defence. It is merely a repetition of what the medical officers of health of Manchester, Glasgow and other large industrial cities have been reporting for generations; and is the well-known result of certain well-defined meteorological conditions in an area where the atmosphere becomes overloaded with poisonous products of combustion to such an extent that the human air passages are irritated until death or acute disability overtakes those least able to withstand such irritation. 'Man-made fog is in effect an epidemic illness whose cause is known. It is therefore preventable, and should be prevented. Can it be that we are now more pre-occupied with the cure of disease rather than with its prevention? 'These terrible fogs have a way of recurring all too frequently, and it would be well if the disastrous nature of the most recent one should lead to further investigation into all causes and effects. 'It is to be hoped that local sanitary authorities and the appropriate central Government departments will devote more of their time and money to smoke abatement by encouraging the replacement of obsolete industrial plant, by providing some incentive to help in the elimination of smoke from domestic sources, and by taking steps to reduce the gross pollution from industries such as railways, gas works and electricity generating stations. Meanwhile town dwellers are languishing for want of the health-giving rays of the sun that cannot penetrate the overhanging pall of smoke, housewives are burdened with the frequent washing and cleaning of curtains and other fabrics, and their houses and public buildings are being defaced and destroyed by the corrosive action of atmospheric pollution. ' 29 Committee on Air Pollution. In July, 1953, the Government appointed a Committee:— "to examine the nature, causes and effects of air pollution and the efficiency of present preventive measures; to consider what further preventive measures are practicable ; and to make recommendations." (a) Interim Report. In November, 1953, the Committee published an Interim Report which outlined the well known features of air pollution and from which the following extracts are taken :— Pollutants. The chief pollutants are smoke, sulphur dioxide, carbon monoxide, and grit. The domestic fire is the biggest single smoke producer. In ratio to the coal burnt it produces twice as much smoke as industry, and discharges it at a lower level. Three-fifths of the sulphur dioxide comes from industrial sources, one-fifth from electricity stations, and one-fifth from domestic consumers. Carbon monoxide is produced in about equal proportions from domestic and other sources, but about one-sixth of the total comes from motor vehicle exhausts. Under certain conditions this may cause relatively high local concentration at or near ground level. Grit, although the total weight emitted is only about one-quarter that of smoke, is produced from a large number of different sources in substantial quantities. The Acts in force for the control of pollution are designed to secure that the best practicable means of prevention are used. Except for the smokeless zone provisions in local Acts they are aimed at pollution from industrial, and not from domestic sources. RECOMMENDATIONS FOR IMMEDIATE ACTION. The Authorities. Every effort should be made without delay (1) to provide adequate supplies of smokeless fuels to domestic consumers in London and other densely populated areas liable to bad fog during the winter; and (2) to inform such domestic consumers when such supplies are available so that they may at least lay in a small stock for use when fog is developing. The appropriate authorities should, by whatever means are most suitable, bring to the notice of the public resident in areas liable to smog the fact that the largest single producer of smoke is the domestic consumer, and that it is to the personal advantage of everyone to co-operate in taking all practicable steps to reduce the amount of smoke discharged into the atmosphere. Steps should be taken to secure fuller and more frequent measurements of pollution, especially during severe smogs, in order to determine the peak concentrations reached. This will greatly assist our further investigation. Local authorities can do most valuable service in this respect. The Householder. Householders in large towns who are dependent on solid fuel and who normally burn coal should, before each winter, lay in a stock of (say) 1 cwt. of coke or other smokeless fuel for use during periods of persistent fog. A mixture of coke and coal will burn reasonably well and will greatly reduce smoke. Instructions to the General Public when Persistent Fog is forecast. Householders who can use only coal should take special care not to make more smoke than can be helped; fires should not be banked at night. Householders who can use smokeless fuels should confine themselves to those fuels during periods of persistent fog. A mixture of coal and coke as already mentioned will effect some improvement. 30 Rubbish should not be burned, nor bonfires lit, while the fog lasts. The general public should refrain from bringing motor cars into densely populated centres during a serious fog warning. In serious fog drivers of all motor vehicles should switch off engines whenever traffic is stationary, even temporarily. Factories, commercial buildings, hotels, institutions, etc., should immediately put into effect action to watch and control all stoking of furnaces, and to prevent smoke. Steps for Mitigating the Effects of Smog. Less smog will find its way indoors, and rooms will be kept warmer, if draughts can be prevented. Elderly people and those suffering from chronic chest and heart conditions would be well advised to keep indoors and to rest as much as they can if the fog is very thick. Those who go out will find that a closely-fitting simple gauze mask, or a woollen scarf wrapped round the mouth and nose, will give some relief by filtering out some at least of the solid contents of the smog. It is emphasised that the measures proposed here are no more than palliatives to be put into force during the next few winter spending the results of permanent and satisfactory measures. In August, 1954, a Special Report on "Mortality and Morbidity during the London Fog of December, 1952" was published by the Ministry of Health. It was a Report by a Committee of Departmental Officers and expert advisers appointed by the Minister; but it was largely confirmatory of the previous findings, and added little to the Interim Report's conclusion that there was no evidence to enable us to identify with any certainty the pollutants and the combination thereof which were responsible for the particularly harmful nature of the 1952 fog; and the problem still remains of why that fog was of such a deadly nature compared with previous London fogs. (b) Final Report. It is encouraging to note the welcome and publicity given by the national and local press to the long-awaited Final Report of the Committee on Air Pollution. In comparison with the rather chilly reception given to the Committee's Interim Report when it appeared towards the end of the year 1953, the enthusiastic public reception of the Final Report is a good augury for the future. The directness of the Committee's attack is evident throughout, and even in the foreword they make their position quite clear. For example:— "We wish to state our emphatic belief that air pollution on the scale with which we are familiar in this country today is a social and economic evil which should no longer be tolerated" "We are confident that our proposals, if carried out, will secure happier and more healthy living conditions for millions of people; and that on all counts the cost of the cure will be far less than the national loss in allowing the evil to continue" "It is basic to all our recommendations that at the outset it should be made the declared national policy to secure clean air." The force of these words should at least help to arouse public attention. These are among the principal recommendations in the Final Report:— 1. Subject to certain exceptions, the emission of dark smoke from any chimney should be prohibited by law. 2. Efficient grit and dust-arresting plant should be obligatory in certain large new industrial installations. 31 3. In those industrial processes where special technical difficulties exist, the responsibility for ensuring that the best practicable means of prevention should be vested in a central inspectorate (the "Alkali Inspectorate "). 4. The most efficient practicable methods of removing sulphur from flue gases should be adopted at all new power stations in or near populated areas. 5. The law for the control of smoke from railways, and of pollution from colliery spoilbanks, should be brought up to date and strengthened. Responsibility for enforcement should rest with the local authorities. 6. Local authorities should have power to establish (1) smokeless zones in which the emission of smoke from chimneys would be entirely prohibited, and (2) smoke control areas in which the use of bituminous coal for domestic purposes would be restricted. 7. Financial assistance should be provided by local authorities and by the Exchequer towards the costs incurred by house owners in converting appliances in smokeless zones and smoke control areas. 8. Domestic heating appliances installed in all new premises should be of approved types. 9. The present purchase tax of 50 per cent. on gas and electric (room and water) heaters should be removed. 10. General responsibility for enforcing the law for the prevention of smoke and grit should be placed as a statutory duty on the local authorities, which should be required to submit annual reports on their progress in smoke abatement to the appropriate Minister. 11. Penalties for smoke offences should be increased. Most of the smoke and grit in the air comes from industrial undertakings and the railways ; but the sulphur dioxide, the chief gaseous irritant, comes also from domestic fires and from electricity power stations. In certain circumstances (e.g., traffic-jams in the still air of streets) the calculated concentration of the products of combustion of petrol and diesel-oil pollute the air to an alarming extent. The erosion of stone and metal by the sulphurous fumes from railway shunting yards is indicative of the damage they must cause to the less resistant linings of the air passages of human beings in the community. Domestic smoke is discharged at a lower level than industrial smoke, and consequently its harmful effects are greater. There is therefore little justification for requiring industry and commerce to take all measures to prevent smoke unless the problem of domestic smoke is also dealt with energetically. Local Authorities are recommended to make their new housing estates smokeless by requiring the occupiers, as a condition of tenancy, to use only smokeless fuels in the appliances with which they are provided. This recommendation is based on experience in Bradford and Nottingham, where this condition of tenancy has had good results. 32 Coke is not, as is popularly supposed, "coal with the goodness taken out of it", but is "coal with the smoke taken out of it"; and, if properly used, it gives more heat (weight for weight) than coal. In addition, there are no grounds for apprehension of danger from carbon monoxide poisoning provided proper appliances are used, for coke produces no more carbon monoxide than raw coal. It is already the practice of local authorities, at the instance of the Central Government, to instal improved appliances capable of burning coke efficiently in the new houses they build; and it is suggested that private builders should be required to follow the same practice. HOUSING Historical Survey. 1919 Owing to the state of housing after the first World War, the Housing Act of 1919 required local authorities to prepare schemes for the provision in their areas of enough houses for the working classes. 1920 The then Medical Officer of Health recommended the appointment of an additional sanitary inspector to carry out housing surveys, but the Council could not see its way to adopt that recommendation because of the heavy Rates at that time. The Medical Officer of Health recommended the clearance of an unhealthy area (Lea Bridge Gardens) in which 300 persons lived in some 47 houses (sic); but, as houses were not available for the families to be de-housed, no action could be taken. 1921 The Medical Officer of Health repeated his recommendation for an additional sanitary inspector for housing duties, but without avail. 1925 New Housing Act to stimulate local authorities to take action regarding slum clearance. The Medical Officer of Health reported that the shortage of houses cannot be measured, but considered that there would still be a shortage of houses even if all available land were built on. 1930 The Housing Act of 1930 required housing authorities to provide houses in advance before clearance areas could be dealt with. Strong action by local authorities, to remove the social evil of slums, was called for by the Government. In that year there were in Leyton still 454 applicants for houses in whose cases the Council was unable to allot accommodation. There were also three areas considered to be so dangerous or injurious to health as to justify them being dealt with as clearance areas, and two areas to be dealt with at a future date. 1932 After an interval of 12 years since the last recommendation, the Medical Officer of Health again recommended that Lea Bridge Gardens be dealt with as a clearance area ; but, as the Council could not provide accommodation for displaced tenants, recourse was had to the relatively unsatisfactory and much more cumbersome method of individual demolition of unfit properties. 33 1936 Part III of the Housing Act, 1936, is the basis of our present day operations for slum clearance; but the Act again stressed the need for ensuring that suitable accommodation is available for displaced persons before any recommendation is made to declare a clearance area. 1937 In March the Medical Officer of Health recommended the ment of two additional sanitary inspectors in order that it might be possible to devote the necessary time to the housing needs of the area; but no action was taken until the following year, when one additional inspector was appointed. 1939 With the onset of the second World War the Government called a halt to slum clearance action by local authorities, and during the next five years the demolition of slums was an activity pursued by the enemy only. 1944 Following a request by the Minister of Health to local authorities to review their housing needs and submit proposals, the Medical Officer of Health drew attention to the number of different Committees of the Council dealing with the same housing problem in different ways, and suggested the advisability of correlating the functions and co-ordinating the work of these committees in order to avoid duplication of effort and to ensure that the best use is made of the powers and facilities available. He also drew attention again to the need to provide alternative accommodation for families de-housed by clearance area procedure. 1945 After two deferments of the recommendation of the Medical Officer of Health "qua" co-ordination, the Public Health Committee recommended the Council to constitute a special Committee to co-ordinate all matters relating to housing. The constitution of the special co-ordinating committee and the number of meetings to be held annually were specified (Minute 919—1944-45). 1952 In March the Council instructed the officers to submit to the June meeting of the Housing and Town Planning Committee a comprehensive report on Future Housing Development. In June a comprehensive report was submitted jointly by the Town Clerk, Borough Treasurer and Borough Engineer and Surveyor; but after considering it the Council decided that a joint report, on areas suitable for rc-development, be submitted by the Medical Officer of Health, Borough Engineer and Surveyor, and Borough Treasurer. The Chairman of the Housing Committee appealed to the Chairman of the Public Health Committee for closer liaison between the two Committees to ensure that the latter Committee would not embarrass the former by making official representations for the demolition of unfit houses as the Housing Committee had not the available accommodation in which displaced tenants could be re-housed The officers of the sanitary authority were asked to hold their hands for two or three years in order to allow the housing authority time to get over what they regarded as a difficult period, and the appeal for a "standstill" has been observed. 34 1953 In July the Medical Officer of Health submitted to the Public Health Committee a Progress Report by the Senior Sanitary Inspector on the results of a Preliminary Housing Survey undertaken in eight of the ten areas selected previously for re-development; and copies of that Report were sent to all members of the Council. Later the Medical Officer of Health submitted, on completion of the survey, a Joint Report by the Senior Sanitary Inspector and himself. This comprehensive report was subsequendy incorporated in the Joint Report submitted by the Town Clerk to the Council at a later date; and it was also included in my Annual Report for 1953 (pages 59-69). 1954 In January, after consideration of the comprehensive report of the chief officers, the Council decided that as a first step the officers be authorised to discuss with the Ministry of Housing and Local Government the possible re-development of Areas 1 and 3 referred to in the report. It was not considered that Area No. 1 should be dealt with under Part III of the Housing Act, 1936, but that it should be dealt with under planning powers. With regard to the Area No. 3, it was considered to be suitable for Housing Act procedure. He therefore suggested that the Council should proceed immediately with Part I of the Area No. 3 under Housing Act powers. FUTURE HOUSING DEVELOPMENT (Joint Report by the Medical Officer of Health and the Chief Sanitary Inspector— November.) INTRODUCTORY Reference : Council Minute 902—1954-55. The Town Clerk suggested that—as several Committees would be concerned with the implementation of the various provisions of the Housing Repairs and Rents Act, 1954, which were intended to improve housing conditions generally—the officers should report on the best method of dealing with the inter-related problems and co-ordinating the action to be taken. Resolved: That the Town Clerk's suggestion be approved. Outline of Previous Joint Report. In December 1953 your Council gave consideration to a comprehensive report by the chief officers which contained a special Joint Report by the Medical Officer of Health and Senior Sanitary Inspector on Future Housing Development dealing with such matters as:— (1) The nature, scope and findings of the Preliminary Survey of the 10 areas in the Borough previously selected for re-development. 35 (2) The two-fold nature of Leyton's housing problem—long-term and short-term. The relative responsibilities of the two responsible committees, and the need for the closest possible "liaison" between these committees and their officers. The powers delegated to the Public Health Committee, whose responsibility it is to deal with the short-term housing need. (3) Procedure under the Housing Act, 1936. Its anomalies. Its impractibility to deal effectively with houses unfit for habitation and dangerous to health. (4) Procedure under the Public Health Act, 1936. Its limited scope. Its use and abuse. (5) Properties abandoned by owners. Alternative methods of disposal: (a) by demolition and closure; or (b) by acquiring the property and carrying out works of renovation and maintenance. Factors to be considered. (6) Difficulties likely to follow the termination of the War Damage Subsidy. Inability of the local sanitary authority either to repair or to demolish certain types of insanitary dwellings. The competing claims—Public Health and Planning—on available new housing units. The Housing Repairs and Rents Act, 1954. Far from introducing new proposals calling for modification or reconsideration of the views we expressed in our previous report, the relevant provisions of the new Act show a practical appreciation of our difficulties by facilitating official procedure for dealing with clearance areas and promoting the repair of insanitary property. The Report we now submit should therefore be regarded as a supplement to our Report of last year on Future Housing Development. SLUM CLEARANCE What is a " Slum " ? No definition of the word "slum" is contained in the Housing Acts, 1936-54; but in common usage the word connotes an area containing insanitary houses which have reached the end of their useful life and are unfit for human habitation to such a degree as to be beyond satisfactory and economical repair, or houses which by reason of their bad arrangement or narrowness or bad arrangement of the streets are dangerous or injurious to the health of the inhabitants. The most satisfactory method of dealing with conditions in a slum is by demolition of all the buildings. 36 Number of Slum Houses in Leyton. In our joint report of last year we expressed the opinion that there were then about 1,000 Category "A" {i.e., " slum ") houses in Leyton, and that there were then many more whose type and condition were such as to justify them being regarded as "border line cases" in respect of their fitness for human habitation. Statutory Duties—Old and New. Section 1 of the Housing Repairs and Rents Act, 1954, requires local authorities to submit to the Minister of Housing and Local Government by 30th August, 1955, proposals for dealing with houses in their district which appear to be unfit for human habitation and with any other houses which they consider should be included in clearance areas. This specified duty carries with it the implied duty of making a housing survey, or at least a reasonably accurate assessment of the number of unfit houses. These duties are not really new, for local authorities are already required by Section 5 of the Housing Act, 1936, to cause an inspection of their district to be made from time to time in order to ascertain whether any house therein is unfit for human habitation. Local authorities were also required by the Act of 1936 to see that unfit houses were repaired, demolished or closed. Just prior to the outbreak of war your sanitary inspectors were engaged in a preliminary survey of the Borough for the purpose of determining what areas might be represented as "clearance areas" at a later date, and as the result of that preliminary survey it was considered that in several areas in the district the most satisfactory method of dealing with the conditions would be the demolition of all the buildings in these areas. Even before the war a considerable proportion of dwellings in the Borough had ceased to comply with modern standards, and had reached the stage when the reconditioning of the premises appeared to be inadvisable. But in September, 1939, the Minister of Health instructed local authorities to defer during war time the carrying out of schemes of slum clearance and to postpone the demolition of unfit houses. In November, 1944, your Medical Officer of Health submitted a special report on post-war policy for dealing with the repair, demolition or closing of individual unsanitary premises and with clearance areas. At that time he called special attention to the need to provide alternative accommodation for de-housed families before clearance areas could be dealt with, and to the need for correlating the functions and co-ordinating the work of the different committees and their officers dealing with different aspects of the same (housing) problem in the area. The Government has decided that the time has now arrived when more attention must be given to the nation's stock of existing houses, and the new Act facilitates the exercise by your Council of its statutory responsibilities for the clearance and replacement of slum houses, the enforcement of essential repairs, and the encouragement of improvements and conversions. 37 Relationship to Future Housing Development. The results of our Preliminary Survey showed that only some 500 of the estimated number of 1000 slum houses in the Borough are situated within the boundaries of the 10 areas surveyed for re-development. In these 10 areas the percentage of Category "A" houses (i.e., unfit for habitation) varied from 1.5 per cent. to 68.3 per cent., the average being 32.4 per cent, (roughly one-third). If therefore it were decided to re-develop these areas it would be necessary to demolish twice as many fit as unfit houses in order to make room for the new plan of development. It will be difficult to convince public opinion that this is the only practicable method of dealing with the slum problem in Leyton; and certainly it will be cold comfort for the tenants of slum houses to be told that, because of the Council's long-term planning commitments, insanitary houses elsewhere in the Borough must remain standing while houses of good habitable standard are demolished in the re-development areas. We are of the opinion that it would be impossible to adhere strictly to any long-term scheme of re-development without taking into account the overwhelming need to deal independendy with aggregations of insanitary property (whether within or without the areas selected for re-development) either as slum clearance areas or by individual demolition, and whenever practicable to make use of the site by building new houses or flats. Whether such new houses should be permanent or temporary would be influenced by such considerations as the urgency of the immediate need, the planning requirements and the purposes (i.e., residential, industrial, open space, etc.) for which the sites are zoned under the long-term development plan for the Borough. But whatever plans may be made for the future re-development of the Borough and for the clearance of slum houses, many years must elapse before their fulfilment. As the rate of demolition must keep pace with the rate of replacement, the process must of necessity be very slow owing to the lack of building sites. Under the circumstances a substantial proportion of the sub-standard property in Leyton may have to be retained and maintained for housing purposes for many years to come—possibly for as long as 20 years in some cases, and it is inevitable that with the passage of time the problem of maintaining existing houses in a habitable state will become progressively more difficult, and that there is bound to take place a consequent increase in the number of houses classifiable as slums. Deferred Demolition. The Housing Repairs and Rents Act, 1954, contains additional powers to enable local authorities to deal with their problems of slum clearance. Briefly, the Government's proposals are:— The Minister envisages an interim stage in the process of clearing slums. Part III of the Housing Act, 1936, has been amended so as to enable local authorities to proceed with the action which normally leads to demolition (Declaration of slum clearance area; submission to the Minister of a compulsory purchase order ; public inquiry, etc.) but to defer actual demolition of the houses until they can carry the process to its proper conclusion. The local authority may acquire whole or 38 part of the condemned houses in the area at site value and, with the aid of a State Grant, carry out such repairs as may be necessary to maintain them in a tolerably habitable condition until such time as the occupants can be re-housed. (In Leyton this may mean anything from one to fifteen or more years.) The Minister is of the opinion that this interim stage in the treatment of slums should form an integral part of each local authority's programme wherever it is not possible to demolish and replace all unfit houses in their district within the next five years. Accordingly authorities are asked to set out in their programmes, in addition to their proposals for demolition and replacement, what they think it will be practicable for them to do by way of acquiring areas which they cannot clear within that period. In these areas they would carry out such repair work as is reasonably practicable. The Minister recognises that this will place an administrative burden on local authorities, and that adequate staff will be required to carry it out. But whatever burden is involved, the Government makes it clear that this is a task which every local authority must face wherever it is forced to leave people in slum houses with no reasonably early prospect of re-housing. It is a responsibility—this temporary care of slum dwellings—which the Minister will share with the local authority by the approval he gives to their programmes, and they will have the support of all who favour a practical and realistic approach to the problem. Finally the Minister states that from a humane point of view the money and work involved in such operations will be well spent, and that there should be corresponding savings in the amount of sickness, disease and human degradation. Submission of Proposals. It will not be possible to formulate any definite proposals (for dealing with slum houses in the Borough) for submission to the Minister under Section 1 of the Housing Repairs and Rents Act until the Council's policy— particularly in regard to the principle of Deferred Demolition—is determined. As already stated, such proposals must be submitted by 30th August, 1955 unless (exceptionally) the Minister extends the period. Alternative Action. The only alternative to the acquisition and repair by the local authority of groups of slum properties in clearance areas in advance of actual demolition would be for the Council to continue the present practice of attempting to force owners of insanitary properties to carry out essential repairs by serving notices under the nuisance abatement procedure of the Public Health Act, 1936. The limitations of this procedure have already been stressed earlier in this Report, and it should now be realised that in the event of such action being challenged by the owner on the grounds that the property has reached the end of its useful life, that it is beyond satisfactory repair and unworthy of further expenditure, or that the Council is acting unreasonably by not exercising its statutory powers and duties under the Housing Acts, 1936-54, the Public Health Committee would have no alternative other than to consider demolition or closing order proceedings under Section 11 or 12 of the Housing Act, 1936. So far only a very small number of such cases have 39 been dealt with by that Committee in this manner, but the number is likely to increase substantially when the provisions of the new Act become more widely known and appreciated by owners of insanitary property. Before concluding proceedings under Section 11 or 12 of the Housing Act, 1936, the Council would have to decide whether to make a demolition order and re-house the occupants, or to operate the deferred demolition procedure in accordance with the provisions of Section 3 of the Housing Repairs and Rents Act. The latter decision would result in the Council purchasing the house at site value and, with the aid of a State Grant, maintaining it in tolerably habitable condition until the occupants are re-housed. The period during which the house is retained for temporary accommodation will depend on the ability of the Council to provide alternative housing accommodation which, as already indicated, may be anything from one to five or more years. The number of slum properties acquired by the Council would be limited to those which have reached a stage where—in spite of all statutory action under the Public Health Act—it has not been possible to effect any improvement in the insanitary conditions in which the occupants are living. We realise that the Council may be reluctant to take this step to acquire financially unprofitable investments, and may dislike the prospect of becoming and remaining landlords of even a comparatively small number of slum properties ; but we submit that in the circumstances there is no reasonable alternative if the health and well-being of the occupants are the paramount considerations. REPAIR AND MAINTENANCE OF DWELLING HOUSES Vigorous and resolute use of the statutory powers available to the local authority for securing the repair and maintenance of existing dwelling houses must form an integral part of the Council's proposals under Section 1 of the new Act. Especially valuable are those powers which enable the local authority to carry out in default of the owner, works required to comply either with notices served under Section 9 of the Housing Act, 1936, or with nuisance orders (Court Orders) made under the Public Health Act, 1936, and to recover from the owner the costs incurred. Comparatively little use has been made of these provisions in the past, and we recommend that in all appropriate cases these powers be exercised to the full. Another provision—of which little use has been made—is Section 4 of the Housing Act, 1949, which empowers the local authority to grant loans to property owners in order to enable them to fulfil their statutory obligations in carrying out essential repairs. IMPROVEMENT AND MODERNISATION OF DWELLING HOUSES It is sound economic policy to devote special attention and care to the rehabilitation of residential property capable of providing comfortable homes for another generation or more. In Leyton there are many thousands of such houses, structurally sound but lacking in amenities considered desirable according to modern ideas. The houses comprise the backbone of Leyton's existing housing accommodation, and unless they are preserved by modernisation many of them will deteriorate beyond the stage of satisfactory repair. 40 Sanitary Arrangements in Leyton Households. The Census of 1951 revealed the following information in respect of Leyton households :— Total number of structurally separate dwellings = 27,134 Total number of households (families) = 34,720 Number of households without exclusive use of:— Water Supply % Cooking Stove % Kitchen Sink % Water Closet % Fixed Bath % 8,628 25 2,564 7 3,99011 9,012 26 23,215 67 It will be noted that, of the 34,720 households in the Borough, 23,215 (67 per cent.) are without the exclusive use of a fixed bath. Of these, some 17,684 households have no bath at all in their homes. Many thousands of households have to share with other families the water supply, kitchen sink, cooking stove and water closet; and it is clear that there is much to be done to bring within the reach of all households the basic amenities of domestic life. It is one of the anomalies of our time that, in spite of the great progress made in environmental hygiene since these houses were built some 50 to 80 years ago, the present occupants enjoy no higher a standard of domestic hygiene than did their forefathers. The scullery sink with cold water is still the only water supply available for domestic purposes, including bodily cleansing, and in 3,990 Leyton households even the kitchen sink has to be shared by two or more families. Grants for Improvements and Conversions. The Housing Repairs and Rents Act, 1954, amends certain provisions contained in Part II of the Housing Act, 1949, which empowered local authorities to deal with this part of the housing problem by making money grants to private owners in order to promote modernisation of structurally sound houses, and amendments are designed to accelerate and simplify procedure. In recent Circulars the Minister of Housing and Local Government urges local authorities to do everything possible to encourage owners to apply for these grants. This should be accepted as sound advice, for by this means existing houses can be provided with such amenities as bathrooms, hot water systems, indoor sanitation, improved heating and cooking appliances, and so can be made to approximate to the standard of new houses at comparatively small cost to the local authority. When compared with the cost of providing equivalent accommodation in new houses (about £2,000 per house), expenditure on improvement grants to owners is obviously a sound financial investment. It is also a sound health investment, but the benefit to the health and comfort of occupants of houses modernised in this way does not lend itself to measurement. GENERAL OBSERVATIONS In spite of the new procedure of deferred demolition there are bound to be many cases in which houses are beyond any sort of treatment short of demolition. The competing claims on available new housing—the immediate 41 need from the point of view of public health versus the long-term need in relation to future planning and development—must therefore figure prominendy in any future consideration of housing development in Leyton. We find it difficult to conceive how a long-term re-development programme can be put into operation with any degree of success unless provision is made for re-housing the occupants of individual houses or groups of houses which have either reached or are rapidly reaching a state of total unfitness for habitation and may therefore require urgent demolition many years before the completion of the scheme of re-development—perhaps even before the scheme is due to be put into operation. It is in the face of the anomalous situation outlined above that the Public Health Committee is endeavouring to discharge the statutory functions, under the Housing and Public Health Acts, delegated to it by the Council. The bridging of the interval between the demolition of slum houses and the provision of new dwellings, an essential part of any long-term re-development programme, is an extremely complicated and difficult task which the Public Health Committee has to undertake. It can be achieved only by the adoption of resolute action and the full exercise of all available statutory powers. By diverting to this sphere of housing activity but a small part of the money and effort spent in providing new houses we could at least bring a substantial measure of hope and comfort into the lives of many who have little other hope of enjoying elementary hygienic amenities now regarded as necessities, and the planning of areas for re-development should not be so rigid as to cause bodily privation and mental distress to the many who must continue to tolerate slum conditions and may never live to enjoy the fruits of the labours of those who have been planning so long on their behalf. POSTSCRIPT (2nd February, 1955). With reference to the information contained in paragraph 7 of the above Joint Report, attention is called to the subsequent consideration of this matter by the Housing and Town Planning Committee at their meeting on 6th January, 1955 and to the following extract from the relevant Council Minute. MINUTE 2227—FUTURE HOUSING DEVELOPMENTREDEVELOPMENT AREAS. As a result of Part I of the Housing Repairs and Rents Act, 1954, and the changed planning proposals in the vicinity of one of the areas under consideration it had been found necessary further to consider the boundaries of the proposed re-development areas concerned with a view to including the maximum number of properties which, from a preliminary survey carried out by the Chief Sanitary Inspector, had been provisionally classified as unfit. The Borough Engineer and Surveyor submitted sketch proposals for the revised areas under consideration and stated that they contemplated further changes in certain planning proposals. Resolved: That the sketch proposals now submitted be approved in principle. 42 OLD PEOPLE LIVING AT HOME (Report by the Medical Officer of Health.) Introductory. It is common knowledge that people are living much longer than they used to do, and in recent Annual Reports I have shown the extent of the increased expectation of life. For various reasons, mostly legislative, "old age" is considered to begin at the age of 60 in the case of women and at 65 in the case of men. The care of the elderly has become a social and economic problem of great magnitude and, after unsuitable or inadequate housing, loneliness is the most distressing feature of old age. Like all other members of the community, old people prefer to be at home and every endeavour should be made to minister to their comfort there; but there is no more distressing and tragic picture than that of the old person, handicapped by physical and mental deterioration, neglected and lonely, and unable to attend to the most elementary of human needs. The greatest need of the moment is for an expansion and co-ordination of the domiciliary services available for old people. ADMINISTRATIVE ARRANGEMENTS During recent years there has been added one more (Geriatrics) to the already long and increasing list of medical specialities; but Local Health Services are, or should be, as much concerned with the care and welfare of Old People as they are with Children under School Age. Unfortunately, as in the case of other Health Services, there are several independentiy constituted Authorities concerned—the Local Sanitary Authority with the prevention and control of disease in old people; the County Council as Health Authority with their care and after-care; the County Council as Welfare Authority with the provision of Homes, Hostels and certain other services; and the National Assistance Board with supplementary financial assistance. There is no statutory liaison between these independent authorities, and any co-operation that exists is effected by the exercise of tact, goodwill and patience—generally at officer level. The existence of so many Authorities, dealing with different aspects of the same problem, results in overlapping of services and duplication of effort ; but it has the risk that old people may remain neglected or unknown, especially if they do not conform exactly to one or other of the administrative set patterns. No matter how efficient the services, they will avail little unless we know where they are required. WHAT WE KNOW 1. The Census of 1951 disclosed that there are in Leyton some 12,803 persons over 65 years of age; these figures give us some idea of their ages and marital status. 43 TABLE I Borough of Ley ton—Population over 65 Years of Age Age Group Marital State Single Married Widowed Divorced 65-69 530 2,907 1,273 9 70-74 396 1,800 1,492 6 75-79 261 982 1,236 7 80—84 160 321 785 1 85-89 50 66 343 — 90-94 23 8 122 1 95 and over 4 2 18 — Total 1,424 6,086 5,269 24 2. Of that 12,803 there were 605 (4.6 per cent.) who received assistance from our Domestic Help Service last year and the extent of their demand on available Help facilities may be gauged by consideration of these figures. TABLE II. Domestic Help Service Total number of cases attended during the year 869 1,680 visits Total number of cases, persons over 65 years of age 605 1,094 ,, Percentage of total (cases of persons over 65 years of age) 69.92 65.12 It is worthy of note that roughly 70 per cent. of persons who received help were over 65 years of age. 3. Again, we know that some 961 old people over 65 years were attended by the District Nurses of the County Council and the figures that follow show the extent to which attendance on old people engages the attention of these Home Nurses. TABLE III. Home Nursing Total number of cases attended during the year 2,124 56,908 visits Total number of cases, persons over 65 years of age 961 38,137 ,, Percentage of total (cases of persons over 65 years of age) 45.24 67 The figures show that over 45 per cent, of the patients requiring skilled nursing attention were over 65 years, and that their visits formed 67 per cent. of the total visits by District Nurses in the area. 4. We also know that some 50 old people partake of meals supplied in the basement kitchen in the Town Hall, and that 50 meals are sent out to old people under the "Meals on Wheels" Service arrangements. Meals are supplied twice a week. 44 WHAT WE DO NOT KNOW But we do not know the number of old people who may be leading lonely lives at home, some neglected even by their own children living nearby; and it is such lonely old folk who require and deserve all the help, comfort and companionship that can be given to them. In spite of the occasionally apparent diminution in family and filial responsibility, there is at the disposal of many lonely old people a heartening fund of neighbourly goodwill and Christian charity dispensed with no thought of recognition or hope of reward. The gratitude shown by lonely old people for any small act of kindness or companionship bears the hall mark of sincerity and it is often moving in its warmth; but even abounding goodwill is not enough, and there are old people—of whom many have done much for their country and their families during times when little public help was available— deserving of all the public help that can now be given them without prejudicing the needs of the younger members of the community. Goodwill abounds— the limiting factor is money, or rather the lack of it. RECOMMENDATIONS (1) That steps be taken forthwith to put into operation some practicable scheme of active collaboration between the local authorities (Health, Housing and Welfare) and the voluntary organisations designed to minister to the care and comfort of old people at home. (2) That consideration be given to the adequacy of the present grant by the Council to voluntary organisations dealing with the care of the aged. (3) That a register be compiled of all old people in the area who are living at home. (4) That the responsible voluntary organisation be notified of all old people who wish to be visited at home. (5) That consideration be given by the appropriate authority to the need for:— (a) a regular home visiting service; (h) provision of sitters-in; (b) additional club facilities; (i) night attendance on sick; (c) domiciliary chiropody; (j) re-housing in small modern bungalows of old people who occupy large houses in too solitary a state; (d) modern kitchen arrangements for the cooking of meals; (e) modern arrangements for serving meals ; (k) a scheme for the provision of "S.O.S." cards for display in the window in case of emergency. (f) extension of the ''Meals-onwheels " service; (g) laundry facilities; 45 THE PUBLIC HEALTH (PRESERVATIVES, ETC., IN FOOD) REGULATIONS, 1925-48. THIOUREA (Report by the Medical Officer of Health—September.) In January, 1954, the Minister of Food issued a Circular (M.F. 2/54) in which he stated inter alia:— " I am directed to draw the attention of your Authority to the possible use by certain orange growers of thiourea, and of fungicides containing thiourea, as a rot and mould suppressant. Thiourea can penetrate the skin of citrus fruits and find its way into the juice. Experiments in the United States have shown that this chemical is lethal to some animals in very low concentrations. Its use is accordingly open to strong objections on grounds of toxicity it would not be appropriate to introduce legislation designed specifically to prohibit the importation and sale of citrus fruit so treated. There is no conclusive evidence that citrus fruit treated with thiourea is being imported into the United Kingdom, but the possibility cannot be excluded and the Minister is confident that appropriate action will be taken by your Authority in the event of infringement of the Regulations being revealed by analysis of samples of citrus fruit." As thiourea comes within the definition of ''preservative" under the above Regulations, and is toxic when present in the skin or juice of citrus fruit, the sale of any article containing thiourea constitutes an offence under these Regulations. During the month of February it was reported to the appropriate Committee that three formal samples of oranges taken from retailers in the Borough were found to contain thiourea. The Council therefore instructed the Town Clerk to make strong representation to the Ministry of Food urging that, with a view to discouraging further importation of such fruit, action be taken against importers of oranges found to contain thiourea; an assurance was received later that there was no reason to believe that Port Health Authorities and H.M. Customs and Excise were not taking such action as may be deemed to be necessary within the limits of their powers. In April there were submitted to the appropriate Committee the results of an additional 10 samples of oranges examined during the previous month and, in reply to another communication from the Council the Ministry indicated that representations had been addressed to the Government of the exporting country, who had given an assurance that action was being taken by them to stop the export to this country of oranges that had been treated with thiourea. During the ensuing months (June to September) there were submitted to the Public Health Committee further reports; the following list gives the relevant information regarding the results of the analyses of samples of oranges examined during the year. It will be noted that, although the chemical is sprayed on the outside of the oranges, quite a large proportion penetrates the peel and contaminates the juice within, and in certain oranges examined (e.g., samples numbered 385, 386, 468 and 473) the concentration of chemical found in the juice was substantially greater than that found in the peel. 46 Sample No. Date of Purchase Country of Origin Concentration of Thiourea (parts per million) In Peel In Juice 273 5.2.54 Spain 40 12 281 10.2.54 Spain 10 4 290 10.2.54 Spain 40 14 335 15.3.54 Spain 14 8 336 15.3.54 Spain 10 4 337 15.3.54 Spain — — 338 15.3.54 Spain 10 6 339 15.3.54 Spain — — 340 15.3.54 Spain 14 8 341 15.3.54 Spain 10 6 348 16.3.54 Spain 10 8 359 30.3.54 Spain 10 4 360 30.3.54 Spain 10 5 385 27.4.54 Spain 12 15 386 27.4.54 Spain 6 12 387 27.4.54 Spain 24 12 389 4.5.54 Spain — — 390 4.5.54 Spain 15 — 391 4.5.54 Spain 10 8 392 4.5.54 Spain — — 393 4.5.54 Spain 38 8 394 4.5.54 Spain — — 396 5.5.54 Spain — — 397 5.5.54 Spain 12 1 398 5.5.54 Spain — — 399 5.5.54 Spain — 418 15.6.54 Spian — 419 15.6.54 Spain — — 420 15.6.54 Spain — — 421 15.6.54 Spain — — 422 15.6.54 Spain 10 6 423 15.6.54 Spain — — 467 24.8.54 South Africa — — 468 24.8.54 Brazil 12 15 469 24.8.54 South Africa — 470 2.9.54 South Africa — — 471 2.9.54 Brazil — — 472 2.9.54 Mozambique — — 473 2.9.54 Brazil 20 25 474 2.9.54 South Africa — 475 2.9.54 (Lemons) — — 476 2.9.54 South Africa — — 477 1.9.54 Brazil 25 25 478 1.9.54 South Africa - - 479 1.9.54 South Africa — — 480 1.9.54 South Africa — — LEPTOSPIRAL JAUNDICE (Report by the Medical Officer of Health—January.) In October, 1953, information was received that in a neighbouring Borough two residents had died from leptospiral jaundice. The causative organism is the leptospira ictero-haemorrhagica, which is commonly found in rats. Although it is primarily a disease of these rodents, it can be conveyed by them to human beings—chiefly by mud, slime and water contaminated by the urine of infected rats. The disease generally attacks persons occupied in such trades as sewer workers, miners and abbatoir workers and it is largely a disease of male adults. An analogous disease of dogs gives rise to cases of modified leptospiral jaundice in human beings. 47 In consequence of their increased liability to develop the disease, sewer workers (and those who may come into close contact with rats) should be warned of the risk, as the disease comes under the Workmen's Compensation Acts. Control of the disease depends on the efficiency of measures taken for the reduction of rats, and the protection of workers exposed to infection. In addition to being the cause of leptospiral jaundice, rats are also to a great extent responsible for the spread of such diseases as plague, rat-bite fever, food poisoning, enteric fever, trichiniasis and round-worms in human beings, and of foot and mouth disease and mange in the lower animals. In order to ascertain the extent of the infection among the local rat population, with the co-operation of Dr. J. C. Broom of the Wellcome Research Institution, arrangements were made for the investigation by him of rats caught in Leyton. Although it is possible to get some idea of the degree of infection by examining rats that have been poisoned or killed in traps, it is much more satisfactory to conduct the pathological examination immediately after death. For that reason only live rats were submitted for post-mortem examination. The catching of live rats is no easy task, and the 32 caught during the winter of 1953-54 were regarded as quite a satisfactory and representative sample of the rat population infesting the Borough. Of six live rats submitted for examination on 4th January, four were definitely established to be black or ''ship" rats (Rattus rattus). This catch of six live rats—of which four were black and two brown"—was surprising in two respects. Firstly, because we had believed that the black rat was confined to ships, ports and wharves; secondly, because we had been taught that the two species would not live together and that the brown rat exterminates the black. It was therefore a matter of surprise when four black or ''ship" rats were caught in a house in Leytonstone High Road and even more so when it was found that the four black rats and two brown rats had spent a long week-end together in the same cage. The unreliability of the colour of fur in identification of the species has been stressed, and it has been pointed out that the black rat is often brown in colour, and the brown rat often black. So now we know where we are. Subsequent enquiries and investigations elicited the information that the black or ship rat is by no means confined to Leyton, and that it appears to be gaining a foothold in other parts of London. Results of Pathological Investigation. The following table shows the results of the pathological examination of the 32 live rats submitted for examination between October, 1953 and April, 1954. The table shows where the rats were caught, and the results of the post-mortem examination of specimens taken from the blood and kidney. It will be seen that, in the 32 rats examined, leptospires were found in the kidney in six cases (i.e., 18.7 per cent.) and evidence of infection of the blood stream was found in 13 cases (i.e., 40.6 per cent.). 48 Date Place where caught Specimen Number Specimen (Blood) Specimen (Kidney) 1953 15.10 Destructor Works 1 Negative Negative. Absent 16.10 Destructor Works 2 Positive 1/1000 Present 16.10 Sewer. Manor Road 3 Positive 1/10 Negative. Absent 19.10 Sewer. Carlisle Road 4 Negative Negative. Absent 19.10 Sewer. Carlisle Road 5 Negative Negative. Absent 21.10 Sewer. Manor Road 6 Negative Negative. Absent 6.11 Sewer. Manor Road 7 Positive 1/300 Present 13.11 Sewer. Park Road 8 Positive 1/300 Present 13.11 Sewer. Manor Road 9 Positive 1/30 Present 16.11 Sewer. Steele Road 10 Negative Negative. Absent 16.11 Sewer. Steele Road 11 Negative Negative. Absent 19.11 Sewer. Melford Road 12 Positive 1/30 Negative. Absent 26.11 Sewer. Knotts Green Road 13 Positive 1/30 Absent 26.11 Sewer. Knotts Green Road 14 Positive 1/30 Absent 30.11 Sewer. Knotts Green Road 15 Negative Absent 21.12 Whipps Cross Swimming Pool 16 Positive 1/300 Absent 31.12 (B.P.) Church Road 17 Negative reaction Negative reaction 31.12 Whipps Cross Swimming Pool 18 Negative reaction Negative reaction 1954 4.1 (D.H.) High Road, Leytonstone 19 Negative reaction Negative reaction 4.1 (D.H.) High Road, Leytonstone 20 Negative reaction Negative reaction 4.1 (D.H.) High Road, Leytonstone 21 Negative reaction Negative reaction 4.1 (D.H.) High Road, Leytonstone 22 Negative reaction Negative reaction 4-1 (D.H.) High Road, Leytonstone 23 Negative reaction Negative reaction 5.1 (D.H.) High Road, Leytonstone 24 Positive 1/1000 Absent 12.1 (B.P.) Church Road 25 Positive 1/300 Present 18.1 (B.P.) Church Road 26 Negative Negative 8.2 Whipps Cross Swimming Pool 27 Negative Negative 11.2 Whipps Cross Swimming Pool 28 Negative Negative 16.2 (B.P.) Church Road 29 Positive 1/300 Present 1-3 (B.P.) Church Road 30 Negative Negative 26.4 Sewer. Grove Road 31 Negative. (Died in captivity) Negative 26.4 Sewer. Grove Road 32 Positive 1/300 Negative B.P. = Business Premises. D.H. = Dwelling House. HYGIENE IN CATERING ESTABLISHMENTS (Report by the Medical Officer of Health—August.) INTRODUCTORY This Report was intended in the first place for submission to the Council Committee primarily responsible—the Public Health Committee. But, as it also concerned other Committees responsible for catering establishments in the Borough, it was submitted finally to three Committees, viz., the Public Health Committee, the Baths and Public Offices Committee and the Leyton Committee for Education. COMMUNITY FEEDING AND ITS DANGERS During and since the last World War there has taken place a radical change in the food habits of the people of this country, to whom the eating of meals away from home has now become the rule rather than the exception. This changeover to community feeding has led inevitably to a great extension of community catering in commercial restaurants and cafes, in industrial and hospital canteens, and in municipal catering establishments such as civic restaurants and school canteens. To meet the increase in demand there was needed a great increase in staff. Although many caterers are well-trained and alive to their responsibilities, many have entered the catering trade because it is one of the few ways still left to an untrained person to acquire a business of his own. Without the necessary technical knowledge himself, he has to contend with an acute shortage of experienced workers by employing casual labour, and 49 staff so recruited and supervised cannot be expected to adopt and maintain a high standard of care and cleanliness. It is unfortunate that in this country, which has so long enjoyed a justifiable reputation for leadership in public health, the low standard of food hygiene should have given rise to invidious comparison with the higher standards of other countries. During recent years there has been a steady increase in the number of outbreaks of food-poisoning reported annually to the Ministry of Health, and it is well known that there occur annually many cases of food poisoning that are never reported. CONTROL OF CATERING ESTABLISHMENTS (a) Existing Legal Powers. The Sale of Food and Drugs Act, 1938, gave to Local Sanitary Authorities much-needed powers to exercise control over premises used for the preparation, storage and sale of food, and to make Bye-Laws for securing the observance of sanitary and cleanly conditions and practices in the handling, wrapping and delivery of food. The Public Health (Infectious Disease) Regulations empower a Local Authority or their Medical Officer of Health to suspend from work—in the preparation or handling of food for human consumption—any person suffering from certain specified infectious diseases. The Shops Act contains certain provisions applicable to catering establishments. The Prevention of Damage by Pests Act requires Local Authorities to take all necessary steps to secure that their districts are kept free from rats and mice and to prevent damage to food by pests. (b) Need for Extension of Powers. But for many years the need has been felt for power to prevent food (including drink) eaten or sold in food premises from being a source of infection to the consumer. This goes far beyond the problem of clean food— for the cleanest of food may be infected by the person who handles it, by the utensils in which it is contained, or by the water and cloths used to clean those utensils. CATERING TRADE WORKING PARTY (i) Terms of Reference. In 1948 the Minister of Food appointed a Working Party of experts " to make recommendations to the Ministers of Food and Health and the Secretary of State for Scotland as to the precautions considered practicable and desirable with a view to securing the observance of sanitary and cleanly conditions in the catering trade." (ii) The Report. The Report of the Catering Trade Working Party—a handbook of some 50 pages published by the Ministry of Food with the title "Hygiene in Catering Establishments"—was issued in 1951. 50 CENTRAL GOVERNMENT ACTION FOLLOWING THE WORKING PARTY REPORT (i) Ministry of Health. In September, 1951, the Ministry of Health issued to Regional Hospital Boards and Hospital Management Committees a Circular—H.M.C. (51) 79—drawing the attention of hospital authorities to the recommendations contained in the Report of the Catering Trade Working Party, and enclosing notes on the Prevention of Food Infection by kitchen and dining room workers. In June, 1953, the Minister of Health addressed to hospital authorities a further official communication—Circular H.M.C. (53) 49—in which he urged Hospital Management Committees to enlist as freely as possible the help of the Medical Officer of Health and his staff in order to ensure that inspection of hospital catering hygiene is fully and effectively carried out. In November, 1953, the Borough Medical Officer of Health, Leyton, and his staff were invited to make periodic inspections of the catering departments of hospitals in the area; a first report on these inspections has been submitted to the Hospital Management Committee. (ii) Ministry of Food. In 1953 the Ministry of Food issued a 59 page booklet entitled "Clean Catering"— a handbook on premises, equipment and practices for the promotion of hygiene in catering establishments. The booklet's avowed object is to give practical advice to caterers. (iii) Ministry of Education. In January, 1954, the Ministry of Education issued to Local Education Authorities, Circular 272 dealing with precautions considered to be necessary in the preparation and service of food in school canteens, and emphasised the risks of food poisoning in the hope that Local Education Authorities would take the measures necessary to avoid these risks. In that Circular the Minister, after suggesting measures for improving co-operation between school medical, teaching and kitchen staffs, emphasised the fact that such co-operation does not exempt the Medical Officer of Health from his statutory duty in respect of food premises (including school canteens) in his area. (iv) Food and Drugs (Amendment) Bill. During recent years satisfaction has been felt among local sanitary authorities and their officers on learning that the Government intended to introduce legislation to implement the recommendations contained in the Working Party Report and give to Local Authorities the powers required to raise the standard of food production and hygiene in the country. Unfortunately, following representations made by the catering trades, the Government has recently replaced certain of the essential clauses in the Bill by." Codes of Practice " to which it is hoped that caterers will conform. CONTROL BY THE LOCAL AUTHORITY Lack of enforceable standards is a serious impediment in the campaign for clean food, for the initiation of legal proceedings without official standards is an unreliable weapon in any attack on dirty food premises. 51 As in the past, we must rely on health education of the food handler in the hope that he will comply with recognised standards of cleanliness ; but the clean caterers don't need the advice, and the dirty ones can still avoid their responsibilities to the public they claim to serve. The officers responsible for supervising food and catering establishments are the sanitary officers of the local sanitary authority, and information regarding their work is contained in my monthly reports to the Public Health Committee and my annual reports to the Borough Council. In order to ascertain how far the catering arrangements in school, hospital and municipal canteens in the Borough comply with the suggestions and recommendations contained in the Government publications issued during the past year I arranged for a survey by the Chief Sanitary Inspector, and fortunately it was possible to complete the survey before the staff of sanitary inspectors became so seriously depleted. In order to reinforce my previously expressed opinion that the ideal form of health education is to practice what we preach, I submit this extract from the Report of the Catering Trade Working Party. "We consider in particular that Government Departments, hospital authorities and local authorities should ensure that catering establishments under their control should not only be above reproach but should serve as a model of good construction, good equipment, and good practice. We would urge that inspection of such establishments and any suggestions made for their improvement by officers of the local authority should be welcomed by the controlling department." The official handbook "Clean Catering"—issued by the Ministry of Food for the use of caterers—concludes with these words— "A FINAL WORD. Catering establishments are of many types, and not all have a ready source of information and service. It is, therefore, worth while to point out that the local sanitary inspector is not solely an inspector ; he is well versed in matters of public health, competent to give the caterer advice on problems of structure, equipment and practices. He should be welcomed as a friend, and his advice should be freely sought." TOWN HALL CANTEEN As the Town Hall Canteen is an undertaking belonging to the category of those in which it is officially considered that "Local Authorities should ensure that catering establishments under their control should not only be above reproach but should serve as a model of good construction, good equipment and good practice;" and especially as the kitchen and dining room facilities are available for use by outside caterers, in March I submitted these recommendations: (1) That an additional sink be provided for the rinsing and sterilising of utensils and crockery in the kitchen. (2) That the draining boards fitted to the sinks should be of stainless steel, to facilitate cleansing. (3) That the bare wooden floor in the dining room be suitably covered in order to facilitate cleansing and promote hygiene. accompanied by my contention that any municipal undertaking should be a model of its kind and that Municipal catering arrangements should be an example to caterers in the Borough. Since that time these recommendations have been under consideration by the appropriate Committee; but as there is still some doubt as to the reason for certain of the recommendations, I submit the following observations. 52 Cleansing and Sterilisation of Utensils. The two-sink method of washing up is that recommended in the official publications of all responsible Government Departments, and it is designed to replace the present unsatisfactory method in which one sink is used for all purposes—including the personal hygiene of the staff. In the two-sink method the first (cleansing) sink is used for cleansing in hot water containing a detergent; the water and detergent are changed as often as they become dirty or greasy. The utensils are then arranged in wire baskets, and immersed in the second (sterilising) sink, where they remain for at least two minutes. The sterilising rinse in the second sink is in clean hot water without added detergent or chemical, at a temperature of not less than I70°F. As the utensils are already clean, it is not necessary to empty the sink when more hot water is added. After two minutes the baskets are removed from the sink and stood on the draining board until dry. The purpose of the rinse in the second sink is threefold: (i) to sterilise the utensils; (2) to raise them to a temperature so high that they will air-dry almost immediately; and (3) to remove dirt and detergent. Drying by cloth should be quite unnecessary for crockery, for drying cloths become contaminated from the hands of the driers-up. Germs do not multiply on dry surfaces ; they need warmth and moisture and they can be assured of a plentiful supply from unclean cloths in the wet and steamy atmosphere one associates with a washing-up room. Floor Surface. All the relevant official publications by the Ministries of Health, Education, and Food, emphasise the need for cleanliness of walls and floors that should be "impervious to liquids and without open cracks". Adequate cleansing of a softwood floor with open cracks is impossible, and for that reason I included in my recommendations a suggestion that the bare wooden floor in the dining room should be suitably covered in order to facilitate cleansing. During the consideration by the Council of the above Report and Recommendations, with particular reference to the advantages of the two-sink method of cleansing and sterilising crockery and utensils, "The Borough Engineer and Surveyor reported that the cost of a complete two-sink sterilising unit would be approximately £250, plus £30 for fixing" and submitted estimates for alternative installations. The Council then deferred for three months the consideration of the installation of suitable equipment for the cleansing and sterilising of utensils in the canteen kitchen. In December, the appropriate Committee again considered the question, after which the Council "RESOLVED. That the Borough Engineer and Surveyor be instructed to arrange (i) for supplies of a suitable sanitising detergent to be available in the (Town Hall Canteen) kitchen at all times; and (ii) for a notice to be displayed requiring the use of such detergent, in the prescribed manner, by all caterers for the cleansing of crockery, utensils, etc., used in the canteen." 53 It is unfortunate that caterers who use the Town Hall Canteen are to be bewildered by the conflict between Municipal precept without and Municipal practice within; but they are fortunate indeed in that they are spared the responsibility of making the difficult decision whether to use a "sanitising detergent "or a "detergent sanitiser Whichever it be, they can at least rely on the fact that their choice is likely to be confirmed by high-powered sales talk and by advertisements that speak well of the preparation chosen. On the last day of the year the Ministry of Health circulated to Regional Hospital Boards and Hospital Management Committees a Circular—H.M. (54) 118—stated to be "Intended for the guidance of staff who are concerned with the sterilisation of equipment and other materials used in the treatment and care of hospital patients. The Minister accordingly asks Boards and Committees to review their present practice and suggests that they should be brought to the attention of all staff concerned." On the first page of the Circular are the authoritative statements that " Heat is the safest and most effective method of sterilisation ;" and that " Sterilisation by chemicals should be used only where heat is not available or is impracticable." TOWN HALL BASEMENT KITCHEN In order to complete the survey of catering establishments, which had been discontinued owing to shortage of staff, a special inspection was made of the catering arrangements for old people in the Town Hall Basement Kitchen. Nature and Scope of Service. The present arrangements for the supply of meals to old people in the basement kitchen of the Town Hall are the outcome of a pioneering charitable activity initiated by Alderman J. B. Shimmin during his Mayoralty in 1932. The scheme is now administered by the Borough of Leyton Council of Social Service, of which Mrs. A. M. Clewer is Chairman and Honorary Organiser of the Canteen Committee. Each Tuesday and Thursday there are cooked in the kitchen some 100 mid-day dinners, of which about 50 are consumed on the premises and approximately 50 are delivered in metal containers to individual homes. The price charged for dinners consumed on the premises is 3d. per meal, and for meals delivered at home the charge is 6d. The service is available to old persons recommended by the staff of the Health Department, local medical practitioners, home nurses, ministers of religion, charitable institutions, etc. Mrs. Clewer works in close liaison with the health visitors and home helps organiser of the Health Department and the meals service for old people should be regarded as a valuable ancillary to the work of the Health Department. 54 Staff. Mrs. Clewer is in charge of the catering arrangements, assisted by a staff of 12 helpers, of whom four or five are on duty each Tuesday and Thursday. Their services are given voluntarily, and Mrs. Clewer's record— extending over a period of 22 years without break or intermission, even during the trying times of the London Blitz—is an outstanding example of long and faithful voluntary service. Premises and Equipment. One large L-shaped underground room, of which the floor is 7 ft. 9 in. below ground level, serves as a combined kitchen, dining room and washing-up room. It is approximately 404 sq. ft. in area, and forms part of the basement of the Town Hall. The equipment, arranged along three walls, comprises kitchen range, gas stove, deep glazed sinks (two), heated container, cupboard for crockery and cupboard for utensils. On the floor are arranged three rather rough wooden tables covered by linoleum, which is discoloured and shabby. On these tables the meals are served. The premises are entered by a stairway from the ground floor of the Town Hall; a second stairway, which could be used as an emergency exit, is blocked with furniture. Although the equipment and utensils are far from being in accord with approved modern kitchen usage, they do not contravene the requirements of Section 13 of the Food and Drugs Act except in two respects to which reference is made later. General Observations. The arrangements began as a pioneering charitable effort some 22 years ago. There can be no doubt regarding the need for the service, which brings into the lives of so many old people a measure of much-needed nourishment, comfort and hope; nor can there be any doubt of the need for modernisation and extension of the service. Mrs. Clewer and her band of voluntary workers have carried out a most beneficent work; but it should be realised that the equipment and utensils with which they have had to "make-do" in the past have served their day and generation, and that an effort should now be made to supply the old people with nourishing meals, cooked in a modern kitchen and served in a separate dining room under conditions approximating to those expected in a modern catering establishment. It is contended that the kitchen is run on more homely lines than is a commercial establishment, and that many old people prefer it that way; but homeliness is no bar to hygienic propriety, nor can it be regarded as a material factor in the prevention of food-poisoning. I submit hereunder certain recommendations designed to abate or prevent the occurrence of nuisance or contravention of the provisions of the Food and Drugs Act, but it should be realised that compliance with these recommendations will not convert the present makeshift arrangements into those of an approved modern catering establishment. 55 With the great increase in the proportion of old people in the community, the provision of meals for them has become a valuable ancillary to the general health services undertaken in their behalf, and steps should be taken to ensure that the present arrangements for the supply of meals to old people be re-organised so as to bring them into line with our knowledge of the principles and modern practice of hygiene. Recommendations. Being underground, the natural lighting and ventilation are deficient. The artificial lighting is adequate, but mechanical ventilation should be provided, especially near the cooking ranges. The concrete floor is defective, and the surface should be repaired so as to facilitate cleansing. The plaster is defective and flaking on the walls above the sinks, and should be made good. An additional cupboard is required, and there should be provided an additional galvanised refuse bin with close-fitting lid. PREVENTION OF FOOD POISONING IN SCHOOL CANTEENS Daring the year 1954 some 4,120 pupils attending Education Authority Schools in Leyton partook of 820,580 meals; in addition some 11,700 pupils drank 2,313,498 issues of milk. It is therefore evident that the Education Authority is directly responsible for the largest catering undertaking in the Borough, and proper that its catering establishments (the School Canteens) should be subject to inspection by the Medical Officer of Health and his sanitary staff. In the section of this Report devoted to the School Health Service will be found (pages 151 to 153) an additional special report to the Education Authority under the title " Prevention of Food Poisoning in School Canteens". PUBLIC HEALTH DEPARTMENT OFFICE ACCOMMODATION In July, 1946, the Leyton Borough Council decided (Minute 2513) to build a new Main Health Centre, supplementary to the existing Centres at Leyton Green and Park House, in which accommodation would be allocated for the administrative offices of the Health Department. In August, 1948, without any opportunity for previous consideration by any of the three Committees concerned with the work of the Health Department, the administrative offices of the Health Department were transferred from the Town Hall to accommodation known officially as "the premises at the rear of 280 High Road ". Before the move took place a verbal undertaking was given that provision would be made for ventilation and natural lighting in the basement; but to-day after repeated complaints and promises over a period of more than six years the dampness of the basement and its unsuitability even for storage, is worse than before. 56 In January, 1949—and again on several occasions since that time— I have had occasion to draw attention to the unsuitability of the premises; but, as the accommodation was regarded as being merely a temporary provision pending the occupation of the new Main Health Centre, no effective action was taken. In 1952, when it became apparent that the accommodation was beginning to qualify for semi-permanent (if not permanent) status, I submitted to two of the Committees primarily concerned (the Public Health Committee and the Baths, Halls and Entertainments Committee) the following Report. THE STATE OF THE PUBLIC HEALTH OFFICES I beg to submit these observations on certain aspects of the work of the Health Department and the extent to which the success or otherwise of the work depends on the state of the premises in which it is carried out. In August, 1948, I was notified that the premises behind 280 High Road (in Sidmouth Road) would be ready in a fortnight for occupation by my Department (previously accommodated in the Town Hall). Before the move took place I was assured that provision would be made for the ventilation and natural lighting of the basement, for the storage of staff cycles, and for the laying out of surrounding ground in grass and flower beds so as to improve the appearance of the place from without. In consequence of the amount of stores attacked by dampness since that time, a belated endeavour is now being made to deal with the dampness in the basement ; but there is still a lack of other amenities, and in some respects matters have become worse with the passage of time. Borough and County Council employees referred for medical examination have the right to expect that they will not be asked to undress for examination in inadequately heated rooms where the sounds of hammering are often so loud that the examining doctor cannot possibly conduct a proper medical examination. Many members of the public first come into contact with the Health Department when they attend in response to sanitary notices or warnings in respect of dirty and insanitary conditions in their homes or catering establishments. Instead of receiving, as they should, advice and instruction in premises which are an object lesson in cleanliness, they are bewildered by the apparent inconsistency of being interviewed by a Senior Sanitary Inspector in a cold, dismal room with walls and ceilings as dirty as those in their own homes or food premises. The local Health Authority employs a large staff of domestic helpers. In my experience these women begin with a high opinion of their vocation, and every endeavour is made to encourage them to adopt a high standard of cleanliness in the homes to which they are sent. When they attend at the Health Offices— as they have to do regularly for briefing—they cannot help seeing the dirty and dilapitated walls of the entrance hall; and they naturally begin to wonder if that is the standard of cleanliness of their employing authority. Section 28 of the National Health Service Act places on local health authorities and their staffs very definite responsibilities for health education. The medical, nursing and sanitary staff devote much time to the dissemination of information and guidance on hygiene in the home; but health talks lose much of their value as soon as members of the public discover that the Health Department does not practice what its officers preach. The ideal form of health education is the efficient administration of the health services by practice as well as by precept. There is now being displayed in the windows of 280 High Road a special health exhibit showing some of the dangers of domestic uncleanliness; and it is hoped that those who have seen the exhibit will refrain from looking along the Council's passageway at the side of the building. Ever since my Department took over occupation of "the premises at the rear of 280 High Road" the precincts of the building have been more like a derelict builder's yard than those of a public building. Towards the end of last autumn there was dumped in the entrance hall a consignment of hot-water radiators which have lain there most of the winter. From time to time the contractor's men have come for a day or two, after which they have disappeared for weeks at a time; but meanwhile their equipment and materials have been left lying about the building, inside and out. Of the making of holes through thick concrete floors 57 and walls there seems to be no end, and much loud knocking has become a weariness of the flesh. If it is necessary to go on converting the heating of the building from one system to another, surely arrangements could be made for such conversion at some time other than in mid-winter. I have seen no modern Health Department housed in buildings and surroundings so unsuitable for the purpose ; and when visitors express surprise— as they so often do—I am getting rather tired of making the excuse that the premises are not typical of the Council's interest in public health. I cannot believe that individual members of the responsible Committees are aware of the state of affairs, and I beg to suggest that they be afforded an opportunity of visiting the premises and seeing the conditions for themselves. Thereafter I hope it will be possible to put the necessary work in hand as soon as possible. Over three years have elapsed since the suggestion contained in the last paragraph of the above Report was made, and since then steps have been taken to effect some improvement in the surrounding conditions, to carry out some internal decoration, and to provide a cycle rack for the staff; but these improvements do not convert the premises into what could be considered as suitable for the accommodation of a modern Health Department. SANITARY INSPECTORS (Report by the Medical Officer of Health—April.) STATUTORY DUTIES OF SANITARY INSPECTORS The duties of a Sanitary Inspector are specified in Article 27 of the Sanitary Officers (Outside London) Regulations, 1935. Briefly, and in broad outline, they are concerned with such matters as: nuisance abatement; atmospheric pollution and smoke abatement; the repair, closure and demolition of insanitary housing; drainage; shops; factories and workplaces; rodent control; schools; water supply; meat and food inspection; food premises and sampling; offensive trades; outworkers; infectious diseases; diseases of animals ; places of entertainment. The sphere of his duties and responsibilities is specified in, and regulated by, a large and ever-increasing number of statutes, statutory orders, regulations and bye-laws. In addition to these statutory duties he has to discharge a variety of functions which, although comparatively minor in themselves, are of importance in the maintenance of the public health. A summary of the work carried out by sanitary inspectors is reported each month to the Public Health Committee, and more detailed information is contained in my Annual Reports to the Council and the Ministry of Health. ORGANISATION OF WORK The work of the District Sanitary Inspectors is under the supervision and control of the Senior Sanitary Inspector, who is responsible to the Medical Officer of Health. The duties of the Senior Sanitary Inspector are generally administrative and supervisory. He prepares reports for Committee and attends Committee Meetings, supervises and deals with correspondence and visits, inspects premises where special action is contemplated, and is the executive officer specially designated under various Acts and Orders appertaining to his office. 58 The Senior Sanitary Inspector is the Council's representative on No. 8 Workable Area Committee (Ministry of Agriculture and Fisheries) for Rodent Control and on the Standing Conference of Co-operative Bodies (Investigation of Atmospheric Pollution) set up by the Department of Scientific and Industrial Research. The Deputy Senior Sanitary Inspector acts as a District Inspector, and deputises for the Senior Sanitary Inspector in the latter's absence. PRESENT STAFF (a) In Relation to Population. Many factors other than population have to be considered in assessing the number of sanitary inspectors required to perform satisfactorily the work of a Local Sanitary Authority. A district such as Leyton, containing much obsolescent property, requires more intensive attention than one of the same size of more modern development. In Leyton there is one Sanitary Inspector for every 11,500 inhabitants, whereas the officially recorded average for England and Wales is one Sanitary Inspector per 9,000 inhabitants. (b) Adequacy. Although the existing staff of nine Sanitary Inspectors may be considered to be adequate to deal with routine day-to-day requirements, there is too little margin to enable less urgent aspects of environmental hygiene to receive adequate attention. For instance, the Preliminary Housing Survey undertaken last year in connection with the Council's Re-development Scheme was carried out at the expense of less urgent but nevertheless important work. ADDITIONAL COMMITMENTS (i) Re-development Areas. The Council's recent decision to proceed with clearance of insanitary houses and re-development of certain areas in the Borough under the Housing Acts and Town Planning Acts will involve the Health Department in a very substantial amount of additional technical and clerical work. Before further consideration can be given to the Council's proposals, detailed surveys of each house in the specified areas will have to be undertaken by the sanitary inspectors in order to obtain the information necessary to prepare the comprehensive schedules of evidence necessary to support the Council's case at public enquiries ; the representative of the Ministry of Housing and Local Government placed great emphasis on this point when the Council's proposals were discussed at that Ministry recently. The survey of each area will require the full-time services of a Sanitary Inspector for a period of at least six months, and, as this is the beginning of a long-term programme of re-development in the Borough, it is reasonable to assume that at least two inspectors will be engaged on this work for an indefinite period of years. 59 (ii) Housing Repairs and Rents Bill. The Housing Repairs and Rents Bill, which is likely to become law within a matter of weeks, will impose still heavier duties on the Health Department, especially the sanitary inspectors. This Bill is of special interest to the general public because it affects rents, and tenants faced with a demand from the landlord for an increase in rent may apply to the Local Authority for a certificate of disrepair which will entitle them to refuse to pay the repairs increase until the house has been put right. Before a certificate can be issued it will be necessary for the Sanitary Inspector to carry out detailed inspection of the properties concerned, and great care will have to be taken in the issue of these certificates, for they may be contested by owners by appeal to the Court. It is reasonable to assume that when this Bill becomes law a great public demand will be made on the time of sanitary inspectors in dealing with applications from tenants for certificates of disrepair and in giving evidence in Court regarding appeals by owners. (iii) Housing Circular No. 30/54. The urgency with which the Government regards the housing situation is indicated in the following quotation from Circular No. 30/54 issued by the Ministry of Housing and Local Government as recently as last month (22nd March):— "As has been repeatedly stressed both in the White Paper (on the Housing Repairs and Rents Bill) and in the debates, it is an essential part of the Government's housing policy that local authorities should now take up again, as a matter of urgency, the campaign of slum clearance which the war interrupted. Accordingly, local authorities should forthwith resume the full exercise of their powers under Part II and Part III (Clearance Areas) of the Housing Act, 1936, and continue to do so until the proposals they will submit under clause I of the Bill (if Parliament enacts it in broadly its present form) have been approved. "In addition local authorities should now take steps to review housing conditions in their areas. Although clause 1 of the Bill as it now stands allows a period of twelve months for the submission of proposals, measures for dealing in one way or another with unfit houses ought to be taken as quickly as practicable, and preparatory work done now will enable proposals to be submitted and approved, and action to be taken under the new law, earlier than would otherwise be possible." RECOMMENDATIONS. In consequence of the great increase in the sphere of duties of sanitary inspectors in order to comply with the extra work entailed by these additional commitments, I recommend:— (1) that steps be taken forthwith to fill the existing vacant posts (Nos. D.14 and D.22) in the establishment—one Sanitary Inspector and one G.D. Clerk; and (2) that favourable consideration be given to the advisability of increasing the existing establishment of Sanitary Inspectors from 10 to 12. Such increase in establishment would merely have the effect of reducing the number of inhabitants per Sanitary Inspector in Leyton to a figure nearer to that of the recorded average in England and Wales. 60 In my opinion 12 Sanitary Inspectors is the minimum number required to enable the Council to carry out satisfactorily and promptly its statutory duties and responsibilities under the Housing Acts and existing Public Health legislation. FUTURE STAFF REQUIREMENTS The above recommendation, to fill existing vacancies on the establishment, and to increase the establishment of Sanitary Inspectors to 12, is made in order to deal promptly with work at present confronting the Department. It does not take account of additional duties likely to be imposed on the Department by the Food and Drugs Amendment Bill and other legislation as a result of the "Beaver Report" on Air Pollution; the Report of the Gowers Committee on Health, Welfare and Safety in Non-industrial Employment; and the Report of the Inter-departmental Committee on Slaughter-houses. In July I had occasion to report to the Public Health Committee that no application had been received in response to the advertisement to fill a vacancy, and that two members of the staff had taken up more lucrative appointments in other areas. The Public Health Committee then RESOLVED (a) That the Committee note with grave concern the existing position regarding the recruitment of Sanitary Inspectors for service with the Council arising from the higher gradings offered by other Local Authorities in the London area; (b) That, as a matter of urgency, the Chairman of the Establishment Committee be requested to convene a special meeting of that Committee before the summer recess for the purpose of considering the action to be taken in this matter; (c) That the Establishment Committee be requested favourably to consider re-grading all posts for Sanitary Inspectors on the Council's established staff in accordance with the scales for Sanitary Inspectors in the London District Council area; (d) That, further to Minutes 3187 and 3325(4) (1953/54), the Establishment Committee be requested also to give immediate further consideration to the recommendation of the Medical Officer of Health that the establishment of Sanitary Inspectors be increased from 10 to 12, in view of his department's additional commitments arising from the Council's proposals regarding Re-development Areas, the Housing Repairs and Rents Bill and other pending legislation ; and (e) That in the event of the Establishment Committee agreeing to these recommendations, or any of them, the Town Clerk be authorised to issue a public advertisement inviting applications for appointment to the vacant posts for Sanitary Inspectors. Extracts from a Report by the Medical Officer of Health—January, 1955. In accordance with instructions of the previous month, last April I submitted to the Establishment Committee a special report in which I drew attention to the inadequacy of the staff of sanitary inspectors. 61 Unfortunately, during the six months which elapsed between the submission of that Report and its consideration by the Establishment Committee, the staff became seriously depleted by the loss of three Sanitary Inspectors to neighbouring authorities. THE POSITION NOW In the nine months that have elapsed since I drew attention to the inadequacy of the staff to carry out satisfactorily and promptly its statutory duties and responsibilities under the Housing Acts and existing public health legislation the progressive depletion of staff has led to a progressive worsening of the position and to a consequent accumulation of arrears of work undone. In April, 1954, the Council instructed (Minute 3040): "that a detailed survey of all residential property in redevelopment areas 1 and 3 be undertaken as soon as possible by the Medical Officer of Health." In spite of a special effort made to comply with that instruction, it has been possible—by neglecting other district work considered to be essential— to carry out only a small part of the work involved in such a survey. With a staff numerically half of what is officially regarded as adequate, and with each district inspector responsible for a population double that of the officially recorded average for the country as a whole, it is impossible to operate a comprehensive sanitary service, and residents in Leyton are being deprived of roughly half the sanitary service to which they should be entitled. The depleted staff are now almost fully employed in dealing with complaints and other matters requiring urgent day-to-day attention, leaving little (if any) time for less urgent work and special duties. Whereas the staff shortage has had a seriously adverse effect on the quantity and quality of all branches of the work, it is to failure to comply with the following statutory responsibilities and Government directives that attention is specially drawn. Housing. Section 5 of the Housing Act, 1936, requires Local Authorities to cause an inspection of their districts to be made from time to time in order to ascertain whether any house therein is unfit for human habitation. The manner of inspection, and records to be kept, are specified in the Housing Consolidated Regulations, 1925/32. Local Authorities are also required by the Housing Act, 1936, to see that unfit houses are repaired, demolished, or closed. Section 1 of the Housing Repairs and Rents Act, 1954, requires Local Authorities to submit to the Ministry of Housing and Local Government by 30th August, 1955, proposals for dealing with houses in their districts which appear to be unfit for human habitation. This specified duty carries with it the implied duty of making a housing survey. 62 The Government has directed Local Authorities to take active steps to review housing conditions in their areas and forthwith resume full exercise of their powers and statutory responsibilities under the Housing Acts, 1936/54, in relation to slum clearance and the enforcement of essential repairs to defective dwelling houses. In Circular 28/54, dated 15th December, 1954, the Ministry of Health directed Local Authorities to include in the Annual Report of their Medical Officer of Health details of the numbers of houses inspected in accordance with the Housing Consolidated Regulations, 1925/32. It is now possible to inspect house property only when complaints are received or in order to follow up notices served, or in special emergencies. This unsatisfactory method of intermittent inspection should be replaced by house-to-house district inspection in accordance with Section 5 of the Housing Act, 1936. An indication of the urgent need for district inspection on a house-tohouse basis may be gathered from statistics revealed by the 1951 Census— of 34,720 households in the Borough, 67 per cent, are in certain respects sub-standard. Each of these households (23,215 in number) should be inspected by a sanitary inspector to ascertain the degree of unfitness and to secure compliance with the relevant statutory provisions. Business Premises. In the Borough there are some 2,683 business premises—factories, food premises, shops, industrial undertakings, etc.—involving some 3,425 activities, and subject to registration or licence under various Acts and Orders. These premises should be inspected regularly by sanitary inspectors to ensure compliance with the provisions of the Acts controlling them and the health of those who work in them. In four districts—about half the Borough—it is possible to inspect business premises only when complaints are received or in connection with matters which require urgent attention, such as the inspection of food to ascertain its fitness for human consumption. Regular routine inspection of about half the business undertakings in the Borough has almost ceased, and visits to the remainder of the business premises have been curtailed. Sampling. Sampling of water, foodstuffs, and other commodities as required by the Food and Drugs Acts and Orders, and the Rag Flock and Other Filling Materials Act, 1951, has been reduced by 50 per cent. GENERAL OBSERVATION It should be realised that your Council's campaign of slum clearance and scheme of future housing development by the re-development of outworn areas depend primarily on the evidence made available by the housing surveys of sanitary inspectors. That is the evidence by which the Ministry of Housing and Local Government will be influenced in coming to a decision whether your Council may acquire dwellings at site value or whether they will have to be purchased at market value. The greater the number of houses proved to be unfit within the terms of the Housing Acts, the greater 63 will be the financial saving to your Council. The appointment of an adequate number of well qualified and experienced sanitary inspectors can therefore be regarded as a sound financial investment, and that consideration has no doubt influenced other sanitary authorities to take the steps necessary either to increase their staff or at least to retain their existing staff. In April I reported that in my opinion 12 Sanitary Inspectors was the the minimum number required to enable the Council to carry out satisfactorily and promptly its statutory duties and responsibilities under the Housing Acts and existing public health legislation. In the short period of six months thereafter, three inspectors left your then inadequate staff in order to take up higher-paid appointments in other areas. SCHEME FOR THE RECRUITMENT AND TRAINING OF STUDENT SANITARY INSPECTORS In October the Establishment Committee—Minute 1326(b)—asked the Public Health Committee to consider the question of the submission to them by the Medical Officer of Health of a scheme for the training of two Student Sanitary Inspectors. Report by the Medical Officer of Health, November, 1954. The Pre-requisites of a Student-Training Scheme. No scheme for training of Student Sanitary Inspectors can hope to succeed unless there are in the permanent establishment a sufficient number of experienced Sanitary Inspectors, settled in the Council's employ, who can provide the necessary practical training and supervision of the students. The importance of this practical training is emphasised in the following extract from a publication issued by the Royal Sanitary Institute and Sanitary Inspectors' Joint Board for the guidance of persons wishing to take the examination. "Great importance is attached to practical knowledge such as a candidate should have acquired in the course of his training. A desirably high standard of theoretical knowledge cannot compensate for any failure to satisfy the examiners in respect of thorough practical familiarity with the work and duties of a Sanitary Inspector." In fairness to the. students who may entrust their future to our care, arrangements made for their practical training and supervision should be based on a solid foundation of the technical experience possessed by those responsible for their tuition. The Chief Sanitary Inspector will be responsible for co-ordinating and directing the practical training of students in accordance with the requirements of the Royal Sanitary Institute and Sanitary Inspectors' Examination Joint Board. He will also be responsible for ensuring that the best possible use is made of students' services as Sanitary Assistants. Suggested Scheme for Training Two Student Sanitary Inspectors. 1. Student Sanitary Inspectors shall be designated as temporary officers of the Council. 2. Applicants for appointment as Student Sanitary Inspectors shall be young persons who have completed their period of National Service. 64 3. All students will be required, before acceptance, to hold the General Certificate of Education or its equivalent as required by the Royal Sanitary Institute and Sanitary Inspectors' Examination Joint Board. 4. Students must attend an approved course of study at a recognised College or Institute leading up to the statutory qualification of Sanitary Inspector. Such courses normally extend over a period of four years, but students who have already taken courses in Building or Sanitary Science as specified by the Examination Board may qualify in less than four years. 5. Students will be responsible for the provision of their textbooks and for the payment of travelling expenses, tuition and examination fees. Students may be eligible for the Council's scheme of financial assistance for post-entry training. 6. Students will be required to enter into a written undertaking not to abandon their studies, to sit for all appropriate examinations as they become due, and to remain if required in the service of the Council for a period of at least two years after obtaining their statutory qualification as Sanitary Inspectors. During such service after qualification the Council will pay a salary in accordance with the A.P.T. National Scales for Sanitary Inspectors. 7. Student appointments will be probationary for six months, and subject to satisfactory reports from the Chief Sanitary Inspector and the Institute where the course of study is taken. 8. Any student who fails to pass the Final Examination at the first attempt may, subject to a satisfactory report from the Chief Sanitary Inspector, remain on the Council's staff as a temporary officer for a further period to enable him to re-sit the qualifying examination. 9. The Council reserves the right to revoke its agreement with any student who, in their opinion, fails to take full and proper advantage of the facilities provided. 10. Students will work full-time in the Public Health Department, and will receive practical training and tuition from the Council's Sanitary Inspectors under the supervision of the Chief Sanitary Inspector. They will attend the office during normal office hours, but will be allowed a limited amount of leave to attend classes and practical demonstrations in connection with their studies. This normally involves one whole day per week in the third and fourth years of a full-time course, or between 20 and 24 half-days spread over two years for a part-time evening course. Practical training will be in accordance with the curriculum set out by the Royal Sanitary Institute and Sanitary Inspectors' Joint Board. 11. Students will be paid a salary according to age within the General Division scale laid down by the N.J.C. The scheme suggested by the Medical Officer of Health was approved by the Council; at the end of the year approval had been obtained for the issue of an advertisement inviting applications for the appointment of one Student Sanitary Inspector. 65 Infectious Diseases PREVALENCE OF, AND CONTROL OVER INFECTIOUS AND OTHER DISEASES Table showing the number of notified cases of infectious diseases and their disposal. Disease Notifications Received Removed to Hospital Smallpox — — Diphtheria — — Erysipelas 56 2 Scarlet Fever 141 30 Pemphigus Neonatorum 1 — Tuberculosis, Pulmonary 70 - Tuberculosis, Other forms 7 — Pneumonia 225 40 Ophthalmia Neonatorum 3 2 Typhoid Fever — — Paratyphoid Fever — — Puerperal Pyrexia 15 13 Meningococcal Infection 5 5 Poliomyelitis, Paralytic 1 1 Poliomyelitis, Non-paralytic — — Acute Encephalitis, Infective 1 1 Acute Encephalitis, Post Infectious — — Measles 753 29 Whooping Cough 220 12 Dysentery 104 41 Food Poisoning 48 2 1,650 178 On consulting the records I find that the number of notifications during the year 1954 is the lowest number since records became available, except for a period during the war years when a large proportion of the population was evacuated to the reception areas. Year Notifications received 1950 2,757 1951 2,973 1952 2,898 1953 2,507 1954 1,630 The above figures show the extent of the decrease in last year's notifications as compared with those of the previous four years. 66 Diphtheria. No case was notified during 1954. The last case notified was in 1951, a very mild throat infection, not confirmed bacteriologically. Information regarding immunisation against diphtheria is to be found on page 118. Dysentery. During the year 35 notifications of dysentery were received. 22 of the cases were admitted to hospital. There has been a very great increase in the number of persons notified to be suffering from dysentery, but very few of these cases have been confirmed bacteriologically and none of the persons notified had the disease in a serious form. Acute Encephalitis (Infective). One case was notified. Acute Encephalitis (Post Infectious). One case was notified and subsequently proved to be Infective (see above). Erysipelas. Of the 56 cases notified, two were admitted to hospital. Food Poisoning. There were 48 persons notified during the year to be suffering from food poisoning. Measles. Of the 753 cases notified, 29 were admitted to hospital. No child died from measles in 1954. Meningococcal Infection. Five cases were notified and removed to hospital. Ophthalmia Neonatorum. Of the three cases notified, two occurred in hospital. Paratyphoid Fever. No cases were notified. Pemphigus Neonatorum. One case was notified. Pneumonia. 225 notifications were received, of which 40 cases were admitted to hospital. 67 Poliomyelitis (" Infantile Paralysis "). One case of paralytic poliomyelitis was notified during the year. The child continues to be under the supervision of a hospital orthopaedic consultant. Annual Incidence since 1947. The following list shows the annual number of cases of acute poliomyelitis notified in the Borough from 1947-1954, inclusive. Year Year 1947 14 1951 — 1948 2 1952 12 1949 20 1953 8 1950 14 1954 1 Puerperal Pyrexia. 15 notifications were received, of which 11 occurred in institutions. Scarlet Fever. Of the 141 cases notified, 30 were removed to hospital. Smallpox. No case of smallpox was notified during 1954. Typhoid Fever. No notifications were received. Whooping Cough. Of the 220 children who developed whooping cough during the year, 12 had to be removed to hospital. Further information regarding Protection against Whooping Cough will be found on page 119. Tuberculosis. Notifications.—77 patients were notified for the first time in 1954 as suffering from tuberculosis. The number was made up as follows :— Males Females Total Pulmonary Tuberculosis 43 27 70 Non-pulmonary Tuberculosis 2 5 7 45 32 77 The 1954 figures are the lowest ever recorded in respect of the two forms of tuberculosis. 68 The following is a statement of particulars appearing in the Register of Notification of Cases of Tuberculosis for the year ended 31st December, 1954:— Pulmonary N on-Pulmonary TOTAL M. F. Total M. F. Total Number on Register at commencement of year 462 387 849 33 53 86 935 Number first notified during the year 43 27 70 2 5 7 77 Number of cases entered in Register otherwise than by Notification 8 8 16 2 2 4 20 Number removed from the Register during the year 22 21 43 4 2 6 49 Number remaining at the end of the year 491 401 892 33 58 91 983 Details of cases removed from the Register during the year:— Died 8 4 12 2 — 2 14 Removed from the district 11 14 25 — 1 1 26 De-notified — 1 I 1 — 1 2 Cured 3 2 5 1 1 2 7 New Cases.—The following table gives particulars regarding the new cases which have occurred during the year :— Age Periods New Cases Pulmonary Non-Pulmonary M. F. M. F. 0 I — — — — 5 1 1 — — 10 — — — 1 15 3 4 — — 20 3 8 — 2 25 7 4 — 2 35 12 4 1 — 45 10 2 — — 55 4 3 — — 6$ and upwards 3 1 1 — Totals ... 43 27 2 5 69 The following table shows the annual number of new cases and deaths over a period of 10 years. Year Pulmonary Non-Pulmonary Total Notifications Deaths Notifications Deaths Notifications Deaths 1945 111 35 11 6 122 41 1946 91 44 17 3 108 47 1947 89 41 9 4 98 45 1948 130 47 14 5 144 52 1949 118 33 9 4 127 37 1950 130 31 15 4 145 35 1951 100 35 14 5 114 40 1952 114 29 13 2 127 31 1953 78 35 13 4 91 39 1954 70 10 7 1 77 11 GENERAL PROVISION OF HEALTH SERVICES IN THE AREA i. PUBLIC HEALTH OFFICERS OF THE AUTHORITY. Medical. There were no changes in the medical staff during the year. Dental. No full-time dental officers have been appointed during the year, but several temporary part-time officers were employed. Nursing. Two Health Visitors (Mrs. I. M. Adamson and Miss M. J. Charters) resigned their appointments with the Local Health Authority during the year. One Health Visitor (Miss B. Jukes) was appointed and two successful students from the County Health Visitors' Course were allocated to the area (Miss K. Rayment and Miss O. Phillips). Sanitary Inspection. Early in the year there were 10 Sanitary Inspectors employed by the Local Sanitary Authority, but since that time there has been a serious depletion of staff, and at the end of the year there were only 6 Sanitary Inspectors out of a total establishment of 12. 70 2. LABORATORY FACILITIES. (a) Pathological Department, Whipps Cross Hospital, E.11. For pathological specimens. (b) Central Public Health Laboratory, Colindale. For special bacteriological investigations ; supply of lymph for vaccination; supply of diptheria toxin (A.P.T.). (c) Counties Public Health Laboratories, Queen Victoria Street, London. For bacterial and chemical examination of water, milk and other foods. (d) Public Analysts, Analytical Laboratory, 20, Eastcheap, E.C.3. For analysis under provisions of Food and Drugs Act, 1938. 3. AMBULANCE FACILITIES. In July, 1948, the County Council became responsible for the provision of ambulance facilities in the area. The service is now administered centrally from Chelmsford, the vehicles and staff being accommodated at the Ambulance Depot in Auckland Road. (Telephone : LEY 6077/8.) 4. HOSPITALS. The following hospitals, administered by the Leytonstone (No. 10) Group Hospital Management Committee on behalf of London N.E. Regional Hospital Board, are situated within the Borough of Leyton. (a) Whipps Cross Hospital. Accommodation: 924 beds. (b) Langthorne Hospital. Accommodation: 687 beds. 5. NURSING HOMES. There are in the Borough three Nursing Homes registered under the provisions of the Public Health Act, 1936. (1) 1 Queen's Road, Leytonstone. With accommodation for 22 patients. (2) " Brooklands " 22 Fairlop Road, Leytonstone. With accommodation for 25 patients. (3) 61 Wallwood Road, Leytonstone. With accommodation for 21 patients. 6. SCABIES CLINIC. With the co-operation of Hackney Borough Council facilities for Leyton patients are made available at the Cleansing Centre, Millfields Road, Hackney. During the year four Leyton residents attended for treatment, and made six attendances. 71 7. CLINICS. There are in the area three Essex Health Service Clinics:— Leyton Green Road, Leyton—opened September, 1933. Granleigh Road, Leytonstone—opened September 1935. Dawlish Road, Leyton—opened September 1951. NATIONAL ASSISTANCE ACT, 1948 Section 47—Removal to suitable premises of persons in need of care and attention. No cases were dealt with under this Section during the year. Section 50—Burial and Cremation of the Dead. During the year arrangements were made for the carrying out of 12 burials under this Section. PUBLIC MORTUARY The arrangement entered into between the Council and the Hospital Management Committee (Leytonstone No. 10 Hospital Group) in September, 1949, for the provision of public mortuary facilities at Whipps Cross Hospital mortuary has continued during the year. Number of Post-mortem examinations performed, 35. NATIONAL BLOOD TRANSFUSION SERVICE In November, 1952, the Local Health Authority placed at the disposal of the National Blood Transfusion Service the use of Essex County Health Services Clinic, Dawlish Road for blood donor sessions. The following table gives the relevant information regarding sessions held during 1954. Date 1954 Number of Donors Bled Not Bled 1st January Essex County Health Services Clinic, Dawlish Road, E.10 36 6 7th February ,, ,, ,, ,, 64 2 5th March ,, ,, ,, ,, 30 3 2nd April ,, ,, ,, ,, 105 2 7th May ,, ,, ,, ,, 75 5 4th June ,, ,, ,, ,, 66 9 25th June ,, ,, ,, ,, 35 8 4th July ,, ,, ,, ,, 68 6 3rd September ,, ,, ,, ,, 89 16 5th November ,, ,, ,, ,, 3 9 Total 681 66 72 Sanitary Circumstances of the Area SECTION 1.—HOUSING. STATISTICS Complaints Received. 1,759 Housing complaints were received and dealt with by the Sanitary Inspectors. In almost every instance the complaint concerned some item or items of disrepair which had given rise to undesirable conditions such as dampness, leaking roofs, broken wall plaster, decayed floor timbers and the like. A proportion of the complaints concerned enquiries from various sources in relation to overcrowding and unsatisfactory housing conditions. The circumstances of each case were fully investigated and reported to the Authority with which the applicants were registered for rehousing. Details of the improvements effected by completion of work specified on sanitary notices are given on page 74, but the benefit to the occupants in terms of comfort and health cannot be measured or fully appreciated by reference to figures. Local Land Charge Enquiries. Land charge enquiries were received in respect of 1,695 properties. These involved a search of office records to ascertain whether any sanitary notices (statutory or informal) had been served in respect of the premises concerned and to what extent (if any) the notices had been complied with. INSPECTION OF DWELLING-HOUSES AND STATUTORY ACTION Housing Acts and Housing Consolidated Regulations, 1925/32. The following table contains details of the number of houses demolished or closed as a result of representations made under the provisions of Sections 11 and 12 of the Housing Act, 1936. ] Number of Houses Persons Displaced (a) Houses demolished as a result of formal or informal procedure under Section 11 11 22 (b) Houses closed in pursuance of an undertaking given by the owners under Section 11, and still in force Nil Nil (c) Parts of buildings closed (Section 12) Nil Nil 73 Overcrowding. Section 61 of the Housing Act, 1936 empowers the Local Authority, having regard to the existence of exceptional circumstances, to grant a licence authorising the occupier of a dwelling-house to permit to sleep in the house such number of persons in excess of the permitted number as may be specified in the licence. An application was received from a resident in the Borough for licence to permit overcrowding to the extent of ½ unit, in order to accommodate her son and his family for approximately two months until such time as the Army Authorities provide married quarters for them. The licence was granted for a period of six months. Housing Repairs and Rents Act, 1954. The undermentioned return giving details of action taken as a result of applications received under Section 26 (i) of Part II of the above Act was submitted to the Ministry of Housing and Local Government in compliance with Circular No. 53/54. ] Number of Applications for Certificates of Disrepair Number Granted Number Refused Number of Applications for Revocation of Certificates of Disrepair Number Granted Number Refused Dwelling-houses which have been the subject of a notice of repairs increase of rent under Part II of the 1954 Act 75 74 I 31 28 (3 pending) Nil No applications were received in respect of dwelling-houses which have not been the subject of a notice of repairs increase of rent under the 1954 Act, or in respect of which permitted increases of rent are recoverable under Section II (i) (c) and (d) of the Increase of Rent and Mortgage Interest (Restrictions) Act, 1920. Proposed Redevelopment Areas—Preliminary Surveys. 576 Visits were made in connection with preliminary surveys of a number of outworn areas in the Borough considered suitable for clearance and redevelopment under the Housing and Town Planning Acts. Attention is also drawn to the joint report by the Medical Officer of Health and Chief Sanitary Inspector on Future Housing Development (page 34). Public Health Acts. Details are given hereunder of action taken under the provisions of the Public Health Acts as a result of complaints received and routine inspections of the district. Houses inspected 1,780 Inspections made for the purpose 9,579 Houses found not reasonably fit for habitation 955 74 Notices served: Informal 955 Formal 319 Lettings involved 1,144 Houses in which defects were remedied by: Informal Action 579 Formal Action 435 Owners 365 The Local Authority 70 Inspections in connection with action taken under the Public Health Acts revealed that of the 1,304 families affected by notices served, 368 (28 per cent.) were without the exclusive use of a W.C. and 43 (3.2 per cent.) were without separate water supply. Dwelling-Houses Improved. The following table contains a summary of the nature of work executed and improvements effected in dwelling-houses and other premises as a result of the aforementioned action (formal and informal) taken under Statutory Powers. Cement work to sink waste gullies repaired 18 Choked drains cleared 34 Coppers repaired or renewed 5 Dampness remedied 518 Drains relaid or partly relaid 23 Floors repaired 161 Guttering repaired or renewed 203 Miscellaneous defects remedied 343 New W.C. pans and traps provided 35 Plaster repaired 573 Rain water pipes repaired or renewed 97 Roofs repaired or renewed 479 Rooms redecorated 208 Sashcords renewed 245 Sinks provided 8 Sink waste pipes repaired or renewed 55 Stoves repaired or renewed 144 Vent pipes repaired or renewed 36 W.C. cisterns repaired or renewed 105 Window sills, etc., repaired 299 Yards paved 25 Total 3,614 Drainage. Drainage systems of some 112 houses were repaired or reconstructed, wholly or in part. In 70 cases the public sewer was involved, and the work was carried out by the Council under the supervision of the Borough Engineer and Surveyor, the expenses incurred thereby being recovered from the owners. 75 Legal Proceedings. Resulting from the 365 statutory notices served on owners under the nuisance abatement procedure of the Public Health Act, 1936, in 3 instances it was necessary to institute legal proceedings to secure compliance therewith. The results of such action are given hereunder. Date of Hearing Address Result of Court Proceedings 2.6.54 73 Crownfield Road, E.11 0Abatement Order, 28 days, 10s. 6d. Costs 2.6.54 122 Millais Road, E.11 Abatement Order, 28 days, 10s. 6d. Costs 9.6.54 16 Melford Road, E.11 Abatement Order, 28 days, 10s. 6d. Costs RODENT CONTROL Extracts from a Report by the Medical Officer of Health to the Public Health and Establishment Committees. Reference. Council Minute 1051—September, 1953. RESOLVED: That the Medical Officer of Health submit a report to the Public Health Committee and this (Establishment) Committee as to the duties carried out by them (Rodent Operatives) during the next six months and on the rodent situation in the Borough generally. Introductory. When the above Resolution was passed by the Council last September, my intention was to submit a short report to comply with the terms of reference, but in the intervening six months the need for a more comprehensive report has become evident for these reasons:— (a) The existence of mistaken beliefs, apparently widely held, regarding the nature of rat infestation and the need for rodent control. (b) The large amount of leptospiral infection found in rats recently caught alive in Leyton. (c) The presence of black rats (Rattus rattus) in our sewers. (d) The occurrence of three recent subsidences in Leyton roads due to the collapse of underlying sewers. (e) The disclosures, regarding the state of sewerage and drainage in the Borough, contained in the last monthly report of the Borough Engineer and Surveyor to the Public Health Committee. (f) My duty as Medical Officer of Health to advise you of the widespread surface infestation likely to follow any relaxation in our measures for rodent control, and the probable need for intensification of our efforts in the direction of rodent control pending the rehabilitation of the Borough's main drainage system. 76 Mistaken beliefs regarding Rodent Control. During recent months I have heard it suggested, in otherwise wellinformed quarters, that rodent control and the appointment of rodent operatives were war-time measures, and that the need for them ceased when the war ended. That belief may be due to the fact that the first organised treatment of sewers in London was carried out in 1942 by the then rodent control central authority (Ministry of Food) in order to conserve the nation's food supply; but it should be realised that rodent control is as much a peace-time as a war-time need, at least until we have a much better main drainage system than we have now. Those who have recently had the opportunity of inspecting a large road subsidence in the Borough have had impressed on them the widespread rat infestation there and the apparent failure of those responsible for rodent control. It should be realised, however, that the infestation was due almost entirely to serious defects in the main drainage system, through which the sewer rats were able to escape and gain entrance to dwellings ; and that no rat, however strong in the jaw, can "gnaw through" a properly constructed sewer. In other words, the rats are the result—and not the cause—of the defective sewers. Local Sources of Infestation. That rat infestation is nothing new in Leyton may be gathered from this extract from a Report I submitted to the Public Health Committee in 1931. "There is abundant evidence of the presence of rats in the area comprising the sites occupied by the Ive Farm Allotments, the shoot on the permanent Isolation Hospital site, the temporary Isolation Hospital, the Destructor and Sewage Works and the Goods Yards of the L. & N.E. Railway. " I am informed that rats have always been very prevalent in that area, and that they are not nearly so prevalent now as they used to be. " With the exception of the railway sidings, all the premises mentioned above are the property of this Council and are situated within this Borough. The conditions obtaining in that large area are conducive to the propagation and sustenance of rats once they have become established there. In fact they are so safely hidden away and so well provided for that they seem loath to move to other quarters— at least I can imagine no more valid reason for the relative freedom from rats of dwellings in the vicinity. "With regard to the possibility of taking steps to free the whole area from rats, it is a tremendously difficult problem which can be appreciated only by those who have seen the nature of the infestation, especially in the overgrown waste ground lying between the sewage works and the railway sidings. Even if drastic and concerted action were taken by this and neighbouring Local Authorities, I doubt if we should succeed in achieving the object. Nevertheless, most of the properties mentioned above belong to this Council, and the Rats and Mice (Destruction) Act, 1919 requires occupiers of premises and land to prevent them from becoming infested." 77 In nine of my Annual Reports as Medical Officer of Health, both before and since the last World War, I have drawn attention to the fact that the Council's sewers and drains are the source of most of the rat infestation of dwellings and business premises; and in February, 1953—within a month of taking over his duties as Senior Sanitary Inspector—Mr. Ashcroft submitted to the Public Health Committee a special report on Rodent Control, from which this is an extract:— "By reason of its age much of the drainage in Leyton does not conform to accepted standards of design and construction. "In those areas which contain groups of obsolescent properties it is found that drainage defects are invariably due to open clay joints or subsidence, and failure of pipes owing to inadequate concrete support. Added to this bombed sites and disused drains, perhaps imperfectly sealed from the sewer, provide ideal harbourage and nesting places for rats. "The rat population on the surface bears some relationship to the rat population below the ground—namely in the sewers. "Rats travel along working sewers when scavenging for food; but they need dry, undisturbed places for nesting." At the last meeting of the Public Health Committee the Borough Engineer and Surveyor submitted a report on Main Drainage in which he drew attention to the dilapidated condition of main drains and sewers, and to the difficulty of estimating the amount of re-drainage work to be undertaken owing to the lack of records. Statutory Powers and Duties. This is another extract from the report on Rodent Control submitted by the Senior Sanitary Inspector to the Public Health Committee in February, 1953 "The important difference between the 1919 Act and the new Prevention of Damage by Pests Act, 1949 is that Borough and District Councils are now Local Authorities for the purposes of the Act and not the County Councils as formerly. "The duty of the Local Authority is threefold: (1) to inspect the area in order to ascertain the degree of infestation by rats and mice; (2) to destroy rats and mice on land of which they are the occupiers; and (3) to ensure, if necessary by legal proceedings, that owners and occupiers of land are taking all practicable steps for the destruction of rats and mice. "In order to qualify for Exchequer Grant the Local Authority must:— (i) maintain an organisation adequate to requirements for effective rodent control according to the condition of infestation in its area; (ii) comply with the Ministry requirements on the methods to be employed; 78 (iii) in particular, pay special attention to efficient rodent control in its sewers, refuse dumps, refuse destructors and its other public service properties and carry out periodical treatment in accordance with the guidance given by the Ministry, unless specifically exempted by the Ministry; (iv) take effective action for the control of rats and mice in all surface properties by securing full compliance of occupiers, or entering and carrying out necessary treatment". Rodent Control Work. (a) Routine Procedure. The technical officers of the Rodent Division, Ministry of Agriculture and Fisheries, are confident that poisoning campaigns carried out by adjoining Local Authorities in the London area over the past nine years have undoubtedly resulted in a considerable reduction of rats in the sewers and a proportionate decrease in surface infestation; but measures taken to destroy rats, however successful, have only a limited and temporary effect. Most people know that rats are prolific, but few are aware of the rapidity with which their numbers increase. Research has shown that a pair of rats and their descendants may produce, in the course of 12 months, well over 1,000 offspring. Poison baiting of sewers was not expected to eliminate sewer rats completely, for the impossibility of bringing all rats to feed at available baiting points is evident. The primary need is therefore to take all possible steps to prevent the migration of rats from defective sewers and drains to adjoining buildings. All infestations are carefully investigated by the Sanitary Inspectors, who then arrange for drainage systems suspected of being a source of trouble to be smoke-tested. If defects in the house drains and/or public sewers are confirmed, a report is submitted to the Public Health Committee requesting authority to enable appropriate statutory action to be taken in accordance with the provisions of the Public Health Act, 1936. The Borough Engineer is then asked to arrange for trial holes to be dug for further inspection by the Sanitary Inspectors with the object of locating defects to enable notices to be served pursuant to Sections 2,4 and 39 of the Act. Some indication of the extent of this work may be gathered from the fact that during 1953 the drainage systems of some 116 houses were repaired or reconstructed, wholly or in part. In 79 cases the public sewer was involved, and the work carried out under the supervision of the Borough Engineer. The extensive defects found recently in the public sewer in Melford Road, Trumpington Road and Odessa Road were discovered by the Sanitary Inspectors (as a result of the procedure outlined above) and reported to the Borough Engineer and Surveyor. (b) Work Carried Out during 1953. During 1953 some 443 complaints relating to infestation by rats and mice were investigated by your Health Department staff, and 651 private houses and 134 business premises were dealt with. The total number of visits, in connection with these investigations and subsequent disinfestation work, amounted to 4,251. 79 The Council's sewers were baited in June, 1953. The treatment was of four to five weeks' duration, involving some 1,265 manholes, each of which was baited on three successive days. The staff required for a sewer treatment comprises four employees of the Borough Engineer's Department (two sewermen and two labourers) and two rodent operatives. Two gangs, with a rodent operative in charge of each, proceed in different parts of the district. During these periods the remaining rodent operative endeavours to deal with complaints and other essential duties in the Public Health Department. The December treatment had to be postponed owing to shortage of rodent staff. Rodent Control Staff and Work. (i) Before October, 1953. Prior to October, 1953 there were three rodent operatives engaged fulltime on rodent control work, and the methods they used for disinfestation were those prescribed by the Ministry of Agriculture and Fisheries. The operatives work in close liaison with the Sanitary Inspectors in the investigation of complaints and the location of sources of rat infestation. They also assist the inspectors in carrying out smoke tests when drains and sewers are suspect, and follow up this procedure with pre-baiting and poison-baiting treatment as appropriate. Groups of premises, in which there is a common infestation, are disinfested as one unit—block control. No charge is made to occupiers of domestic property, but occupiers of business premises are charged on a labour and material basis. Regular visits are made to Council properties. The rodent operatives were at that time designated as temporary employees, and their salary grading was the same as it is now, viz., the Local Authorities' agreed rate for a normal (44-hour) working week. At that time work of disinfection following infectious disease, and disinfestation of premises of vermin, etc., was carried out by a casual driver hired from the Council's motor pool, at a rate of 9s. 6d. per hour, under the control of the Borough Engineer and Surveyor. A similar arrangement existed for the conveyance of samples (taken by the Sanitary Inspectors under the Food and Drugs Act and Regulations) to the various laboratories, and for the collection and transportation of infected bedding and unsound food for disinfection and/or destruction. In July, 1953 I outlined in a report to the Public Health Committee the disadvantages inherent in that arrangement, and after the recommendation of the Public Health Committee had been considered by the Establishment Committee the Council—Minute 1051, September, 1953. RESOLVED: "That in the circumstances now reported two posts of rodent operative/handyman be added to the Council's permanent establishment and that for the time being a third rodent operative/handyman be engaged in a temporary capacity, the matter to be reviewed in March, 1954". 80 Period 28th September, 1953 to 13th March, 1954 Type of Work Done Hours 1. General duties in connection with rodent control 2,1771 2. Operation of smoke machine and assisting Sanitary Inspectors in carrying out smoke tests of drainage suspected of being the source of rodent infestation 139¼ 3. General handyman duties in and around the Health Offices and Stores (including maintenance and cleaning of equipment, smoke machines, pressure sprayers, poison bait containers, etc. 166 4. Disinfection of premises following infectious disease, and disinfestation of premises of vermin (bugs, flies, etc.) 120 5. Collection of infected/soiled bedding following infectious disease or death, and the operation of the steam disinfection process 26 6. Delivery by public transport of samples of food and drugs to the Public Analyst and other laboratories 39 7. Other duties in connection with sampling—cleaning and sterilisation of equipment, utensils, jars, bottles, etc., and supervision of stores 28 8. Collection of foodstuff's condemned by the Sanitary Inspectors, and supervision of its destruction at the Council's destructor works 44½ Total 2,740 With reference to duties 4, 5 and 6 (above), it will be noted from the tabular statement which follows that the present arrangements, when measured against the old procedure of hiring a motor van and driver at 9s. 6d. per hour from the motor pool, shows a financial saving to the Council for the six months period of £51 0s. 6½d.; and there appears to be no valid reason why the saving should not continue—which means that in 10 years the saving to the Council would be in the region of £1,000. Summary showing financial saving for period 28th September, 1953 to 13th March, 1954—six four-weekly periods Type of Work Total hours Comparative Costs Financial Saving Old Rate at 9s. 6d. per hour New Rate at 3s. 3id. per hour £ s. d. £ s. d. £ s. d. 4. Disinfection (I.D.) Disinfestation (Vermin) 120 57 0 0 19 15 0 37 5 0 5. Collection of bedding, etc.* 26 12 7 0 4 5 7 8 1 5 6. Delivery of samples to laboratories 39 18 10 6 6 8 4½ 12 2 1½ Totals 185 87 17 6 30 8 11½ 57 8 6½ * Less cost of transport for collection, etc., 10 hours at 9s. 6d. 4 15 0 Less fares (public transport) 1 13 0 6 8 0 Net saving £51 0 6½ 81 Apart from the financial saving above indicated, I am satisfied that the re-allocation of duties as outlined has proved of considerable benefit to the Council and the Public Health Service generally. The work of disinfection and disinfestation has been carried out with greater economy and more efficiently than previously, and a greater measure of control has been exercised over the collection and destruction of food condemned by the Sanitary Inspectors, so that there is now no possible loophole through which such food may again reach the consumer. A nucleus of labour has been made available to supervise proper maintenance of stores, poisoned baits, etc., and as a result there has been an overall improvement in the condition of equipment, ensuring longer life and further economy. Recommendations. I recommend that the present arrangements continue, and that the third post of rodent operative/handyman be included in the Council's permanent establishment. The Town Council at their meeting on 29th April, 1954, agreed to my recommendation. Work carried out during 1954. 551 Complaints relating to infestation by rats and mice were investigated by the Health Department Staff; 544 private houses and 70 business premises were dealt with. The total number of visits, in connection with these investigations and subsequent disinfestation work, amounted to 4,435. Sewer Treatment. The Council's Sewers were baited in June and December 1954. Each treatment was of four to five weeks duration, involving some 1,265 manholes, each of which was baited on three successive days. The percentage "takes" were : June 65.5 per cent., December 44.3 per cent. Statistics. Prevention of Damage by Pests Act, 1949. Complaints received and investigated 551 Premises not treated (not genuine infestation) 12 PREMISES TREATED : Rats Mice Total Dwelling Houses 394 150 544 Business premises 41 29 70 Total 435 179 614 NOTICES Informal Notices served 4 Informal Notices complied with 5 Disinfection/Disinfestation. Number of verminous houses treated 114 Number of houses disinfected 42 156 82 SECTION 2.—INSPECTION OF BUSINESS AND INDUSTRIAL ESTABLISHMENTS. Approximate numbers of business premises in the Borough and functions involved. Food and business premises which are licensed or registered for a specific purpose. Type of Premises ADDITIONAL LICENCES, REGISTRATIONS AND OTHER FUNCTIONS INVOLVED Total 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Ice Cream Milk Preserved Food Shell Fish Power Factory Non-Power Factory Catering Off-Licence Bakehouse Confectionery Fish Frier Grocer Barber With Storage Poultry Slaughterhouse 1 Hairdressing A Baker 28 1 28 2 42 B Butcher 46 3 4 1 76 C Catering 54 1 103 D Confectionery 55 147 E Fish 13 10 29 47 F Greengrocer 1 3 80 G Grocer 52 86 1 2 205 H Multiple Store 3 2 3 1 5 I Milk 1 2 12 J Ice Cream 106 K Rag Flock 7 2 9 L Pet Animals 1 15 M Horse Flesh 2 N Hairdresser 43 79 O Hawker 50 80 P Public House 10 32 35 Q Off Licence 4 3 2 45 R Factory 64 36 459 S School 1 17 18 T Council Property 2 2 4 U Hospital 2 2 Total Premises 1,571 * Totals Additional Functions 173 90 47 13 40 66 80 32 28 2 29 15 43 51 1 1 711 * See Summary on page 83. 83 Factories. These figures are inclusive of those shown in Columns R, 5 and 6, and constitute the total number of Power and Non-Power Factories maintained on the Factory Registers under statutory legislation. Description Total Factories with Mechanical Power 401 Factories without Mechanical Power 58 Total 459 Miscellaneous Shops and other Business Establishments. The approximate number of miscellaneous shops and other business establishments is 754. (This includes boot and shoe retail shops, builders' merchants, drapers, florists, furniture dealers, gents' and ladies' outfitters, hardware shops, newsagents, radio and television dealers, etc.) Summary. Food and other business premises 1,571 Additional functions involved 711 Factories—power and non-power 459 Miscellaneous shops and other businesses 754 Total number of premises and functions 3,496 Inspection and Supervision of Food Premises. Summary of Inspections by Sanitary Inspectors. The following inspections were carried out in relation to the undermentioned food premises, having regard to the requirements of the Public Health Act 1936, Food and Drugs Act 1938 and associated Orders and Regulations, Clean Food Bye-laws 1950, Ice-Cream (Heat Treatment Reg.) 1947/52, Shops Act 1950, Factories Act 1937, Leyton Corporation Act 1950, Essex County Council Act 1952, and relevant legislation. Type of Premises Number of Inspections Bakehouses 83 Bakers 123 Butchers 303 Catering Establishments 309 Confectioners 221 Dairies and Distributors of Milk 139 Factory Canteens 37 Fish Friers 72 Fishmongers 119 Greengrocers 218 Horse-flesh Dealers 7 Ice-Cream Places 319 Itinerant Food Dealers Stalls and Vehicles 148 Food Storage Accommodation 39 Off-Licences 27 Provision Shops 708 Public Houses 31 School Canteens 63 Shell-fish Vendors 30 Slaughterhouses (Poultry) 232 Total Inspections 3,238 84 Food and Drugs Sampling. Food and Drugs Authority and Sampling Officers. The Council is the food and drugs authority for the district and your Sanitary Inspectors are authorised under the Food and Drugs Act, 1938, to procure and purchase samples of food and drugs for chemical analysis or for bacteriological, or other, examination. Public Analyst. Dr. J. H. Hamence, F.R.I.C., and Mr. George Taylor, F.R.I.C., 20, Eastcheap, London, E.C.3, continued to act as Public Analysts for the area. Samples Submitted for Chemical Analysis. During the period 1st January to 31st December, some 267 samples of Food and Drugs were procured by the Sanitary Inspectors for submission to the Public Analyst for chemical analysis. It will be seen from the tabular statement which follows that a wide variety of commodities was sampled, and that in 36 instances adverse reports were received of which 23 concerned citrus fruits. The circumstances relating to these samples were fully reported to the Public Health Committee and are summarised hereunder. Insects in Cough Mixture (Syrup of Calcidrine). In January, 1954 a complainant brought a 4 oz. bottle of cough medicine alleged to contain foreign matter which made it unfit for human consumption. Upon examination the mixture was found to contain two dead insects— a small fly and a wasp. Subsequent enquiries revealed that this medicine (as prescribed by the doctor) was a proprietary brand of Syrup Calcidrine. The cough mixture was submitted to the Public Analyst and subsequently representations were made to the Executive Council for Essex. Cheese Spread. In March a complaint was received concerning a carton of pre-packed branded cheese which was alleged to contain fragments of glass. The cheese was submitted to the Public Analyst who reported that the crystals were formed of Sodium Phosphate and were not glass, indicating that the goods were out of condition. A warning letter was sent to the retailer. Pork Sausages (2). The Meat Products (No. 3) Order, 1952, prescribes the minimum meat content for sausages:— "The prescribed minimum meat content for pork sausages, beef sausages and sausage meat remains as follows:— Uncooked Pork Sausage and Sausage meat, including Pork slicingsausage 65 per cent. (of which not less than 80 per cent. shall be pork). This Order was revoked in March, 1953, and its provisions are no longer enforceable. 85 Two samples of pork sausage submitted to the Public Analyst during the first quarter of 1954 were found to contain only 57 per cent. and 56 per cent. of meat respectively, being therefore deficient in meat to the extent of 8 and 9 per cent., compared with the standard referred to above. Although there is no longer a legal standard, Public Analysts are of the opinion that sausages should conform to the above-mentioned Order. The Public Health Committee resolved that no justifiable statutory action was possible in this case. Bread (half a loaf). The outer crust and one thick slice of bread were submitted for examination for the purpose of identifying some small greyish-black foreign bodies which were embedded near the top of the outer crust. The Analyst reported that they consisted essentially of masses of dough, and that approximately a quarter of their weight consisted of oil. The characteristics of the oil were similar to those of white slab oil used for greasing tins and not those of an oil used for lubricating purposes. Ice Cream. An informal sample of ice cream was found on examination to contain only 4.3 per cent. of fat, whereas the Food Standards (Ice Cream) Order, 1953, requires that ice cream shall contain a minimum of 5 per cent. of fat. This sample was therefore deficient in fat to the extent of 14 per cent. of the prescribed standard of 5 per cent. In respect of the other requirements of the Ice Cream Order, namely, the percentage of sugar and the percentage of milk solids other than milk fat, the sample was satisfactory. Further formal samples of ice cream from the same manufacturer were obtained, and it was found that the standard required was being complied with. Butter Walnuts and Butter Almonds In August an informal sample of butter walnuts was reported by the Public Analyst as being unsatisfactory, in that the description " butter " was false and misleading. Further formal samples of butter walnuts and butter almonds were taken and submitted to the Public Analyst and were similarly described. Representations were made to the manufacturers. Oatmeal. A local grocer submitted for examination a portion of fine oatmeal. Following examination, the Analyst reported that in his opinion it consisted, not of pure oatmeal, but of a mixture of barley flour and oatmeal. A further formal sample was obtained, but this proved to be genuine. Lead Contamination of Ice Lollies—Special Investigation. As a result of a complaint received from a neighbouring Borough when an ice lolly, alleged to have been made in Leyton, had been found to contain lead in excess of the recommended limit of 1 part per million (1.4 parts per million) a special investigation was carried out, and the following is an extract from the report of the Chief Sanitary Inspector to the Public Health Committee. 86 Food Standards—Report on Lead (M.o.F., 1954). On 31st October, 1951, a Food Standards Committee of the Ministry of Food received a report from their Metallic Contamination Sub-Committee recommending limits for lead in foods. The report was revised in the light of representations received from trade and other interests. The revised report has since been adopted by the Food Standards Committee, which recommended that the limits specified should be made statutory. Action Taken. The above complaint has been taken up with the management of the firm in question, who provided every facility and co-operated fully in our investigations to ascertain the probable source of lead contamination of their product. The plant has been carefully inspected and samples of ingredients used in the preparation of ice confectionery were obtained during various stages of the process. Samples of lolly mixture were taken before and after freezing. These samples were submitted for examination by the Public Analyst, whose findings are tabulated hereunder. For each of the ingredients sampled the limits of lead contamination recommended by the Metallic Sub-Committee are given in column 2(b). Sample No. Description of Sample Lead contamination in parts per million Remarks (a) Actual (b) Recomm. limit 516 Lolly mixture before freezing 0.4 1 Satisfactory 517 Lolly frozen in new mould 0.6 1 Satisfactory 518 Lolly frozen in new mould 0.5 1 Satisfactory 511 Lolly frozen in used mould 2.0 1 Unsatisfactory 520 Lolly frozen in old mould 4.0 1 Old mould specially chosen for the test 519 Residue in moulds (Samples 517, 518) after freezing 6.4 — This residue is normally thrown away 521 Orange essence 1.3 2 Satisfactory 522 Saccharine solution, 12½% 0.9 10 (full strength) Satisfactory 523 Citric Acid, 66% 2.1 10 (full strength) Satisfactory 507 Lemon-flavoured sugar syrup 0.5 5 Satisfactory 508 Pineapple syrup with added sugar 0.5 5 Satisfactory 509 Pineapple pulp 0.4 1 Satisfactory 510 Alginade 4.0 10 Satisfactory General Observations The results of our investigations and the Public Analyst's findings indicate that excess lead contamination may be due to the action of citric acid and the natural fruit juices and pulp from which the lollies are manufactured on the metal moulds used for freezing the lolly mixture. Some of the moulds used in the test were old moulds no longer used by the firm for 87 manufacturing purposes, which accounts for the high lead content of sample No. 520. The residue from the moulds (sample No. 519) would normally be thrown away, and was retained and sampled purely for the purpose of our investigation. As a result of our representations to the firm, the management have returned all metal moulds to the manufacturers, who have replaced them with others coated with an alloy guaranteed to contain 99.82 per cent. pure tin. The management are also endeavouring to obtain moulds of material other than metal, which would appear to be the only sure method of eliminating entirely the possibility of lead contamination of the finished product. Oranges (23). See special report by Medical Officer of Health on " Thiourea " (pages 45 to 46). Samples taken for Chemical Analysis. Commodity No. of Samples Analysed No. of Samples unsatisfactory Alginade 1 — Almonds 1 — Anchovy Relish 1 — Aniseed 1 — Apple Pectin 1 — Apricots, Dried 1 — Aspirin Tablets 2 — Beans in Tomato Sauce 2 — Biscuits 2 — Boracic Ointment 1 — Bread (half a loaf) 1 1 Brisling and Tomato Spread 1 — Bronchial Mixture 1 — Bubble Gum 3 — Butter 4 — Butter Almonds 1 1 Butter Beans 1 — Butter Walnuts 2 2 Cake Mixture 1 — Cheese Spread 3 1 Chocolates 1 — Chlorophyll Tablets 1 — Citric Acid 1 — Coffee r — Condiment, Non-Brewed 1 — Confectionery 1 — Cooking Fat and Oil 2 — Crab, Dressed 1 — Cream 2 — Cream Doughnuts 1 — 88 Commodity No. of Samples Analysed No. of Samples unsatisfactory Dolly Mixture 1 — Dripping 2 — Dripping, Beef 1 — Flour 2 — Fruit Bon-Bons 1 — Fruit Chocolate 1 — Golden Raising Powder 1 — Grape Juice 1 — Haricot Beans 1 — Herrings in Tomato 1 — Ice Cream 32 1 Jam 1 — Jam (Strawberry) 1 — Jellies 1 — Joke Sweets 1 — Lard 1 — Lemons 2 — Lemon Curd 2 — Lemon Squash 1 — Lentils 1 — Loaves 3 — Ice Lollies, Ingredients 11 3 Macaroni 1 — Margarine 6 — Marmalade 1 — Meat Loaf Minced 1 — Meat Pudding 1 — Milk 33 — Milk (Condensed) 2 — Nutmeg, Ground 1 — Oatmeal 2 1 Orange Essence 1 — Oranges 52 23 Orange Squash 4 — Pancake Mixture 1 — Pearl Barley 1 — Penicillin Lozenges 1 — Pepper 1 — Pineapple Pulp 1 — Pineapple Slices in Syrup 1 — Pineapple Syrup 1 — Pork Luncheon Meat 1 — Rice, Flaked 1 — Roll and Butter 3 — Saccharin Solution 1 — Salmon Spread, Scotch 1 — Sauce 1 — 89 Commodity No. of Samples Analysed No. of Samples unsatisfactory Sausages, Beef 2 — Sausages, Blood 1 — Sausages, Liver 1 — Sausages, Pork 5 2 Sausages, Unclassified 1 — Sausage Meat 1 — Seed Tapioca 1 — Self Raising Flour 6 — Semolina 2 — Soup 2 — Soup Powder 1 — Suet, Shredded Beef 1 — Sugar 1 — Sugar, Syrup, Lemon Flavour 1 — Sweets 1 — Syrup Calcidrine 1 1 Tea 3 — Vinegar 2 — White Wine 1 — Zinc Ointment 1 — Totals 267 36 Samples submitted for Bacteriological Examination. Thirty samples of designated milk were taken and submitted to the County's Public Health Laboratories for bacteriological examination. The results of such examination are summarised as follows:— Designation No. of Samples Taken Result Phosphatase Reaction Methylene Blue Test Satisfactory Unsatisfactory Satisfactory Unsatisfactory Tuberculin Tested 6 6 — 6 — Pasteurised 21 21 — 21 — Sterilised 3 3 — 3 — Total 30 30 — 30 — 90 Forty samples of ice cream and 13 of ice lollies were taken and submitted to the County's Public Health Laboratories for bacteriological examination. The results of such examination are summarised as follows:— Commodity No. of Samples Taken Result Grade I Grade II Grade III Grade IV Satisfactory Ice Cream 40 25 9 4 2 39 Ice Lollies 13 — — — — 13 Meat and Food Condemned. Condemnation certificates were issued in accordance with the provisions of Sections 9 and 10 of the Food and Drugs Act, 1938 in respect of the undermentioned unsound foodstuffs surrendered by various traders in the Borough as a result of routine inspection of food premises. The food condemned was destroyed by fire at the Council's Destructor Works. Commodity Cwts. Qrs. Lbs. Commodity Units Sausages 2 4 Milk 114 tins Offal — I 7 Luncheon Meat 138 tins Fish 7 0 5 Fruit 679 tins Meat 11 0 6 Vegetables 76 tins Dried Fruit — 1 6 Ham 28 tins Ham — — 18 Jam 65 tins Tomato Paste 55 tins Soup 39 tins Cucumbers 10 tins Pig's Plucks 2 barrels Cheese 135 boxes Miscellaneous Foodstuffs 105 pkts. Poultry 664 Notices Served. Food and Drugs Act, 1938 (Sec. 13). This Section sets out certain minimum requirements as to hygiene, cleanliness, structural conditions, hot and cold water and washing facilities, and affects rooms in which food intended for human consumption is prepared for sale or sold or offered or exposed for sale, or deposited for the purpose of sale or in preparation for sale. Notices in relation to contraventions of this Section were served in respect of 37 food premises, and all notices were complied with. In addition to these written notices, numerous verbal intimations were given by Sanitary Inspectors to occupiers of food establishments—more in the nature of advice than of official direction—with the object of securing co-operation in maintaining a high standard of food hygiene. 91 The following table contains a summary of the nature of work executed and improvements effected as a result of the afore-mentioned action. Nature of Defects and Contraventions Drain inlet within the room 1 Walls, doors, windows not kept in a proper state of repair or cleanliness 37 Ceilings not kept in a proper state of repair or cleanliness 32 Floors not kept in a proper state of repair or cleanliness 13 Suitable and sufficient receptacles for refuse not provided 6 Accumulation of refuse in the room 1 Cleanlinesss not observed in regard to articles, apparatus, utensils, counters, slabs and crockery 6 Facilities for personal cleansing inadequate in respect of: Suitable and sufficient wash-hand basins 5 Suitable and sufficient hot water 9 Suitable and sufficient soap, clean towels 3 Food not protected from contamination 2 Accumulation of refuse in yard 3 Yard not kept in proper state of repair or cleanliness 2 Rain water down pipe not in proper state of repair 1 Store-room not kept in proper state of repair or cleanliness 2 Roof not kept in proper state of repair 2 Grating of yard gulley not kept in proper state of repair 1 Waste water preventer not kept in proper state of repair 1 Fresh air inlet not kept in proper state of repair 1 W.C. not kept in proper state of repair or cleanliness 2 Sink waste pipe not kept in proper state of repair 1 Sink waste gulley not kept in proper state of repair 1 Shops Act, 1950, Sec. 38. Six notices were served under this Section on occupiers or owners of shop premises regarding insufficient sanitary arrangements available for use of persons employed in or about the shop. These notices were satisfactorily complied with. The following list gives details in respect of the nature of defects and contraventions dealt with: Nature of Defects and Contravention Suitable and sufficient means of heating not provided 1 Suitable and sufficient sanitary conveniences not provided or maintained 5 Suitable and sufficient washing facilities not provided and maintained 2 92 Exemption Certificates. Sub-section 6 of Section 38 provides for the granting of a certificate exempting a shop from the above-mentioned provisions on the Local Authority being satisfied that: "by reason of restricted accommodation or other special circumstances affecting the shop it is reasonable that such a certificate should be in force with respect thereto, and that suitable and sufficient sanitary conveniences or washing facilities, as the case may be, are otherwise conveniently available, and, subject as hereinafter provided, a certificate in force with respect to any shop shall be withdrawn if the authority at any time cease to be so satisfied as aforesaid." Five Certificates of Exemption were granted to the occupiers of various shops in the Borough in accordance with the above provisions. Legal Proceedings. In two instances it was necessary to institute legal proceedings and the following are extracts from the reports of the Chief Sanitary Inspector to the Public Health Committee. Foreign Bodies in Food. On Monday, 3rd May, a complainant brought to the Public Health Department for examination a packet of Crispbread alleged to be unfit for food. The complainant stated that the food had been purchased at 1.45 p.m. that day, and opened almost immediately. On examination by the Sanitary Inspector the food was found to be heavily infested with maggots, which were identified as being larvae of the Flour or Mill Moth, an insect which inhabits wheat, flour and similar meal. The packet of food was seized in accordance with the procedure under Section 10 of the Food and Drugs Act, 1938, as being unfit for human consumption, and dealt with by a Justice of the Peace, who signed a condemnation certificate in the presence of the proprietor of the premises from which the article was purchased. Legal proceedings under Section 9 of the Food and Drugs Act, 1938 were taken by the Town Clerk, and at a hearing on 16th September, 1954, the retailer was fined 40s. Foreign Body in Bottle of Milk. On nth May, 1954, a complaint was received by the Department concerning a quart bottle of pasteurised milk alleged to be unfit for human consumption, due to the presence of a foreign body. The complainant stated that the milk had been delivered to a local hospital in the early morning of the previous day, along with a large consignment. On examination by the Sanitary Inspector it was found that the unopened bottle contained foreign matter having the appearance of yellow sand or clay. The bottle of milk was seized as being unfit for human consumption, in accordance with the procedure under Section 10 of the Food and Drugs Act, 93 and later dealt with by a Justice of the Peace, who signed a condemnation certificate in the presence of a representative of the firm who supplied the milk, and of the complainant. Legal proceedings under the provisions of Regulation 26, Milk and Dairies Regulations 1949, were taken by the Town Clerk and at a hearing on 29th September, 1954, the defendant was fined £10. Registration and Licensing of Food and other Premises. Food and Drugs Act, 1938, Sec. 14. This section provides for the registration by the Local Authority of premises used in connection with the sale, or the manufacture for the purpose of sale, of ice cream, or the storage of ice cream intended for sale, or the preparation or manufacture of sausages or potted, pressed, pickled or preserved food intended for sale. In connection with the retail sale and storage of ice cream 11 new applications for registration were approved. Details are given hereunder of the number of ice cream premises registered under this Section. Premises on register at 1st January, 1954 295 Premises removed from register during 1954 27 — 268 Premises registered during 1954 11 Premises on register at 31st December, 1954 279 During the year 319 inspections of ice cream premises were carried out, and of the 32 samples obtained for chemical analysis, all but one (see report on page 85) conformed with the standard prescribed by the Food Standards (Ice Cream) Order, 1953. The results of 40 samples of ice cream submitted for bacteriological examination are given on page 90. No new applications were received and approved for registration of butchers' premises for the manufacture of preserved food. The following table gives details of premises registered for this purpose. Premises on register at 1st January, 1954 64 Premises removed from register during 1954 17 — 47 Premises registered during 1954 — Premises on register at 31st December, 1954 47 Food and Drugs (Milk and Dairies and Artificial Cream) Act, 1950— Milk and Dairies Regulations, 1949. These Regulations require Local Authorities to keep a register of persons carrying on the trade of milk distributor and of all dairy premises other than dairy farms in their districts, and make special provisions relating to the treatment, handling and storage of milk. 94 Shops where milk is sold only in the unopened containers in which it is received are registered as distributors, and nine such registrations were approved during the year. Details of premises registered under these regulations are : Premises on register at ist January, 1954 100 Premises removed from register during 1954 13 — 87 Premises registered during 1954 15 Premises on register at 31st December, 1954 102 One hundred and thirty-nine visits were made to premises dealing in milk, and of the 33 samples submitted for chemical analysis, all complied with the Sale of Milk Regulations, which provide (subject to certain exceptions) that milk shall contain not less than 3 per cent. milk fat and 8.5 per cent. milk solids other than milk fat. Milk (Special Designations) (Pasteurised and Sterilized Milk) Regulations, 1949, and Milk (Special Designations) (Raw Milk) Regulations, 1949. On the 30th September, 1954, the Minister of Food issued Circular MF 19/54; this related to the change in the law relating to specially designated milk, i.e. ;— "Producers' licences to use the special designation 'Accredited' expire on 30th September, 1954; the use of the special designation 'Accredited' will not be permitted and dairymen retailing Accredited milk in specified areas or supplying caterers with Accredited milk in such areas will need instead to sell or supply pasteurised milk, sterilised milk or tuberculin tested milk." One hundred and seventy-seven licences were granted in respect of designated milk as a result of applications received. The following is a summary of these licences. Special Designation Tuberculin Tested Pasteurised Sterilised Number of licences granted 25 43 92 Number of supplementary licences granted 5 5 7 Total 30 48 99 The results of 30 samples of designated milk submitted for bacteriological examination are given on page 89. Essex County Council Act, 1952—Section 103. Applications were received from five persons for registration as hawkers of food, and for registration of their premises to be used for storage of food. Applications were received from six persons for registration as hawkers of food. 95 Details of the number of persons and premises registered under this Section are given hereunder. Persons Premises On Register at 1.1.54 79 51 Removed from Register during 1954 10 69 6 45 Registered during 1954 11 5 On Register at 31.12.54 80 50 Leyton Corporation Act, 1950—Section 63. An application was received from a fishmonger in the Borough for registration as a vendor of shell-fish and for registration of premises to be used for storage. Details of the number of premises registered for this purpose are:— Persons and premises on register at 1st January, 1954 13 Persons and premises removed from register during 1954 2 — 11 Persons and premises registered during 1954 2 Persons and premises on register at 31st December, 1954 13 Slaughter of Animals Act, 1938—Section 3. Two applications were received from suitably qualified applicants for licence to slaughter and/or stun animals in a slaughter house or knackers yard. Inspection of business premises other than food premises. Summary of inspections by Sanitary Inspectors. The following inspections were carried out in relation to the undermentioned business premises having regard to the requirements of the Public Health Act, 1936; the Shops Act, 1950; the Factories Act, 1937; the Pet Animals Act, 1951; the Rag Flock and Other Filling Materials Act, 1951; the Diseases of Animals Acts and Orders; the Leyton Corporation Act, 1950; and relevant legislation. Type of Premises Number of Inspections Factories with Mechanical Power 677 Factories without Mechanical Power 96 Hairdressers and Barbers 130 Hospitals and Nursing Homes 17 Local Authority Properties 85 Miscellaneous Shops, etc. 482 Offensive Trades 1 Outworkers 322 Pet Animal Shops 89 Places of Entertainment 27 Public Conveniences 24 Rag Flock 25 Schools 78 Stables 4 Total Inspections 2,057 96 Factories Act, 1937/1948. The following is an extract from a statutory return, made annually to the Ministry of Health, showing inspections made and an analysis of notices served under the provisions of the Factories Act, 1937. Premises Number on Register Number of Inspections Written Notices Occupiers Prosecuted (1) (2) (3) (4) (5) Factories without Mechanical Power 58 96 4 — Factories with Mechanical Power 401 677 23 — Other Premises under the Act (including works of building and engineering construction but not including outworkers' premises) — — — — Total 459 773 27 — Particulars Number of Defects Found Remedied Referred to H.M. Inspector (1) (2) (3) (4) Lack of Cleanliness 6 6 — Sanitary Conveniences:— Insufficient 4 1 — Unsuitable or Defective 25 18 — Not Separate for Sexes 3 2 — Other Offences 2 2 — Total 40 29 — Registration and Licensing. Pet Animals Act, 1951. This is an Act to regulate the sale of pet animals, and the persons in occupation of Pet Shops are required to be licensed by the Local Authority in respect of :— (i) the accommodation provided for the animals, with regard to size, temperature, lighting, ventilation and cleanliness ; (ii) the provision of suitable food and drink ; and (iii) animals, being mammals, not being sold at too early an age. Applications were approved, and licences granted in respect of, 13 pet animal shops. Such licences are reviewed annually. 97 The following table gives details of registration and licences issued:— On register at 31st December, 1953 13 Licences issued during 1954 15 Removed from register during 1954 Nil On register at 31st December, 1954 15 Leyton Corporation Act, 1950 (Section 48). Eight new applications were approved for registration as hairdressers/ barbers and of the premises in which the business is carried on. On register at 1st January, 1954 79 Removed from register during 1954 8 — 71 Registered during 1954 8 On register at 31st December, 1954 79 Rag Flock and Other Filling Materials Act, 1951. No applications were received for registration of premises under the provisions of the above Act. The present position regarding such registrations is : On register at 1 st January, 1954 9 Removed from register during 1954 — 9 Registered during 1954 — On register at 31st December, 1954 9 Six formal samples of various filling materials were taken in accordance with the requirements of the Rag Flock and Other Filling Materials Act, 1951. Set out below in tabular form are the findings of the Prescribed Analyst. Appropriate Tests Standard prescribed by R.F. and O.F.M. Regs., 1951 Results of Analysis Remarks and Action Taken (i) Sample No. 1/54—Cotton Flock Oil and Soap Test Not to contain more than 2% of oil Oil 0.7% Sample Satisfactory Trash content test (in triplicate) Not to contain more than 15% of trash, namely seed, chaff (leaf and stalk), sand or other impurities Trash content : (i) 11.4% (ii) 11.7% (111) 11.5% Average 11.5% 98 Appropriate Tests Standard prescibed by R.F. and O.F.M. Regs., 1951 Results of Analysis Remarks and Action Taken (ii) Sample No. 2/54—Washed Layered Flock Impurities test (in triplicate) Not to contain more than 1.8% of soluble impurities Sol. impurities: Sample Satisfactory (i)1.5% (ii) 1.4% (iii) 1.4% Average 1.4% Oil and soap test Not to contain more than 5% of oil and soap Oil 2.3% Soap 1.6% Chlorine test Not to contain more than 30 parts per 100,000 of chlorine in the form of soluble chlorides Chlorine content : 3 parts per 100,000 (iii) Sample No. 3/54—Coir Fibre Impurities test (in triplicate) Not to contain more than 1.5% of insoluble impurities and where the filling consists wholly or partly of used materials not to contain more than 1.5% of soluble impurities Insol. impurities : Sample Satisfactory (i) 0.9% (ii) 0.8% (iii) 0.8% Average 0.8% (iv) Sample No. 4/54—Rag Flock Layered Impurities test (in triplicate) Not to contain more than 1.8% of soluble impurities Sol. impurities Sample Satisfactory (i) 1.2% (ii) 1.2% * Animal fibre test made to ascertain correct description (iii) 1.3% Average 1.2% Oil and soap test Not to contain more than 5% of oil and soap Oil 1.1% Soap 1.0% Chlorine test Not to contain more than 30 parts per 100,000 of chlorine in the form of soluble chlorides Chlorine content: 25 parts per 100,000 *Animal fibre content 50.1% (v) Sample No. 5/54—Rag Flock Impurities test (in triplicate) Not to contain more than 1.8% of soluble impurities Sol. impurities : Sample Satisfactory (i) 1.2% (ii) 1.3% (111) 1.1% Average 1.2% Oil and soap test Not to contain more than 5% of oil and soap Oil 2.8% Soap 1.1% Chlorine test Not to contain more than 30 parts per 100,000 of chlorine in the form of soluble chlorides Chlorine content: 14 parts per 100,000 (vi) Sample No. 6/54—Rag Flock Impurities test (in triplicate) Not to contain more than 1.8% of soluble impurities Sol. impurities Sample Satisfactory (i) 1-1% (ii) 1.0% (iii) 0.9% Average 1.0% Oil and soap test Not to contain more than 5% of oil and soap Oil 0.6% Soap 0.8% Chlorine test Not to contain more than 30 parts per 100,000 of chlorine in the form of soluble chlorides Chlorine Content: 12 parts per 100,000 99 Diseases of Animals, Acts and Orders. Administration. The Diseases of Animals Acts, and Statutory Rules and Orders, deal generally with:— (a) Prevention of scheduled diseases of animals. (b) Control of outbreaks of diseases of animals. (c) Prevention of the introduction of diseases of animals from abroad ; and (d) Protection of animals against unnecessary suffering. The administration of the law relating to diseases of animals is carried out partly by officers of the Ministry of Agriculture and Fisheries and partly by officers of County Councils and Local Sanitary Authorities. In this Borough your Sanitary Inspectors are officers authorised under the various Acts and Orders to deal with the matters which are the responsibility of the Leyton Council. Fowl Pest. The following is an extract from Circular letter T.A.Y. 26675 to all Local Authorities by the Ministry of Agriculture and Fisheries pursuant to the provisions of the Diseases of Animals Acts. The Live Poultry (Mid-Norfolk) Order, 1954 Fowl Pest "I am directed to inform you that during the last few weeks about forty outbreaks of fowl pest have been confirmed on premises in central Norfolk. The position is giving rise to much concern and in view of the highly infectious nature of the disease it has been decided to take immediate and drastic measures to prevent the spread of infection to other parts of the country and to bring the situation in central Norfolk under more effective control. The Minister has, accordingly, made the above Order. Its main effect is to prohibit as from the 29th November, 1954, the movement of live poultry (except day-old chicks and hatching eggs) into, out of and within the area of Norfolk specified at the foot of this letter. It is hoped that by taking this timely action it will be possible to contain the disease and clear up the position in a relatively short time. "The prohibition of movement of live poultry within the scheduled area does not apply to poultry consigned into and out of the area by rail on a through booking. No markets, fairs, sales or exhibition of poultry in the scheduled area may be held. "The movement ban applies not only to store poultry but also to birds intended for immediate slaughter which will have to be killed on the premises on which they are kept in the area. The carcasses may be moved anywhere without restriction. "The Minister will be prepared after the lapse of a suitable period, and in the light of the trend of fowl pest in the scheduled area to consider, exceptionally, the issue of licences under his general powers authorising the movement out of the area of breeding stock of poultry from the premises of accredited poultry breeders and perhaps of other breeders. An announcement as to the time and form in which such applications may be made will be issued later. In addition, the Minister will also be willing to consider the issue, exceptionally, and at any time of licences for essential movement within the scheduled area (e.g., for the purpose of re-stocking) of store poultry." Measures were taken to publicise the requirements of the Order in accordance with Article 7 of the Animals (Miscellaneous Provisions) Order of 1927, and inspections made at the premises of poultry keepers, bird fanciers, pet shops, etc. 100 Illegal Landing of Dogs and Cats. The following is an extract from a Circular letter received from the Minister of Agriculture and Fisheries in respect of the illegal landing of dogs and cats: "Every year a number of dogs and cats are landed in Great Britain in contravention of the Importation of Dogs and Cats Order of 1928; there were 72 illegal landings in 1954. This Order, which is designed to prevent the introduction of rabies, prohibits the landing of dogs and cats unless a licence of the Minister has previously been obtained. The licensing procedure is intended to ensure that all imported dogs and cats are detained in quarantine for the six-months period prescribed by the Order. "It is evident that some of the people who attempt to land dogs and cats without having obtained a licence do so with the deliberate intention of evading the quarantine restrictions. Occasionally the attempt succeeds and the animal either does not enter quarantine at all (although this is thought to be infrequent) or when subsequently detected goes into quarantine after having been at large for some time. "Although there has recently been a serious increase in the incidence of rabies on the Continent of Europe it is so long since there has been an outbreak in this country (1922) that the offenders may not realise how disastrous it would be if the disease were reintroduced here. It is invariably fatal in dogs and cats ; when transmitted from these animals to man it is known as hydrophobia and can result in one of the most dreadful forms of death to which the human race is liable. The value of the quarantine regulations is demonstrated by the fact that in the last thirty years no less than twenty-two imported dogs have developed rabies whilst in quarantine kennels. Any one of these cases could, but for the quarantine regulations, have caused a serious outbreak of the disease with great suffering and loss of life. "Local authorities are asked to take proceedings and prosecute with the utmost vigour in all cases in which the Order is deliberately contravened. It is suggested that at the hearing of a case the tragic consequences of an outbreak of rabies in this country should be emphasised ; it should also be stressed that it is only because of the stringent regulations that the country continues to enjoy the benefits of remaining completely free from the disease." SECTION 3.—ATMOSPHERIC POLLUTION Smoke Abatement. Inspections by Sanitary Inspectors. Some 87 observations were made of the quantities of smoke emitted from chimneys of industrial and commercial premises. Letters were sent to the management of a number of business undertakings regarding excessive smoke and grit emission, but no statutory nuisance was established within the terms of the Public Health Act, 1936. Investigation carried out in conjunction with the Department of Scientific and Industrial Research. Investigation. A description of the procedure adopted for the systematic measurement of the concentration of atmospheric smoke and sulphur dioxide was given in my Report for 1950. Daily observations, which were begun in March 1950, have continued throughout 1954. The investigation is carried out in full co¬operation with the Fuel Research Station of the Department of Scientific and Industrial Research. A summary of the observations is included in the monthly "Atmospheric Pollution Bulletin "published by the Department. The recording apparatus is situated at the Public Health Department, Sidmouth Road, E.10. 101 The following tables show the results recorded during 1954, together with the corresponding figures for 1953. No results are available for the month of March, 1953; and the figures for April, 1953 relate to 14 days only. CONCENTRATION OF SMOKE EXPRESSED IN MILLIGRAMS PER 100 CUBIC METRES Month Monthly average Highest daily average Lowest daily average 1953 1954 1953 1954 1953 1954 January 48.7 27.1 162.6 37.5 9.0 13.4 February 26.3 28.7 60.1 51.1 10.5 13.2 March — 21.1 — 38.1 - 9.5 April 12.5 16.3 28.9 40.8 4.7 7.6 May 4.9 8.6 16.2 21.0 1.9 4.7 June 4.0 4.4 7.6 6.6 0.5 1.0 July 3.1 3.6 5.6 7.0 0.5 1.3 August 3.7 4.5 5.6 7.0 2.0 1.5 September 6.5 6.0 21.4 18.4 1.5 3.8 October 26.3 13.2 71.4 64.6 4.4 4.4 November 36.6 35.3 115.6 138.5 12.1 6.8 December 36.7 28.9 56.8 99.5 22.0 6.2 CONCENTRATION OF SULPHUR DIOXIDE EXPRESSED AS PARTS PER 100 MILLION Month Monthly average Highest daily average Lowest daily average 1953 1954 1953 1954 1953 1954 January 13.7 8.6 45.9 13.2 3.6 5.4 February 8.8 9.8 24.3 16.3 3.5 4.7 March — 9.0 — 16.3 - 3.8 April 4.5 6.7 13.3 17.4 1.2 2.5 May 2.3 5.0 5.8 9.4 1.1 2.3 June 2.4 3.2 5.6 5.1 0.4 1.6 July 2.1 3.2 3.2 6.0 0.2 2.0 August 2.5 3.7 3.9 5.9 1.6 1.9 September 3.7 4.3 9.4 8.1 1.7 2.9 October 7.7 7.0 18.8 20.9 3.1 3.2 November 12.5 14.7 29.2 42.2 4.6 6.4 December 13.2 12.3 21.6 28.9 4.9 4.8 The total amount of smoke pollution recorded during 1954 was 13.4 per cent. less than in 1953, and the total amount of sulphur dioxide was 9.3 per cent. greater than in 1953. 102 The following graphs show the annual and monthly variations of smoke and sulphur dioxide pollution during each of the past five years. ANNUAL VARIATION 0F SMOKE ANNUAL VARIATION OF SULPHUR DIOXIDE 103 National Health Service Act, 1946 Part III SECTION 21 HEALTH CENTRES There are three Health Service Clinics in the area:— Leyton Green Road, Leyton, E.10. (Opened in 1933). Granleigh Road, Leytonstone. ( „ „ 1935). Dawlish Road, Leyton. ( „ „ 1951). On page 104 is shown in tabular form the various Clinic Sessions held. SECTION 22 CARE OF MOTHERS AND YOUNG CHILDREN Births. 1,232 births were registered during the year:— Males Females Total Legitimate 618 570 1,188 Illegitimate 22 22 44 640 592 1,232 The birth rate per 1,000 of the population was thus 11.95. 1,303 notifications of births were received during the year:— From medical practitioners 24 From midwives 1,279 Ante-natal Clinics. Attendances. First Subsequent Attendances Attendances Total 569 3,567 4,136 The above figures include expectant mothers in attendance at the Ante-natal Clinics held at the Council's four Centres and at the homes of the two municipal midwives. The number of home visits made by Health Visitors to expectant mothers during the year was 190. HEALTH CLINICS—CLINIC SESSIONS Health Clinic Monday Tuesday Wednesday Thursday Friday Saturday Leyton Green Leyton Green Road, E. 10. (LEYtonstone 3650, Ext. 267) A.M. Dental Minor Ailment Dental Orthoptic Minor Ailment Dental Minor Ailment Orthoptic Ophthalmic Dental Minor Ailment Ante-natal Dental Minor Ailment Ophthalmic Orthoptic Minor Ailment Dental P.M. Dental Infant Welfare Dental Infant Welfare Dental Orthoptic Infant Welfare Ophthalmic Dental Immunisation P.N. (2nd and 4th) A.N. Exer. Orthopaedic (1st Thurs.) Dental Orthoptic Special Medicals A.N. Exer. (Alt. Fridays) Park House, Granleigh Road, E.11. (LEYtonstone 3650, Ext. 268) A.M. Dental (1) & (2) Minor Ailment Ante-natal (2nd and 4th) Oral Hygiene Dental (1) Oral Hygiene Minor Ailment Dental (1) & (2) Minor Ailment Oral Clinic Dental (1) Oral Hygiene Minor Ailment Dental (1) Oral Hygiene Minor Ailment Dental (1) alternate Minor Ailments Oral Hygiene (Alt.) P.M. Dental (1) & (2) Ante-natal Exercises Dental (1) Oral Hygiene Infant Welfare Dental (1) & (2) Infant Welfare Dental (1) Oral Hygiene Infant Welfare Dental (1) Immunisation Ante-natal Exercises Dawlish Road, Dawlish Road, E.10. (LEYtonstone 3650, Ext. 287) A.M. Minor Ailment Dental (1) Dental (2) Foot Clinic Dental (1) Dental (2) Minor Ailment Dental (1) Dental (2) Minor Ailment Ante-natal Toddlers Foot Clinic Dental (1) & (2) Minor Ailment Dental (i)& (2) Minor Ailment B.C.G. Foot Clinic Minor Ailment P.M. Dental (1) & (2) Infant Welfare Foot Clinic Dental (1) &(2) Immunisation Dental (i)& (2) Foot Clinic Infant Welfare Foot Clinic Dental (i)& (2) Dental (i)& (2) Foot Clinic Ante-natal Exercises Evening Foot Clinic Foot Clinic 104 105 EXPECTANT MOTHERS—MASS MINIATURE RADIOGRAPHY In 1953 the incidence of active tuberculosis among expectant mothers in the Area served by Mass Radiography Unit 6.B was 1.38 per 1,000 examined. Although that figure appears to be comparatively low, the disease has such an important bearing on the health of both mother and child that any time devoted to its detection among expectant mothers is considered to be time well spent, and I felt justified in inaugurating in this Area a scheme whereby X-ray examination of expectant mothers can be held at intervals sufficiently frequent to enable each expectant mother to be X-rayed within the first three months of pregnancy. Inauguration of Scheme. The number of cases in Leyton is so small that it does not justify special visits to Clinics by a Mass Radiography Unit; but in October, 1954 I was able to arrange with the Medical Director of the Unit and with the Medical Officer of Health, West Ham for expectant mothers from Leyton to attend for Mass Radiography at an Ante-natal Clinic in West Ham when the Radiography Unit is operating there. Procedure. It is necessary for the purpose of the X-ray to be explained to the expectant mother by the Clinic Medical Officer, Health Visitor or Midwife. It is made clear to the mother that the X-ray examination is a routine chest examination to exclude the possibility of tuberculosis of the lungs, and not an abdominal examination to ascertain the state of the pregnancy. Care is taken to impress on the mother that she is being referred as a routine precaution, and not because she is in any way ill. The expectant mother is referred for X-ray examination preferably before the end of the third month of pregnancy, and certainly not later than the end of the sixth month. Should there be any special reason to justify an X-ray examination after the end of the sixth month, the mother will be referred for such examination to the Chest Clinic. This is done because mass radiography films of expectant mothers are difficult to interpret and assess when the mother has been pregnant for more than six months. It is found that about 10 per cent. of mothers are recalled for a large X-ray film to be taken—generally about a week after the first examination. In the event of any pathological findings, the Unit Medical Director sends a letter to the mother's doctor suggesting that the mother should be referred to the Chest Clinic. A copy of this letter is sent to the Area Medical Officer. The Unit follow up the case later and, in the event of the mother having failed to attend the Chest Clinic, the Area Medical Officer is notified. Child Welfare Clinics. On page 108 will be found a Table giving detailed information regarding the attendances of infants and children at the Child Welfare Clinics during the last three years. It is interesting to record that, although there has been a 7 per cent. decrease in the number of children eligible to attend the Child Welfare Clinics during 1954, as compared with the previous year, the attendances show an increase of 8.6 per cent. over the attendances in 1953. This may be 106 due in part to the wisdom of establishing the distribution points for welfare foods at Health Clinic premises at such times as Child Welfare Clinics are in session. When the mother attends to buy her food there is an excellent opportunity for her to seek the advice of the Doctor or Health Visitor concerning behaviour problems and the general care of children. DISTRIBUTION OF WELFARE FOODS General. On 28th June the Local Health Authority assumed responsibility for the distribution of welfare foods formerly carried out by the staff of the Ministry of Food from the Local Food Offices and, as an interim arrangement, 14 weekly sessions for distribution were made available at four centres : the Essex County Health Services Clinics at Granleigh Road, Dawlish Road and Leyton Green Road, and the Health Offices, Sidmouth Road. It soon became evident that it would be advisable to make available an additional centre for distribution on Saturday mornings, and on 17th July an extra session was commenced at the Clinic in Granleigh Road, Leytonstone, E.11. Later, on 16th August, an additional centre was opened at Emmanuel Church Hall (corner of Hitcham and Lea Bridge Roads) on Monday afternoons. There are now 16 sessions available at five centres in the area, and it is considered that the service is adequate meantime. No complaints have been received regarding the centres or distribution times, and it is pleasing to report that mothers have welcomed the new service as a great improvement on the former distribution. The arrangements for the distribution of welfare foods are :— Distribution Centre. Days of Opening and Times. Essex County Tuesday — 9.0 a.m. to 1.0 p.m. Health Services Clinic, 2.0 p.m. ” 5.0 p.m. Granleigh Road, E.11 Wednesday — 2.0 p.m. ” 5.0 p.m. Thursday — 2.0 p.m. ” 5.0 p.m. Saturday — 9.0 a.m. ” 12.30 p.m. Essex County Monday — 2.0 p.m. ” 5.0 p.m. Health Services Clinic, Wednesday — 9.0 a.m. ” 1.0 p.m. Dawlish Road, E.10 Thursday — 2.0 p.m. ” 5.0 p.m. Essex County Monday — 2.0 p.m. ” 5.0 p.m. Health Services Clinic, Tuesday — 2.0 p.m. ” 5.0 p.m. Leyton Green Road, E.10 Wednesday — 2.0 p.m. ” 5.0 p.m. Thursday — 9.0 a.m. ” 1.0 p.m. Health Offices, Friday — 9.0 a.m. ” 1.0 p.m. Sidmouth Road, E.10 2.0 p.m. ” 5.0 p.m. Saturday — 9.0 a.m. ” 12.30 p.m. Emmanuel Hall, Lea Bridge Road, E.17 Monday — 2.0 p.m. ” 5.0 p.m. 107 Staff. Three afternoon sessions at Essex County Health Services Clinic, Leyton Green Road are staffed by members of the Women's Voluntary Services (Miss Reid and Mrs. Gill). There are 13 sessions being carried out by temporary officers employed for the purpose. Storage Facilities. Storage facilities are adequate at all distribution centres, with the exception of the Essex County Health Services Clinic, Granleigh Road, Leytonstone, E.11, and I recommended that a combined distribution and storage centre be erected on the vacant land adjoining this clinic. Provision has been made in the Capital Building Proposals for this to be carried out. Issues. The total issues during 1954 (from 28th June) were:— National Dried Milk 22,919 Cod Liver Oil 6,692 Vitamin A and D Tablets 1,912 Orange Juice 32,700 Post-Natal Clinic. Leyton Green Clinic Lady Rayleigh Training Home Total Number of Sessions 15 13 28 Number of New Cases 122 98 220 Total Attendances 232 131 363 Care of Premature Infants. The term "premature infants" refers to babies weighing 5½ lbs. or less at birth, irrespective of period of gestation. Still-births are excluded. (a) Number of premature infants notified during the year (including transferred notifications) whose mothers normally reside in the Authority's area. (1) Born at home 18 (2) Born in hospital or nursing home 56 (b) Premature infants born in the area (whether their mothers normally reside in the area or not) but excluding babies born in maternity homes and hospitals in the National Health Service 18 ATTENDANCES, EXAMINATIONS, Etc., 1952-1954. Leyton Green Park House Dawlish Road All Centres 1952 1953 1954 1952 1953 1954 1952 1953 1954 1952 1953 1954 Under 1 year— First attendances 413 344 335 506 472 484 262 251 261 1,181 1,067 1,080 Subsequent attendances 6,275 4,904 5,104 6,108 5,880 6,026 3,641 3,742 3,601 16,024 14,526 14,731 Total attendances 6,688 5,248 5,439 6,614 6,352 6,510 3,903 3,993 3,862 17,205 15,593 15,811 1-5 years— First attendances 60 67 80 85 69 66 79 40 25 224 176 171 Subsequent attendances 2,161 2,475 2,343 2,669 1,995 2,396 2,007 2,129 1,758 6,837 6,599 6,497 Total attendances 2,221 2,542 2,423 2,754 2,064 2,462 2,086 2,169 1,783 7,061 6,775 6,668 Total attendances, both age groups 8,909 7,790 7,862 9,368 8,416 8,972 5,989 6,162 5,645 24,266 22,368 22,779 Average attendance per session at Infant Clinics 48.36 46.92 52.41 52.08 48.93 58.26 54.6 48.9 46.27 51.68 48.31 52.72 Number examined by clinic doctor 2,942 2,601 2,083 3,376 2,601 2,587 1,768 1,726 1,602 8,086 6,524 6,272 Number weighed 8,906 7,783 7,858 9,492 9,163 8,964 5,951 6,164 5,640 24,349 23,110 22,462 108 109 Care of Premature Infants—(contd.) Born at Home Nursed Entirely at Home Transferred to Hospital Died in First 24 hours Died on 2nd to 7th day Died on 8th to 28th day Survived 28 days Total 3 lb. 4 oz. or less - - - - - - 3 lb. 5 oz.—4lb. 6 oz. — — — — I- 1 4 lb. 7 oz.—4 lb. 15 oz. — — — — 3 3 5 lb.—5 lb. 8 oz - - - - 14 14 Puerperal Pyrexia. Fifteen cases of puerperal pyrexia were notified during the year. Maternity Mortality. There were three maternal deaths of Leyton residents during the year. All occurred in hospitals outside the area. Ages and cause of death are set out below:— 1. 34 yrs. Cause of death (1a) Post-partum haemorrhage. 2. 31 yrs. Cause of death (1a) Acute suppurative pneumonitis following vomit soiling of the bronchial tree during anaesthesia (nitrous oxide oxygen and ether for induced labour) for foetal distress. 3. 23 yrs. Cause of death. (1a) Toxaemia and portal pyaemia following septic abortion. In an area such as Leyton, with a low birth rate, yearly variations in the Maternal Mortality rate can be quite considerable, and a truer picture is obtained by taking the number of deaths over a period such as five years. Since 1950 there have been two years with no maternal death, one year with one death, and two years with three deaths—seven in 6,644 births, giving a rate of 1.05 per thousand births. One death, listed as a maternal death because the woman was six weeks pregnant, was not related to the pregnancy at all. All of these deaths occurred in hospital, and the patients had had every available medical care. 110 Dental Treatment. Report by the Area Dental Officer (Mr. A. E. Hall). While the dental staffing position is not yet good enough to enable pre-school children to be inspected and treated as often as is desirable {i.e. every three months from about two years of age), one pleasing feature of the work done during 1954 was that many patients were seen and treated more than once during the year. When the work found to be necessary is a small filling not taking many minutes, the majority of pre-school children make remarkably good patients and, not being kept long at any visit, are usually ready to return for re-inspection and treatment at a later date. The Oral Hygienist (Miss Watts) has done much good work among these patients by way of talks, also to the expectant mothers who are usually keen to know what they should do in the best interests of the infants' dental welfare. All cases referred to the dentist by the Council's Medical Officers were seen and treated during the year, and any former patients seeking re-examination were treated if necessary. It is pleasing to note that many more patients are now willing to undergo full treatment instead of only for the relief of pain, as was quite common years ago. Patients inspected and treated during the year. Expectant Mothers Nursing Mothers Children under School Age (1) Patients examined 118 55 487 (2) Patients found to require treatment 118 55 471 (3) Patients who have commenced treatment 118 55 471 (4) Patients who have completed treatment 98 46 414 (5) Patients awaiting treatment — — — (6) Attendances for treatment 373 252 1,184 Ill Types of treatment given. Expectant Mothers Nursing Mothers Children under school age Extractions— (a) Permanent teeth 166 108 - (b) Temporary teeth — — 456 Fillings (a) Permanent teeth 126 108 - (6) Temporary teeth — — 570 Inlays provided — — — Crowns provided — — — Anaesthetics administered (a) Local 64 26 57 (b) General (i) by Medical Officers on County staff - - _ (ii) by others 35 22 195 (a) Scaling 62 22 7 (6) Prolonged scaling and gum treatment 11 3 — Silver nitrate treatment 2 6 532 Dressings 152 120 306 X-ray examinations 32 11 6 Dentures provided (a) Full 5 5 (b) Partial 9 19 - Dentures repaired 1 Dentures re-made (a) Full - - - (b) Partial — — - Orthodontic appliances (a) Fixed - - - (6) Moveable — — - Prophylactic treatment and other operations - - - Gum treatment 23 8 - Cleaning and polishing 36 11 - Oral hygiene instruction 7 hrs. 1½ hrs. - Number of treatments (scaling and prophylactic) carried out by Oral Hygienists). 132 44 — 112 Orthopaedic Clinic. During the year fifty children were referred from the Child Welfare Clinics to the Orthopaedic Surgeon. The following is a summary of the work carried out:— New Cases 50 Re-inspections 56 Referred for physiotherapy 2 Minor alterations to footwear 65 Special Eye Clinic. The Consultant Ophthalmic Surgeon had referred by the Clinic Medical Officers 28 pre¬school children, who made 51 attendances for examination and treatment. Convalescent Home Treatment. Children. Six children recommended by the Clinic Medical Officers were sent to convalescent homes. Mothers and Children. Arrangements were made for three mothers and their children to have a period of convalescence. Ophthalmia Neonatorum. No. of Cases Notified Treated , Vision Unimpaired Vision Impaired Total Blindness Deaths At Home In Hosp. 3 1 2 3 — — — Infant, Neo-natal and Foetal Mortality. Year Live Births Deaths under Mortality Rate Stillbirths No. Rate per 1,000 (live and still) Births 1 year 4 weeks Infantile Neo Natal 1950 1,447 29 22 20.04 15.20 27 18.31 1951 1,311 27 17 20.59 12.96 31 23.1 1952 1,355 37 24 27.30 17.71 30 21.66 1953 1,279 30 21 23.45 16.05 29 22.17 1954 1,232 18 10 14.61 8.11 31 24.54 Infantile Mortality and Neo¬natal Rates. This year the Infantile Mortality rate of 14.61 per thousand births is the lowest ever recorded in Leyton, the previous lowest rate being 20.04 1950, which was the third occasion since 1948 that the rate had been between 20 and 21 per thousand births. In any case, the infantile mortality rate in Leyton has always been below the national average. If toxaemia in pregnant women could be prevented, it is possible that both these rates could be lowered even beyond the low rate recorded this year. 113 Of the 18 infant deaths, 10 occurred in the first four weeks, giving a neo¬natal death rate of 8.1 per thousand births which compares very favourably with the rate of 17.7 per thousand in England and Wales in 1954. All these ten children were born in hospital. None was older than three days at the time of death, and the causes of death were:— Severe congenital abnormalities 3 Prematurity: (a) Toxaemia in mother (one with congenital abnormalities) 4 (1b) Cause unknown 2 Difficult labour 1 The two premature babies—there was no cause found for the prematurity—were extremely small. One, twenty weeks gestation lived an hour and weighed 1 lb. 14 ozs.; the other was a twin, weighing 2 lb. 6 ozs.— the other twin being stillborn. With the knowledge that we have of these cases it is difficult to say that this rate could be reduced, as in every case the mother has had adequate ante-natal care. Of the eight babies who died between one month and twelve months, there was only one whose death might have been prevented—a baby who died of pneumonia and gastro¬enteritis where the home care was very bad, the family had been evicted for non-payment of rent a few weeks previously and the child was living in over-crowded conditions. Stillbirth Rate. The stillbirth rate of 24.54 is higher than usual in this area. Six of these births took place at home. All had ante-natal care, and it is not possible to see in what way the stillbirth could have been prevented. Of the 22 cases born in hospital, all except one were having good medical attention. The mother who refused to co-operate with the hospital or the clinic had toxaemia, which was the cause of her baby's premature birth and death. This was the only death which one might have said was avoidable. Day Nurseries. There are two Day Nurseries in the area, each having accommodation for 60 children. (1) Ellingham Road Day Nursery, Ellingham Road, Leyton, E.15. (Tel. MARyland 3683). (2) Knotts Green Day Nursery, Leyton Green Road, Leyton, E.io. (Tel LEYtonstone 4100). Knotts Green Ellingham Road Total 0-2 yrs. 2-5 yrs. 0-2 yrs. 2-5 yrs. 0-2 yrs. 2-5 yrs. Number of approved places at end of year 15 35 15 35 30 70 Number of children on register at end of year 17 43 15 45 27 93 Total attendances during year 2,875 9.424 2,845 9,346 5,720 18,770 Number of days open 255 255 114 SECTION 23 MIDWIFERY Cases attended by Council Midwives. Midwives Essex County Council Attached to the Lady Rayleigh Training Home Beachcroft Road Total Cases attended:— (a) As Midwives 78 170 248 (b) As Maternity Nurses 11 14 25 Ante-natal Visits 399 716 1,115 Ante-natal Examinations 648 1,104 1,752 Post-natal Visits 1,362 5,207 6,569 Administrations of Gas and Air Analgesia 87 138 225 Administrations of Pethidine 25 75 100 Administration of Gas and Air Analgesia. The following list shows the number of domiciliary confinements attended by midwives (not including cases attended as maternity nurses) during the year and the number of such cases to whom gas and air analgesia was administered:— Cases attended as Midwives 248 Number of administrations of gas and air analgesia 225 Percentage of administrations 91.9% Maternity Outfits. Maternity outfits were issued to 185 expectant mothers who were having domiciliary confinement. Medical Aid. Numbers of cases in which medical aid was summoned by midwives under Section 14 of the Midwive's Act, 1951:— (1) Where the Medical Practitioner had arranged to provide the patient with maternity medical services under the National Health Service 11 (2) Others 80 Total 91 Fees paid to Doctors. 57 accounts were received from general medical practitioners for assistance rendered to midwives under the provisions of the Medical Practitioners (Fees) Regulations. The total amount paid to medical practitioners during the year was £160 16s. 6d. 115 Domiciliary Midwives. Lady Rayleigh Training Home, Beachcroft Road, Leytonstone, E.n Telephone: LEY 2385 Miss E. Daines, 149, Francis Road, E.10 LEY 4909 Mrs. C. L. Wackett, 111 Fairlop Road, E.11 LEY 4731 BIRTHS IN INSTITUTIONS AND MATERNITY HOMES The following table shows the percentage of births taking place in other than the patient's home since 1936. The steady increase in the percentage was not maintained during the war years, due to evacuation of expectant mothers, and subsequently due to the shortage of maternity beds in hospitals. Year Percentage Year Percentage 1936 53.48 1946 56.67 1937 54.01 1947 56.29 1938 56.99 1948 63.86 1939 59.64 1949 68.03 1940 52.32 1950 71.18 1941 62.79 1951 69.71 1942 56.05 1952 73.20 1943 55.86 1953 74.07 1944 68.38 1954 78.28 1945 65.87 Inward Transferable Births. Births in Institutions, Maternity Homes and Private dwellings outside the Borough of Leyton: Queen Mary's Hospital, E.15 166 Forest Gate Hospital, E.7 206 Plaistow Maternity Hospital, E.13 12 Wanstead Hospital, E.n 92 Thorpe Coombe Maternity Home, E.17 94 Mounts Bay Maternity Home, E.17 1 Mothers Hospital, E.5 272 Hackney Hospital, E.8 36 Royal Northern Hospital, N.7 1 St. Andrews Hospital, E.3 4 London Hospital, E.1 13 German Hospital, E.8 3 St. Bartholomew's Hospital, E.C.I 1 Bearstead Memorial Hospital, N.16 9 University College Hospital, W.C.I 3 Royal Free Hospital, W.C.I 2 Ilford Maternity Hospital, Ilford 4 Mile End Hospital, E.1 12 Maycrcfc Maternity Home, E.18 1 116 St. Margaret's Maternity Home, E.9 2 St. George's Hospital, S.W.1 1 East Ham Memorial Hospital, E.7 4 The Leys, Black Notley, Braintree 4 War Memorial Hospital, Ongar 1 Warley Hospital, Brentwood 1 Queen Charlotte's Hospital, W.6 1 St. Mary's Hospital, W.2 1 Lambeth Hospital, S.E.11 2 City of London Maternity Hospital, E.C.2 2 St. Mary Abbotts Hospital, W.8 1 Middlesex Hospital, W.1 4 Barking Hospital, Essex 1 General Hospital, Yarmouth 1 Rush Green Hospital, Dagenham 2 Bushey Maternity Hospital 1 Bethnal Green Hospital, E.2 1 General Hospital, Brighton 1 General Hospital, Rochford 1 Others (private dwellings, etc.) 6 Total 970 SECTION 24 HEALTH VISITING Health Visitors. During the year the Health Visitors made 15,987 visits to homes. (a) To expectant mothers:— First visits 113 Total visits 190 (b) To children under 1 year of age:— First visits 1,309 Total visits 5,746 (c) To children between the ages of 1 and 5 years 6,019 (d) Other visits:— Whooping cough 20 Measles 3 Ophthalmia neonatorum — Discharging eyes 2 Diarrhoea 9 Puerperal Pyrexia 11 Children's Act 8 After deaths 9 After stillbirths 34 Miscellaneous 1,072 Ineffective 2,744 Old people 55 Hospital follow-up 64 Pemphigus neonatorum 1 117 Chest Clinic. In addition to the above the Health Visitors interviewed 5,720 patients at the Chest Clinic and made 4,432 home visits. The General Practitioner and the Health Visitor. During the year the British Medical Association and the Society of Medical Officers of Health stressed the need for the closest possible cooperation between general medical practitioners and health visitors. In order to promote such co¬operation it was considered that, in the first place, an opportunity should be afforded to local medical practitioners to meet the Local Health Authority medical officers and health visitors working in their areas for an introductory exchange of information in order to further collaboration in the care and after-care of patients. As the health visitors in Leyton have their headquarters at the three Essex County Council Health Service Clinics in the area (Leyton Green, Park House and Dawlish Road) it was felt that the most convenient arrangement would be for meetings to be held at each of these three clinics, where medical practitioners could meet the health visitors working in the same area and discuss common problems. Such "get together" meetings were held at these clinics in the afternoons of these dates:— Leyton Green Clinic Friday, 4th June Dawlish Road Clinic ,, 11th June Park House Clinic „ 25th June and general practitioners were cordially invited to the meetings in the clinics which served their areas. Unfortunately the attendance was not sufficient to justify the holding of further meetings. SECTION 25 HOME NURSING The County Council has made arrangements for Home Nurses to nurse sick persons in their homes. The services of these nurses are available free of cost on the recommendation of the family doctor. The local centre for this service is:— The Lady Rayleigh Training Home, Beachcroft Road, Leytonstone, E.11. (Tel. : LEY 2385). During 1954 the following work was carried out:— No. of new cases (surgical and medical) 1,667 No. of visits paid to above 58,722 118 SECTION 26 VACCINATION AND IMMUNISATION Vaccination against Smallpox. NUMBER OF PERSONS VACCINATED (OR RE-VACCINATED) Age at date of Vaccination Under 6 months 6-12 months 1 year 2-4 years 5-14 years 15 years and over Total Number Vaccinated 221 104 29 20 21 83 478 Number re-Vaccinated — — — 1 6 177 184 Diphtheria Immunisation. During the year, by the exhibition of posters at the Clinics and surgeries of private medical attendants and Press advertising, we have been participating in the campaign to secure immunisation of not less than 75% of babies before their first birthday. The incidence of diphtheria continues to fall; but only if an adequate level of immunisation is maintained can this country be rid of diphtheria altogether. If parents leave their children unprotected there may well be outbreaks. Continuous publicity is therefore essential to prevent parents of young children being lulled into a false sense of complacency by the dramatic fall in the incidence of diphtheria and the rarity of its occurrence among the children of friends and neighbours. Age (in years) at final injection Children* who completed a full course of primary immunisation during the year Children * who were given a reinforcing injection during the year By General Practitioners By County Staff By General Practitioners By County Staff Under 1 227 345 — — 1 118 193 — — 2 11 26 1 — 3 9 13 1 1 4 11 11 12 53 5-9 10 26 76 194 10-14 3 4 23 22 Total 389 618 113 270 *Including temporary residents. 119 PERCENTAGE OF SCHOOL CHILDREN IMMUNISED. Entrants Second Age Group Third Age Group No. Exmd. No. Immunised % No. Exmd. No. Immunised % No. Exmd. No. Immunised % 1945 693 487 70.2 965 779 80.7 743 561 75.5 1946 1,240 919 74.1 1,191 889 74.6 913 634 69.4 1947 2,465 1,866 75.7 994 834 83.9 208 121 58.1 1948 1,200 914 76.1 1,062 879 82.7 1,018 752 73.8 1949 773 594 76.3 1,041 835 80.0 1,117 815 72.9 1950 1.405 1,061 75.5 1.237 951 76.0 1,079 880 81.5 1951 1,460 1,108 75.9 968 747 77.2 1,065 822 77.2 1952 1,939 1,492 76.9 855 696 81.4 1,123 919 81.8 1953 1,680 1,438 85.59 1,271 1,019 80.2 1,587 829 76.3 1954 1,298 1,015 77.7 1,127 915 81.1 1,365 1,113 81.5 Protection against Whooping Cough, Arrangements for public whooping cough immunisation in the area were put into operation on 10th September, 1951, and the following table gives the available information regarding the number and age groups of the children who were immunised during 1954. Age at time of final injection Children who completed a full course under the County Scheme Records of combined diphtheria-pertussis immunisations received By General Practitioners By County Staff Under 6 months 5 8 5 6-12 months 84 355 115 1 year 33 155 54 2-4 years 25 62 15 5 years and over 8 45 4 Total (primary courses) 155 625 193 Reinforcing injections 7 1 13 The protection is conferred by three injections of whooping cough vaccine at intervals of four weeks. Because the period of highest mortality from whooping cough is during the first six months of life it is recommended that immunisation should be begun as early as possible, even at as young an age as two months. PROTECTION AGAINST TUBERCULOSIS BY B.C.G. VACCINE In my Annual Report for 1952 I submitted a comprehensive report on " Protection against Tuberculosis by B.C.G. Vaccine." At the end of that report I outlined the steps taken to obtain the approval of the Ministry of Health for B.C.G. vaccination being undertaken in Leyton by Dr. Ethel Emslie, Assistant County Medical Officer of Health owing to the fact that the then Chest Physician was not prepared to undertake the work. 120 In that Annual Report, and in my Annual Report for 1953, I included reports by Dr. Emslie on her work ; and the following is an extract from the former of these two reports:— "In my opinion there are great advantages in having this work done at our Infant Welfare and School Clinics. The children are accustomed to come there, where they feel quite at home, and the Health Visitor and the Doctor are generally known to them already. On the other hand, at the Chest Clinic there is only one session a week at which children can attend, and this would make it very difficult to read tuberculin tests there. If, however, appointments were to be given for children to attend the adult sessions at the Chest Clinic, they would be exposed to a risk of infection there ; but, on the other hand, primary tuberculosis in children is not infectious to others. Again, the necessary follow-up of cases is much easier to arrange at our own Welfare Clinics. "Preliminary tuberculin testing is done at all ordinary sessions at Dawlish Road Clinic, and no special session is set aside for that purpose. The actual B.C.G. vaccination must be done on one particular day for each batch of vaccine, which must be fresh; but it is done by appointment during or after the School Clinic session. "Adults with tuberculosis have to be given special accommodation apart from others because of the danger of infection, but in the case of children separate accommodation is not necessary. By encouraging the attendance of children at Local Health Authority Clinics we are helping to show that tuberculosis is is not due to malignant fate, but is a preventable infectious disease in the same category as diphtheria and whooping cough. "It is well known that infants and young children are very susceptible to tuberculous infection, and a Local Health Authority should be in a position to offer immediate protection by B.C.G. vaccination whenever we learn that children are exposed to infection. "Dr. Emslie has shown that the work can be undertaken satisfactorily in a Local Health Services Clinic, and has given reasons why it should be done there rather than at a Chest Clinic. "All the evidence at our disposal is to the effect that B.C.G. vaccination is a valuable preventive measure, and the prevention of tuberculosis is not only better, but infinitely less expensive, than its cure." It will be seen from the following report by Dr. Emslie, on B.C.G. Vaccination during 1954, that this work—which she is so well qualified, and so keen, to undertake—has now been undertaken by the new Chest Physician. After all the trouble taken to obtain Ministry of Health approval for Dr. Emslie to carry out this work, it is unfortunate that mothers and children should be "switched about" from one to another of the two public authorities who are each dealing with the same problem (Tuberculosis) in different ways. In 1952 I reported:— "Before 1948 the prevention of tuberculosis was regarded as being more important than its cure, and all the work connected with prevention and treatment (domiciliary and institutional) was under the control of the Local Health Authority. Since 1948 the Regional Hospital Boards have been responsible for the staff and the work undertaken in Chest Clinics, and for all treatment either at home or in hospital; whereas the Local Health Authorities have been responsible for the appointment and work of the tuberculosis health visitors. Such dichotomy of effort has given rise to administrative difficulty of the type inherent in any scheme which is subject to dual control. "Owing to the lack of essential medical equipment and facilities at Leyton Chest Clinic, Leyton patients are subjected to unnecessary inconvenience, delay and expense by having to attend at the various institutions to which the work of the Leyton Clinic has been farmed-out; and the supervision of contacts is therefore more difficult than it should be." Unfortunately the dual control, and the associated dichotomy of effort, are still with us; but for those imbued with faith in things to come there should be consolation in the assurance that there is somewhere in existence "a long-term plan" for the co¬ordination of chest clinic facilities in Leyton with those of a neighbouring area. 121 B.C.G. VACCINATION DURING 1954- (Report by Dr. Ethel Emslie) Vaccination with B.C.G. for contacts with tuberculosis has continued to be provided at Dawlish Road Clinic during most of 1954, and below are set out details of the work done. Attendances in 1954 699 No. vaccinated in 1954 105 First attendances 123 No. not vaccinated but already Mantoux positive 19 No. of cases seen 201 No. vaccinated in 1953 first re-test 14 No. postponed by Dr. Swoboda 19 No. re-tested a year after vaccination 40 Excluded permanently by Dr. Swoboda 3 No. examined a year after vaccination not retested 7 Refused or failed appts. 7 Moved before vaccination 1 Of the 19 children who had already experienced infection without vaccination, one was only 3 months old, two were 2 years old, one 3 years old, three were 4 years old and the others were past the most dangerous age. Of these Mantoux positive cases four were in one family, and there were two in each of two other families. All cases were Mantoux tested after vaccination, and were found to be converted to Mantoux positive, except two who left the Borough before being re-tested. There were no serious complications. One child vaccinated in 1953 had a gland under the arm (the size of a hazel nut) which softened. Although this occurred a year and a half after vaccination, I regarded it as the result of vaccination because there was nothing else to account for it, and it was on the same side as the vaccination. Fluid from the gland was found on bacteriological examination to be sterile, and a special culture remained sterile; nevertheless I have no doubt that B.C.G. was responsible. As the gland seemed to be filling up again I sent the child to hospital to see whether the surgeon would advise excision, but he preferred to leave it alone, and I am glad to say it has now subsided and apparently healed without any treatment. The child's general condition remains good. Apart from this case 16 children had an enlarged gland which varied from just palpable (or the size of a pinhead) in five cases, to the size of a split pea in five cases, and the size of a bean in six cases. None of these caused any trouble, and the children themselves were probably unaware of them. It is interesting that the percentage of cases with palpable glands (14 per cent.) is almost the same as last year (15 per cent.). The number of children dealt with is less than last year, and in fact our B.C.G. Clinic at Dawlish Road had ceased to function altogether by the end of the year as the new Chest Physician decided to take over the work himself at the Chest Clinic. Tuberculosis Nurses and Health Visitors were instructed to send their contacts to him, and, as I was largely dependent on information from the Chest Clinic staff for case finding, I preferred not to 122 engage in a struggle for cases which must inevitably be unequal and would not be in the best interests of the service. Nevertheless I should like to express my regret that this work has been lost—not only to me personally, but to the School and Welfare Health Service which I consider has advantages in dealing with it. SECTION 27 AMBULANCE SERVICES I am indebted to the County Medical Officer for the following statistics relating to the work carried out, during the past five years, from the Ambulance Station, Auckland Road, Leyton, E.io. (Tel. : LEY 6077.) 1950 1951 1952 1953 1954 Patients conveyed 23,300 24,196 29,586 31,268 35,873 Total mileage 108,654 114,558 123,995 130,110 137,454 The patients conveyed by Ambulances and sitting-case cars from the Leyton Ambulance Station during 1954 were:— Stretcher cases 5,590 Emergency cases 3,567 Other cases 26,716 SECTION 28 PREVENTION OF ILLNESS, CARE AND AFTER-CARE Foot Clinic. In my Annual Report for 1953 I submitted a brief historical outline of the treatment facilities available since the Foot Clinic at High Road Baths —one of the first municipal foot clinics in the country—was established in 1936, and some idea of the progressive increase in annual attendances may be gained from these figures:— Year Attendances Year Attendances 1936 4,622 1946 9,042 1937 6,529 1947 10,002 1938 8,756 1948 13,311 1939 6,181 1949 13.637 1940 5,117 1950 14,106 1941 4,713 1951 15,895 1942 6,464 1952 19,901 1943 5,838 1953 21,528 1944 5,972 1954 22,695 1945 6,035 123 With the available staff of Chiropodists the time between successive appointments has never been less than seven weeks, and has occasionally been much longer. The Foot Clinic facilities are available to all, the only priority being that given to children referred from School Clinics. Under the circumstances it is of interest to see the age groups of those attending for treatment, and the following list shows the ages of 2,000 adult patients who attended at the Foot Clinic. Age Men Women Total 20-25 6 15 21 25-30 11 26 37 30-35 17 50 67 35-40 22 54 76 40-45 35 96 131 45-50 42 125 167 50-55 50 159 209 55-60 52 177 229 60-65 55 182 237 65-70 82 217 299 70-75 67 201 268 75-80 37 110 147 80-85 17 61 78 85 and over 7 27 34 Total 500 1,500 2,000 These figures show that in Leyton the Foot Clinic facilities are in greatest demand by persons from 65 to 70 years of age, the 70 to 75 age group being a close runner-up. Foot trouble is one of the most crippling disabilities of old people, a large proportion of whom can be converted from bed-ridden patients to ambulant members of the community by skilled attention to the feet. A prolonged confinement to bed is recognised as a major disaster, especially in old people, and it should be unnecessary to stress the beneficent value of chiropody in a community in which the proportion of old people is increasing at such a rate. In addition to its humanitarian aspect, the economic value of expert foot treatment is becoming increasingly appreciated, especially in connection with the freeing of beds in geriatric hospitals. Summary of Attendances and Treatment. During the year there were 22,695 attendances for treatment, an increase of 1,167 over the attendances during the previous year. First Attendances (New Cases) Subsequent Attendances Total Attendances Males 297 3,580 3,877 Females 996 16,479 17,475 Children 171 1,172 1,343 Total 1,464 21,231 22,695 124 Convalescence for Adults. (a) Number of applications during year 86 (b) Length of convalescence of cases sent during year:— Length of stay No. of Cases One week 2 Two weeks 36 Three weeks 36 Four weeks 10 Over four weeks 2 (c) Where cases have been sent:— Name of Convalescent Home No. of Cases sent Essex Convalescent Home, Clacton 38 Bell Memorial Home, Lancing 12 Spero Fund Homes 11 Samuel Lewis Home, Walton 9 Rustington Convalescent Home, Littlehampton 3 Mental After-Care Home 2 Wordsworth Home of Rest, Swanage 1 Edith Cavell Home, Windermere 1 Victorian Convalescent Home, Bognor 1 Hermitage Convalescent Home, Hastings 1 Cumberland Convalescent Home, Herne Bay 1 St. Michaels Convalescent Home, Westgate 1 St. Josephs Convalescent Home, Bournemouth 1 Brook Lane Rest House, Brighton 1 "Gatley" Epileptic Home, Hastings 1 Armitage House, Worthing 1 National Association for the Paralysed Home 1 Health Education. Shop Window Displays, 280 High Road, Leyton, E.io. Dates Subject 3.1.54 to 5.3.54 Coughs and Colds 5.3.54 to 12.4.54 Sanitary Inspectors 12.4.54 to 26.5.54 Mobile Mass X-Ray 5.7.54 to 20.9.54 Diphtheria Immunisation and Health Visiting 21.9.54 to 8.10.54 Tuberculosis Care Association 15.10.54 to 12.1.55 Health Visiting and Midwifery Lectures. Five lectures (one illustrated by a film show) were held during the year. These were attended by 329 persons. An average of 65 persons at each. Talks. The Health Visiting staff gave 13 informal talks to groups of mothers at the Health Clinics in the area. These talks were illustrated by the projection of film strips. Home Safety. For many years it has been the routine practice in this Area for the Health Visitors to deal with the necessity for efficient fireguards during their visits to homes, for posters to be exhibited in the clinics, and for suitable pamphlets to be distributed to expectant and nursing mothers. 125 In my Annual Report for 1953 I outlined additional publicity undertaken by exhibitions and film shows on home safety shown at the different clinics. Attention was then drawn to the large number of home accidents primarily caused by carelessness or ignorance, to the need for education of the general public, and to the necessity for collaboration between the health, fire and education departments of local authorities. A special report was submitted showing the extent of the problem, the commonest kind of accidents in the home, the commonest causes of accidents and the precautions that should be taken. In spite of the awful toll of road deaths and accidents, there are roughly four times as many accidents in the home. During recent years there has been an alarming increase in the number of children poisoned by swallowing drugs left within their reach, and it is unfortunate that so many such drugs and tablets are in appearance so attractive to young children. Mass Radiography. Submitted hereunder in statistical form is the result of the survey undertaken by Mass Radiography Unit 6.B in the Borough in May, 1954. Males Females Total Number of attendances for miniature X-Ray 4,566 5,112 9,678 Number passed as normal on miniature film or subsequent large film examination 4,438 4,998 9,436 Number showing some abnormality ... 128 114 242 Percentage showing some abnormality 2.80 2.22 2.50 Classification of abnormalities noted— Congenital abnormality of bony thorax 3 3 6 Chronic bronchitis and emphysema 18 13 31 Pneumonia, lobar — 1 1 Broncho-pneumonia 3 1 4 Bronchiectasis 9 5 14 Pulmonary fibrosis 8 7 15 Pleural thickening 1 2 3 Intra-thoracic tumours 8 — 8 Congenital cardio-vascular lesions 1 — 1 Acquired cardio-vascular lesions 5 13 18 Miscellaneous 9 6 15 Failed to attend for large film examination 7 8 15 Pulmonary tuberculosis, all types 56 55 111 Total 128 114 242 Tuberculosis lesions. Inactive tuberculosis— Primary 14 18 32 Post-Primary 34 31 65 Total 48 49 97 Active tuberculosis— Primary — 1 1 Post-Primary 8 5 13 Total 8 6 14 Note: The eight intra-thoracic tumours discovered were all bronchial carcinomata. Five were operable, and three unfortunately not so. 126 It will be seen that of the total of 9,436 persons examined, 97 showed evidence of pulmonary tuberculosis, and 14 of this number were found to have active disease at the time of examination, i.e. 8 males and 6 females. The combined rate for active tuberculosis discovered was 1.44 per 1,000 examinees. The rate for males was 1.75 and for females 1.17. These figures are the lowest so far recorded for the Borough, as will be seen from the following table:— Active Tuberculosis. Rates per 1,000. Mass Radiography Survey Males Females Combined 1951 2.24 3.07 2.64 1952 2.26 1.82 2.03 1953 1.96 2.68 2.36 1954 1.75 1.17 1.44 Tuberculosis. (a) Open Air Shelters. (1) Number of shelters in use at end of year 1 (2) Total number of visits made to shelter by health or tuberculosis visitors during year 13 (b) Extra Nourishment. Number of new cases during year supplied with free milk 89 Total number being supplied with free milk at end of year 122 (c) Rehabilitation. (1) New cases— Preston Hall Papworth Hall Number of new cases assisted during year - - Number of cases for whom the Council ceased to be responsible 1 1 Number of cases being assisted at end of year 1 - 127 Loan of Sick Room Equipment. During the year 266 articles of sick room equipment were loaned on the recommendation of doctors, hospital almoners, etc. From Central Store From Lady Rayleigh Home Air Beds 3 — Air Rings 26 26 Bed back rests 25 7 Bed cradles I 6 Bed pans 33 25 Crutches 2 — Invalid chairs 15 — Rubber sheets 20 25 Sputum cups — 4 Urinal bottles 13 19 Feeding cups — 3 Steam kettles — 3 Commodes 9 — Thermometers — 1 Totals 147 119 266 TUBERCULOSIS CARE ASSOCIATION (By Mr. F. C. Ware, Secretary) During 1954 the Association raised more funds, and spent more on assistance to patients, than ever before. Once again the most successful fund-raising activity was the Christmas Seals Campaign which established a new record for the Association. The provision of extra-nourishment vouchers to patients at home continues to be one of the most important items of assistance, and the total value of vouchers issued during the year was £1,168 15 0. These vouchers are issued to patients according to their needs and financial circumstances, and they are invariably supplementary to National Assistance Allowances. In the majority of cases the wage-earner of these families is incapacitated by tuberculosis and the vouchers are the means of providing additional nourishment for patients whose incomes are already ear-marked for life's necessities. During the year an average of 47 patients received vouchers every four weeks, and the value of each voucher was 10s. or 7s. 6d. per week. Only two or three vouchers were for the smaller amount, the remainder being for 10s. per week. The average cost of this assistance alone for a four-week period was £90. Members of the Association maintain a keen interest in the Occupational Therapy Centre and continue to assist in the sale of finished articles of weaving, jewellery, woodwork, leatherwork, basketwork, etc. 128 Due to increasing income from strenuous voluntary efforts the Association was able to assist many patients who would have been beyond its financial scope previously. But it is not by financial assistance only that the Association helps patients, and wives or relatives appreciate that this is an organisation which exists for the specific purpose of dealing with their problems. It is regrettable, however, that two of the main causes of anxiety to tuberculosis patients and to those concerned with their welfare are the same now as they were four years ago, when I was appointed Secretary of the Association (i) Overcrowding and poor housing. (ii) Re-employment when fit. Unfortunately the Association is powerless to assist patients in obtaining suitable and sufficient housing accommodation, and can only appeal to Housing Authorities as it has done to give urgent consideration to this vital social and health problem. Overcrowding can foster the spread of tuberculosis, and until adequate accommodation is available for infectious patients to be effectively isolated at home, the risk of contacts developing the disease is gready increased. In many infectious cases shared homes continue to be an economic necessity until such time as the local authority can undertake the re-housing of these cases. Often the patient returning from the ideal environment of a sanatorium to overcrowded conditions at home suffers a psychological set-back which is in no way conducive to his convalescence and recovery, and this can be a contributory cause of a fresh break-down in health. The re-employment of patients, once they are fit to resume work, is a problem which arises frequently and requires an increasing measure of goodwill and commonsense from employers and fellow workmen. Due to fear or ignorance some ex-tuberculous patients are still shunned by their employers and ostracised by the people with whom they formerly worked. It cannot be emphasised too strongly that working with a patient passed fit by a chest physician constitutes no greater danger to one's health than travelling in an overcrowded train. The Association is fortunate in having as honorary medical advisers the chest physicians of both areas (Dr. J. A. F. Swoboda and Dr. H. Duff Palmer), with whom close liaison is maintained and from whom valuable support is received. During the year additional assistance for patients has been enlisted from the British Legion, the Women's Voluntary Services, the R.L. Glasspool Trust and the St. John and British Red Cross Library Department, with whom the Association works in close co-operation. The National Assistance Board has also dealt most sympathetically with cases referred to them by the Association. The Essex County Council continue to finance Care Associations in the County, and approximately £600 is received from this source annually in the form of grants. The Association has raised as much again by voluntary efforts, and must continue to increase the amount of funds raised each year in order to maintain assistance to patients at the present level. 129 No report on the Association's activities would be complete without reference to the efforts of the patients themselves. The majority are not content just to receive assistance, but will support enthusiastically any activity organised to raise funds. During the Christmas Seals Campaign there were some outstanding sales achieved by patients, and in the selling of concert tickets they have also rendered valuable service. OCCUPATIONAL THERAPY (Report by the Instructor : Mrs. S. A. Wiltshire) At the beginning of the year there were sixteen patients on the register, including two men from Walthamstow. By the end of June five men were back to work, and by August another four had been re-employed. We were once again at the County Show in June, and in spite of rain had two successful days. Much the same interest was shown as in previous years. Five more students joined the class by December. Weaving, leatherwork, cane and wood work had been in progress, and the Centre was open to the public on Mondays, Wednesdays, Fridays and Saturdays during December for Christmas sales. In addition to articles shown at previous Christmas shows, we now had calendars and crackers, and had woven and made up som; men's ties. The rug loom had been turning out pile door mats ordered; the woodworkers had made and sold bed trays—a new venture ; and shopping baskets and cane-edged trays found a ready market. We hope this year to begin a new line in jewellery in addition to the gold wire work we still do. We are also working with nylon in addition to the wool and cotton we use on the looms. Twelve students are at present on the register. At a recent gathering of thirty two students—past and present—we heard how they had settled down to re-employment. All were now holding situations, and were able once again to resume work which their illness had interrupted. Keen interest is still shown by those attending the class, and students are encouraged to try out their own ideas in all kinds of crafts. SECTION 29 DOMESTIC HELP Eight years have now elapsed since Leyton Council, the then Maternity and Child Welfare Authority, extended their scheme for domestic help by including the provision of domestic help in necessitous cases other than mothers and infants; and some idea of the work may be gathered from these figures:— Year Number of Cases Maternity Other Total 1947 211 27 238 1948 162 85 247 1949 168 214 382 1950 136 464 600 1951 119 564 683 1952 88 547 635 1953 69 693 762 1954 75 794 869 130 (а) Number of helps and hours worked:— Number of domestic helps enrolled at end of year— Whole-time helps 13 Regular part-time helps 70 Number of domestic helps actually employed at end of year 76 Number of hours worked during year 117,572½ (b) Work of the Domestic Help Organiser:— (1) First Visits 654 (2) Re-visits to beneficiaries— (a) Domestic help present 266 (b) Domestic help not present 609 (3) Other visits 151 (c) Help Provided:— Maternity Acute Sick Tuberculosis Chronic Sick Aged Not Sick Others Total Aged Others Requests for help from new cases during the year 106 67 21 321 85 29 2 631 New cases helped during the year 71 45 13 255 60 18 — 462 Total cases completed during the year (a) 74 44 12 215 57 24 — 426 Cases being helped at end of year who have received help for— Under 3 months - 3 - 46 8 - - 58 3-6 months 3 5 35 3 5 - 51 6-12 months - — 3 71 11 4 — 89 Over 12 months - — 13 185 26 21 — 245 Total (6) 1 6 21 337 48 30 - 443 Total cases helped during the year [(a) plus (6) 75 50 33 552 105 54 — 869 Hours of help provided during the year 4,991½ 3,213¾ 4,232½ 78,264½ 15,607 11,263¼ — 117,572½ Medical Examination of Staff. (1) County Council employees— Number of medical examinations for: (а) Entrants to County Council's service 121 (b) Retirement on Superannuation 1 (c) Other purposes - (2) Employees of other local authorities, etc. Name of local authority, etc. No. of medical examinations Leyton Borough Council 82 City of Bristol 2 Entrants to teaching profession and training colleges 20 131 NURSERIES AND CHILD MINDERS REGULATION ACT, 1948 During the year one child minder, who was registered and allowed to take up to four children ceased to act in this capacity. One new child minder was registered during the year, and allowed to take up to three children. School Health Service THE CHANGING FACE OF SCHOOL MEDICINE By Mary L. Gilchrist, m.d. d.p.h. For a long time now the criticism of the School Health Service which has irritated me most is the one which declares that we are in a " rut", and are merely carrying out, in an unimaginative way, duties that were laid down nearly half a century ago. I am prepared to accept criticism which is constructive, which points out our deficiencies, inadequacies and mistakes, and to improve and amend these when necessary, but I am not prepared to accept the criticism that the service is out of date and has never changed since its inception. I hope to show this afternoon how it has progressed logically and has undergone that " organic development " predicted by Newman, the first Chief Medical Officer to the then Board of Education ; how it has met each new need as it has been revealed by our experience and how it has catered for those needs in whatever manner has been required and justified by the resources at our disposal. I should also like you to remember that I speak to you not from the standpoint of the administrative officer seated at a desk, but out of the experience gained over a period of 22 years as a field worker engaged daily in school and clinic and conscious all the time of the parents and children who are my teachers. I have chosen the title of my address deliberately because I am so deeply aware of the changes that have come over not only our service but these same children and ourselves. How best to show this change gave me much thought. At first it seemed best to do it with graphs and charts and much statistical material but, after spending much of my own time and that of our clerical staff in producing rows of figures, I decided it was not the right method. If I demonstrate to you that the deaths from rheumatic fever and heart disease in children under 15 years of age have shown a steady fall from 1930—as shown in Table I—it would look as though I were claiming this as our achievement. Table I Period Death rate per million at ages under 15 years Rheumatic fever Heart disease 1901-1910 56 132 1911-1920 54 117 1920-1930 56 88 1931-1939 43 60 1940-1949 23 28 1942 18 36 1944 29 39 1946 18 25 1948 22 24 1950 17 17 1951 9 12 That, of course, would not be true; we are but one of many and diverse factors operating in this field. Equally misleading I found graphs of defects noted at routine medical inspections since severity of defects may lessen though still noted, or, because of expanding services, comparisons between one year and another became impossible. 132 I have chosen, then, what I call the historical approach—that is, noted our expansion year by year and how, starting as a School Medical Service, we are slowly changing over to a School Health Service. This necessity to be a medical and treatment service as well as a preventive service was imposed upon us by circumstances, if not by conscious design, but our idea of treatment was somewhat different from that held by the usual medical agencies. Our aim was so to treat the child that " he was able to benefit from the education provided for him." In other words, we dealt with the whole child, not just a part of him. The child has always been more to us than the disease and, in making him fit for education, we were making him fit for life itself. In the early years of this century medical treatment for many children was not easy to come by. In his report for 1908 the Medical Officer of Health for Bradford, Dr. Lewis Williams was constrained to say that, after 15 years of medical inspections, the defects discovered among Bradford school children remained untreated despite the medical agencies, the private practitioners, the Royal Infirmary, the Children's Hospital and the E.N.T. Hospital apparently available to all. Dr., later Sir, George Newman's reports endorsed all that the Bradford Medical Officer of Health had found and it was soon evident that inspection without treatment was a waste of time and money. It was not enough that skilled medical advice should be available; it had to be organised before the children could take advantage of it ; it had to be available in a form convenient of access or the neglectful parent would not accept or seek treatment, or complete it when begun; and it had to be within the parents' economic resources or free if the circumstances required it. The great majority of defects found at these early routine medical inspections, apart from those caused by poverty and under-feeding, were due to dirt and ignorance, neglect and bad home conditions as well as to lack of medical care. The first clinics set up were, therefore, "minor ailment" clinics in which a school nurse could work, along with the school medical officer, and deal with these " dirt " diseases. The growth of the minor ailment clinic was pitifully slow at first. The provision of any treatment centres produced the usual protests about undermining the parents' sense of responsibility—a complaint still heard to-day ! Growth of the Service. As you see in Table II, by 1910 only 21 Local Education Authorities had provided treatment centres. The greatest impetus to their extension came from the revelations of the medical boards during 1914-18 and the clauses in the Fisher Act making the provision of treatment facilities compulsory for the elementary school child. By 1938 there were still three areas where treatment facilities were not available. Table II Year Number of L.E.A. providing treatment in school clinics Number of clinics providing for Minor ailments Dental defects Visual defects Orthopaedic defects 1910 30 21 14 Not re corded 1914 179 254 189 55 55 1921 291 749 567 55 55 1925 312 891 955 552 70 1929 316 1,008 1,151 606 228 1938 314 1,279 1.673 774 382 Next to the poverty and dirt diseases, defective vision and dental caries and sepsis were the outstanding defects revealed at the early inspections but these "special" clinics also got off to a slow start, as Table II shows. However, once the mass of obvious disabilities were provided for, progressive education authorities began to enlarge their treatment facilities. They did this, not to take work away from the existing agencies but because the treatment was, in the main, not being provided at all or it was so difficult or expensive to obtain that it was 133 never started, or, if started, not completed, and the child was left with his disability or only partially restored to health or fitness. Early in the 1920's the special clinics began to make their appearance in areas all over the country. By 1925 there were 70 orthopaedic clinics, rising to 382 in 1938. Along with these went the appointment of physiotherapists and, in many areas, ultra-violet ray clinics were combined with the orthopaedic clinic. With the improvement of the mortality figures in children of school age from other diseases, the returns noting rheumatic fever and heart disease as a cause of death in children of school age began to loom more prominently than in the earlier years of the School Medical Service and many education authorities started " rheumatism " clinics and an increasing number of hospital schools were provided in the late 1920's and early 1930's. About this time, too, Child Guidance Clinics made their appearance and many Local Education Authorities agreed to support cases attending them even if they did not actually run one themselves. In the 20 years, then, from 1918 to 1938, the foundations of the School Health Service were laid. If every Local Education Authority had implemented the 1921 Act as fully as the more progressive authorities had done, and if there had been no panic economy measures cutting down the services in the days of the "depression", the bills we are having to pay to-day for the National Health Service and the needed extensions to the School Health Service would not have been so high. Changes in Nutritional States. It was in these 20 years, too, that an effort was made to study nutritional needs and standards. As you all know, the necessity to feed adequately the children in our poorer schools was the first recommendation made by the Royal Commission on Physical Training in Scotland (1903) and the Interdepartmental Committee on Physical Deterioration in England (1904), but the niggardly Poor Law spirit with which school feeding was administered right from the start is rather a shameful story. Even up to the 1930's that spirit peristed. You will remember we were not supposed to order free meals or milk unless the children showed signs of malnutrition. It is true that this was subsequently amended, after protests, to "however slight", but it was not really until the Second World War that this mean spirit was finally exorcised. It is not only that that attitude has changed, however. Twenty years ago we were all preoccupied by questions of basic needs for health, optimum standards, and "measurements of nutrition", fallible and infallible. I can remember a packed meeting (Public Health, 1935) of specialists and consultants at the Society's old headquarters telling the medical officers of health and assistant medical officers of health there, including the late Dr. McGonigle, that we could give them no scientific evidence that the economic depression was affecting our school children adversely, and so we set about the search for standards, and many measurements were made and many " sums " were done, as the late Prof. Major Greenwood would have said, all in an effort to find a foolproof yardstick for " nutrition " that does not exist. I even joined in the research myself but, looking back on it all to-day, I doubt if it was necessary. If a child has no demonstrable disease or emotional feeding difficulties the question of whether or not it is suffering from underfeeding depends mainly on economics. We know what constitutes a balanced diet and how much of certain foods are needed to keep a child fit and well. If we know how much of the weekly wage is left to spend on food per head in a family after all other commitments are met then we know which children require watching on the question of good or bad nutrition. I think the following extract from Public Health of July, 1953, illustrates this point. Prof. Fraser Brockington, in reviewing a report on " Domestic Food Consumption in 1950 " by the National Food Survey Committee, said, " In terms of the B.M.A. recommendations, the diet of families with over three children was 'marginal'. Both protein and calcium were below standard at all seasons of the year ; vitamin C fell below in April and May ; after the lowering of the extraction rate of flour, iron and riboflavine fell below the standard in October and November". He goes on, "We are, therefore, left with little doubt that the average diet of working class families with more than three children in 1950 was only on the borderline of sufficiency". And it should be realised that food prices have risen considerably since 1950. That the deficiency is much less than it was in pre-war days I am well aware, but it does mean that there is still a necessity for the School Medical Officer to report to the education authority quickly on cost of living changes, remembering that it is the children in our larger families who are the first to suffer from a rise in prices of food. 134 The number of children taking school meals is falling. Is it due to the greater freedom in buying food now that rationing has almost ceased, or is it due to the price of dinners having risen and the parents being unable to pay the increased cost? We should try to find out and act on the information. Perhaps the time has come when we need once more to be occupied by the question of nutrition but this time from the economic angle. Of course, none of us has any doubts about the improvement in the children's nutrition and general well-being and that particularly in the last 10 years. I know that Martin has suggested in his memorandum on "The Physique of Young Adult Males" (1949) that there has been no real increase of average height. The steady increase in the heights and weights of school children shown in our returns since 1911 has apparently merely brought forward the age of physical maturity from 26 years of age some 50 years ago to 21 years of age to-day. It would be interesting to know if there is any difference in the National Service men reporting to-day. Martin's analysis was done on 1939 figures; but, be that as it may, none of us can doubt that the years of full employment, the priority food policy of the war years, cheap milk for under fives, free milk in school, and the family allowance (in my opinion one of the best social security measures ever brought in) have all helped, and are still helping, to conquer the first of the "biological stresses" for the school child described by the late Dr. Dunstan Brewer in an address on "The Future of School Medicine" given at the Royal Sanitary Institute (1941) when he said: "It soon became apparent to the more enlightened School Medical Officers that the defects they found were not haphazard accidents, but the inevitable outcome of certain biological stresses to which the organism was unable to adjust itself—these stresses could be reduced to three—ill-nutrition, infection, and faulty environment." In 1941 Dr. Brewer was very gloomy, sure that we had still a long way to go to conquer the nutritional deficiencies. I feel he would be much more cheerful to-day but we should remember that the price of good nutrition is eternal vigilance—economically. I think he would agree that his second "biological stress"—infection—has been greatly reduced in severity but I have no time to enter into the reasons this afternoon. What of his third "stress"—faulty environment? Here, materially, the picture is not so encouraging for the provision of better school buildings and better homes has been much handicapped by war and its aftermath, but I prefer to deal with a special form of "faulty environment" this afternoon and that is the emotional environment, and here it seems to me we have fresh fields to conquer. Emphasis on Mental Well-being. Dr. Margaret Mead, the well-known American anthropologist, in a broadcast after the first International Conference on Mental Health held in London in August, 1948, appealed to the preventive health services to do for mental health what they had done for physical well-being. To-day the children passing through our schools are incomparably better than they were 20 years ago. The children coming into the schools are equally improved; the work of our Maternity and Child Welfare colleagues is also bearing fruit. Perhaps the statistics of numbers of defects found show little change, but those working in the service know that the severity of these defects has also been greatly reduced and, indeed, defects are listed to-day which, in the mass of more worrying physical lesions, were rarely listed before the war. One of these coming more and more to the fore is the "Behaviour Problem" or "The Emotionally Maladjusted Child". We had already begun to take note of emotional states before Dr. Mead made her appeal but, as she said, it took 20 to 30 years to improve the physique of school children and it is likely to take a similar span of time before we see a comparable improvement in mental well-being. Until our attention could be released from the pressure of dealing with obvious and remedial physical ills we could not give time and consideration to the less obvious emotional difficulties, and indeed the school medical officer himself had to begin to acquire the knowledge to detect and deal with this new and difficult field of work. It was not that these behaviour difficulties did not exist 20 or 30 years ago. We only have to look at the neurotic adults of to-day, or read the literature of the past, to know that emotional maladjustments have always been with us—at least, in organised and highly civilised societies ; but we are to-day more aware of the problem and must equip ourselves to deal with it. At one time I thought that the provision of Child 135 Guidance Clinics would be the answer, with its team of specialists to whom we could refer our disturbed children and their parents, but, obviously, there will never be enough of these highly trained specialists to give an adequate service in every area of the country ; the ordinary staff of the School Health Service and Child Welfare Service will have to be the preventive team working with the mass of the child population, sending only the seriously disturbed child to psychiatrist and special clinic. It is in this field of preventive mental health that the Health Visitor/School Nurse has so much to give and I think that probably the Child Welfare Officer and School Medical Officer should be one and the same person. Preventive health work begins long before school age (as our Maternity and Child Welfare colleagues are well aware) but many children do not show their difficulties until they get to school and the School Health Service must continue this work of preventing or ameliorating emotional difficulties and, if necessary, train itself more to do so. We must also take stock of the retarded and the dull child. Intelligence testing needs reviewing in the light of experience in the schools. The dogmatism of much of the early work has been shown to be unwarranted and I think the time has come for us to undertake some research work along with our educational psychologist and teacher colleagues into the whole question of the educationally sub-normal child. The 1944 Act is nearly 10 years old; experience has been accumulating about the educationally sub-normal child as distinct from the classification of backwardness under the 1921 Act and I, for one, am not too happy about it. Perhaps we could have a conference with our colleagues of the Ministry of Education on these problems. We could include in it the "problem family" and the juvenile delinquent. They have always been the families who have refused to co-operate with us when treatment was needed and, apart from the sterile procedure of prosecution, we have tended to leave them too much to their own devices. We are seeking to find a new approach to these families but we still have a lot to learn and must explore new ways with them. What Changes Do We Need in the Future? I hope I have said enough to show that our service is a flexible one; that as the state of the children has altered so has our service grown or changed to meet their need. Are we really just doing to-day what we did 45 years ago ? Let me remind you of our origins (Newman, 1939). If there is anything that has been proved over the last 50 years it is the remarkable vision of the men who laid the foundations of the School Medical Service. Here are the eight questions which they set out to consider when devising its structure. 1. Has the child had any illness in the past which would be likely to affect his physical future? 2. What is the present condition of his body as regards cleanliness and nutrition? 3. Are his senses normal—hearing, seeing, taste, touch, smell? 4. Has he sound or decayed teeth? 5. Are the throat and tonsils normal and healthy? 6. Is he normal and sound in mind? 7. Does he show any sign of disease or deformity—rickets, tubercle, rupture, glandular disease, ringworm, anaemia, epilepsy, psychoneurosis, etc.? 8. Has he any weakness or defect unfitting him for ordinary school life and physical exercise or requiring any exemption from any branch or form of instruction ? These questions may be put in an old-fashioned way but we still require an answer to them. The medical history of the child must come from its parents and we must still, by our examination, find an answer to the above questions—even if to-day, fortunately, the physical ills are less severe and the emphasis has shifted to many minor degrees of defect ; but the minor degrees of defect may not be so easy to detect and to discuss the problem which may be presented by the child's personality can take a long time. 136 The Routine Inspection. I do not think, therefore, that "rapid surveys" can cope with the more subtle defects we are interested in to-day and I do not believe that the routine medical inspection should be scrapped. The defects we are concerned with, if we are interested in the whole child mentally as well as physically, do not strike the casual observer. The parent should be with the child and, what is most important, the doctor must have time to talk to her in a friendly and personal way so that she feels the School Medical Officer is really interested in the child and not just its possible ailments. I feel very strongly, then, that the routine medical inspection must stay and that three is the minimum required. For the following reasons I would wish to retain the inspection which takes place about the age of 10 to 11 years. It is just as important to have a survey of the child after he has been some years in school as it is when he enters school or leaves it to go out into the world. The School Health Service has become a preventive service in a way it has never been able to be until now, and this necessitates discussion with the parents as well as examination of the child for defects. To find out how the child is progressing physically, mentally and emotionally one must talk to the parent and make sure no worries have arisen since the first examination. Minor degrees of school failure are brought to our notice about this age; some of this is due to innate dullness but some is also due to emotional or environmental difficulties in home or school and it is important that help be given in such cases before the child enters the secondary school. Parents, too, still feel that this second routine inspection is worth while. In my own district in 1952, 96.5 per cent. of parents attended the entrance examination; 79.5 per cent. of parents attended the second examination, and this in spite of some 30 per cent. of the mothers being at work. The drop in parents' attendance is very marked when it comes to the final examination—38 per cent. of mothers attended this inspection. It is true, of course, that the adolescent 14- to 15-year-old does not wish the parent to attend the medical inspection, especially the boys and, also, he can speak up for himself. If your last contact with the parent was eight or nine years before you are going to know very little about that child at his final examination. For these reasons I still favour a minimum of three routine inspections, which has indeed been the consistent policy of the School Health Service Group. The Minor Ailment Clinic. In the area of Leyton these clinics have changed out of all knowledge. The packed clinic, full of children with skin troubles, sores, otitis, verminous heads, with the impetigo and adenitis which went with that state, are things of the past. These dressing cases are so reduced in number that the work can be done by one nurse at each clinic instead of two or three and so the staff can be released for school and home visits. The School Medical Officer still sees there the special cases referred by school and medical staff but, of course, not so many cases of acute minor illness now as formerly. Before the National Health Service Act the School Medical Officer saw many sick children because the parent could not afford a private doctor. Without the need to write a prescription a great deal could be done for these children and in addition, being practitioners of preventive medicine, we could and did discuss other facets of physical or mental well-being beside the immediate ailment. Perhaps it is this type of case, which we find fruitful and rewarding because of the opportunity it offers to us for preventive work, which our colleagues in curative medicine do not want. They say that their surgeries and hospital out-patient departments are filled with patients suffering from trivial complaints. In the case of the children we are only too happy to relieve them of this burden, if they will allow us to do so. I see signs that this work is coming back to us. Changes in the Personnel of the School Health Service. Since 1945 an increasing proportion of our nursing staff has been in possession of the Health Visitor's Certificate and this should prove of great importance in the field of mental health. Their training in the emotional development and the management of children which has been of so much use to them when dealing with " under fives " is not lost when the child goes to school, but this metamorphosis of the School Nurse into Health Visitor could not come until the time was ripe for it, as it surely is in many areas to-day, but not yet, I believe, in all areas of the country. 137 The work of the minor ailment clinic and the struggle to get the school child "cleaned up" needed the full-time energies of the State Registered Nurse. The special training of the Health Visitor could not have been put to much use in the old days: she would not have had enough time left over from her hygiene work; and 15 years ago, even in my own district I doubt if I would have welcomed the change. In Leyton the cleanliness problem is a very minor one now; e.g., in 1952, 315 cases of uncleanliness discovered in 25,000 inspections is a very small number and the majority of these cases were of minor degrees of infestation. Our Health Visitor/School Nurse can do the hygiene inspection in her school and use it as the means to survey each child each term in her school. She is allowed to take a proper amount of time to do it. From it she can refer to the clinic any child giving cause for worry and it is not just a "hunt for nits". I think, therefore, in areas where a high standard of cleanliness has been reached, it is a mistake to talk of it being a waste of a highly trained person's time to do hygiene inspections for it is one of the ways in which she gets to know her school children well, and not only the children but the Head Teacher and the school staff, too. "Cleanliness Assistants" are not required in an area such as ours: it would make only another person coming into school and not be helpful to anyone. "Dilution" of the staff may be necessary where there is a great shortage of trained personnel and the hygiene problem still a serious one; but I do not think it is a movement to be encouraged in all districts.* There is great danger in sending a multiplicity of people from the Health Department into the schools; neither health staff nor school staff, let alone the children, ever get to know with whom they should deal. Also, I think there is a danger that we hedge ourselves about with a barrier of superiority, refusing to do the routine tasks, forgetting that it is in the day-to-day work that we get to know our children so well and so can see if any deviation from health and fitness is taking place. The School Medical Officer. Over the years our service has shown great flexibility in its organisation and in coping with new situations. Similarly, our School Medical Officers have had to acquire the new knowledge and skill to deal with these problems as they went along by the hard way of experience; but perhaps this is not quite good enough for to-day. Twenty years ago the service was still immersed in the ascertainment of physical ills and the training that all doctors had fitted them more or less for this work; many had post-graduate experience in fevers or children's hospitals and frequently had a D.P.H. in addition. Most of the highly qualified, however, went on to administrative work, but there was no requirement, as there was for Maternity and Child Welfare work, that the School Medical Officer should have special post-graduate experience and some School Medical Officers were not equal to the opportunities that the School Health Services offered them. To-day we have highly trained Health Visitors in our service and we must ask now for some special post-graduate experience in our medical personnel. Do not mistake me. I am not asking for the label "specialist " to be tacked on to us. We are, in the main, pretty ordinary folk who have chosen to work in one branch of medicine; the general practitioner has chosen another branch; so has the surgeon. But our medical education has not completely fitted any of us for our chosen branch and to be skilful at whichever one we have chosen we require extra training to do it well. I think, therefore, all new candidates in the School Health Service should have the same post-graduate training as is required for the Child Welfare Officer and, as soon after appointment as possible, should take a course allied to the course already run by the National Association for Mental Health, but dealing with the whole range of child development, not just intelligence testing alone. Also, training in the assessment of physical handicaps in hearing and seeing, etc., and visits to all types of special schools should be part of this course. It should last for six to eight weeks and all should take it in their first year of appointment. I am not thinking of a refresher course but something more elaborate. I should like our School Health Service Group to think this out and approach the Ministry of Education medical officers and discuss the possibilities. These ideas are not new. The late Dr. E. H. Wilkins, of Birmingham (1941), thought it was needed and I believe he was right. *1 do realise that many school medical officers have a serious infestation problem still facing them in their schools and that the "cleanliness assistant" is very necessary indeed, and could not be dispensed with without serious curtailment of the hygiene work in these areas with a high infestation rate. 138 I do not believe the future of the School Health Service lies in part-time officers and general practitioners doing the work. Neither do I believe that it is good for the child to be divided up into a series of "specialities" all enquired into and surveyed by different technicians. The School Medical Officer himself should be equipped to deal with the whole child and then refer to the specialist the deviations from the normal when such referral is required. Neither do I believe the work is best done by senior registrars serving for a year to gain experience before becoming paediatricians, for the work only reveals its interests and satisfactions when you have done it for a period of years and get to know the school staffs, the children and the parents in a district. As in general practice it is the personal element that counts. The impersonal, detached medical officer has not the right personality for this work and should not be doing it; the medical officer who finds it boring should quickly be told to go elsewhere—this work is not for him. I do not feel that the fact that every child now has his own doctor makes our service redundant. There is still much we can do for him. Nor the fact that the Regional Hospital Board has taken the responsibility for the payment of the specialists to attend the clinics we first created means we are no longer interested in seeing that the child really gets the care he needs. I do not feel a bit despondent about the service—though I sometimes do about the lack of faith which afflicts many of our more senior medical officers who know little of the practical work of the School Health Service. I believe that there was fashioned some 46 years ago in the School Health Service an admirable instrument for the promotion of physical well-being in our younger generation; I do not think it is the instrument that is at fault when it fails; the areas where the personnel have been keen and enthusiastic and where good services have been provided show that it works admirably. I think that our next task lies in the extension to all areas of complete services and the speeding up of that work; in senior officers taking far more interest in the staff working in the field; not paying lip service to the need for research but in seeing that the staff have time and encouragement to do research; and giving them more responsibility in the arrangement of their own work. The Service has never been treated as it should be; it has been cramped for money, its services curtailed and its resources meagre in too many areas of the country; it is not an expensive service. It cost the local education authorities just over £6,000,000 in 1939 and in 1951 that figure had risen to under £10,000,000. Even if you double that it would compare more than favourably with the National Health Service bill. It will not grow, however, to its full usefulness unless you have faith in it; enthusiastic juniors need enthusiastic seniors. We have been suffering from an inferiority complex too long; the clinicians and the hospital specialists have been lecturing us about our work. Let us remember when we are so talked down to that we have chosen a special branch of medicine to practice. In Dr. Weaver's appreciation of the late Dr. Ralph Crowley, one of the architects of the School Health Service, he says this, "His concern was not entirely with medical problems; he was as interested in the educational as in the physical development of the child, so that there was never any possibility of the school medical service being for him a mere organisation for the ascertainment and cataloguing of defects "(1953, Brit. Med. J.). Let us remember that we are disciples of Dr. Crowley and men like him, and let me remind you, too, of the words of another great man, the late Dr. Rene Sand (1953, Brit. Med. J.): "Neither students nor practitioners fully realise that, as Hippocrates already said long ago, in medicine the function of protecting and developing health must rank even above that of restoring it when it is impaired. "If the nobility of medicine resides in the selflessness of the physician, the hygienist and their assistant, its greatness resides in the scope of the services which they render; and, from this point of view, the medicine which preserves health has a considerably greater influence for good than the medicine which restores health." The figures set out below relate to the calendar year ended December, 1954 Number Roll Average Attendance Percentage of Attendance 1. Secondary Schools 9 4,961 4,199 84.6 2. Primary Schools 20 9,014 8,243 91.44 Totals 29 13,975 12,442 89.00 139 ROUTINE MEDICAL INSPECTION A.— Routine Medical Inspection. Number of Inspections in the prescribed groups. Percentage of parents present Entrants 1,298 95.14 Second Age Group 1,127 81.54 Third Age Group 1,365 30.26 Total 3,790 Of 3,790 children who were examined in the code age-groups, 2,567 (67 per cent.) were accompanied by their parents. B.—Other Inspections. Special Inspections. The number of special inspections during the year was 4,225 comparing with 9,005 during the previous year. Re-inspections. The number of re-inspections during 1954 was 9,748. The Findings of Medical Inspection. Number of Individual Children found at Routine Medical Inspection to require Treatment (excluding Defects of Nutrition, Uncleanliness and Dental Diseases). Group (1) Number of Children Percentage of Children found to require treatment (4) Inspected (2) Found to require treatment (3) Code Groups— Entrants 1,298 158 12.17 Second Age Group 1,127 104 9.23 Third Age Group 1,365 112 8.20 Total (Code Groups) 3,790 374 9.6 140 Uncleanliness and Verminous Conditions.—In my last Annual Report I dealt rather fully with uncleanliness in school children, showing how the percentage found to be unclean had fallen from 19.07 per cent. in 1913 to 1.09 per cent. in 1953. I am pleased to be able to report a further fall in the incidence of uncleanliness—to 0.67 per cent. in 1954. It should be realised, however, that the verminous child is still with us, and that it is only by dint of unremitting inspection, exclusion and treatment of the unclean, that the clean are protected against infection. At the special inspections held by the school nurses, 197 children were found to be unclean out of a total number of 29,364 examined (i.e., 0.67 per cent.). Cleanliness Surveys in Individual Schools School Number of Examinations Number Cautioned Number Excluded Canterbury Road 1,621 5 - Capworth Street 1,060 7 2 Cann Hall Road 27 11 2 Church Road 2,650 6 9 Tom Hood 380 — - Connaught Road 1,720 7 3 Downsell Road 3,004 14 2 Davies Lane 2,779 25 — Farmer Road 567 1 - Goodall Road 1,502 4 3 Lea Bridge Road 426 3 - Mayville Road 3,088 36 5 Norlington Road 570 - - Newport Road 2,089 14 2 Sybourn Street 2,841 13 — St. Joseph's 402 7 3 Trumpington Road 681 5 - Knotts Green and Harrow Green 447 5 — Leyton County High School 500 - — Occupation Centre 410 3 — Total 29,364 166 31 Number of individual children found unclean, 166; of whom 31 were referred to the Minor Ailments Clinics. MEDICAL TREATMENT Minor Ailments Clinics. Attendances. During the year 3,231 individual children attended the clinics, and made 8,069 attendances. Defective Vision. Of the 3,780 children subjected to routine code group inspection in the schools, 159 (4.21 per cent.) were found to be suffering from some eye defect requiring treatment. 141 Special Eye Clinic. During the year there were referred to the Ophthalmic Surgeon 1,700 children. They made 2,412 attendances for examination and treatment. Ninety-two children were found to have no defect requiring treatment. Orthoptic Clinic. The special Orthoptic Clinic for children suffering from squint is held at Leyton Green Clinic on five sessions per week—Tuesday (morning), Wednesday and Friday (all day). As the Consultant Ophthalmic Surgeon (Dr. A. Logan Adams) holds special ophthalmic clinic sessions in the same building at the same time on Wednesday (all day), and Friday (morning), there is close co-operation between the Eye Specialist and the Orthoptist (Mrs. K. S. Box, S.R.N., S.C.M., D.D.O.). Cases of squint requiring operation are referred to Mr. M. Klein, Ophthalmic Surgeon at Whipps Cross Hospital, and by virtue of the fact that the Orthoptist (Mrs. Box) also acts as Orthoptist at Whipps Cross Hospital, there is close liaison between the two Departments and arrangements can be made with the minimum of delay for the treatment of cases requiring surgical operations. Report for 1954. Number of Sessions held 242 Number of cases investigated 447 Number of cases treated 410 Number of new cases seen 145 Number of cases discharged cured— After operation 15 Without operation 30 — 45 Number still under treatment 230 Number under observation 130 Number failing to attend for complete course 2 Number discharged unsuccessful — Number transferred to other clinics 3 Total number of attendances for the year 1,751 School Dental Service. Staff. The authorised establishment of dental staff for this Area is six full-time Dental Surgeons (or the equivalent thereof) to carry out the combined services of the Health and Education Authorities. At the beginning of 1954 the total Dental Staff (whole-time and parttime) was the equivalent of 3 4/11ths full-time Dental Surgeons; but the number fell to 2 6/11ths in July and rose to the record figure of 4 2/11ths at the end of the year. Of the dental staff in recent years only one—the Senior Dental Surgeon— is a full-time officer, the others being temporary part-time officers whose service tends to begin and end somewhat abruptly. For instance, two of those who commenced duty at the beginning of the year resigned shortly afterwards, and two others taken on at a later date terminated their services before the end of the year. 142 Report of Senior Dental Surgeon. (Mr. A. E. Hall.) While appreciating that the work done by the temporary part-time dentists has been invaluable, and of a high standard, one would like to be able to report that full-time dentists have been recruited who wish to make the study and practice of children's dentistry their life's work. Such permanence is to the advantage of both dentist and patient, the former finding a greater interest by seeing and being responsible for the same patients year after year, and the latter by knowing that the same dentist with whom he/she has become conversant will be there to see him/her again. The school population to be inspected and treated where necessary is now about 13,900, compared with approximately 12,000 before the war, when there were three full-time dentists and the school leaving age was 14 years instead of 15 years as at present. Dental Inspection. Five of the schools in the Area have been inspected and treated during the year, but any child who has been a regular patient in years past has been seen and treated on application for appointment. In addition, all children with toothache or children referred by school doctors, general medical practitioners or school teachers have been seen and treated. Findings of Dental Inspection. The following table shows in statistical form the results of school dental inspection in the individual schools mentioned. School No. of Children inspected No. requiring treatment No. approved for treatment No. accepting treatment No. refusing treatment Percentage of acceptances Canterbury — - - - - - Cann Hall — — — — — — Capworth — — — — — — Church — — — — — — Connaught 599 399 370 250 29 67.56 Davies Lane 1,090 660 628 414 15 65.92 Downsell — — — Farmer — — — — — - Goodall 486 462 462 354 — 76.6 Harrow Green 132 93 87 72 3 82.75 Knotts Green - - - - - - Lea Bridge — — — — — — Mayville — — — — — — Newport — — — — — — Norlington — — — — — — Sybourn — — — — — — St. Joseph's — — — — — — Tom Hood — — — — — — Trumpington — — — — — — County High (Girls) 503 338 328 192 64 58.53 143 Oral Hygienist. The Oral Hygienist has continued to devote 7/11ths of her time to Leyton, and the remainder to Walthamstow. As has been previously reported, the incidence of tartar deposit on the teeth of school children is not sufficiently high to enable Dental Surgeons working in the Area to find sufficient of this work to occupy an Oral Hygienist full time; but the importance of her work, from the point of view of instruction to children on matters of oral hygiene, cannot be overstated. The young patients are brought up to look on visits to the dental surgery as a normal part of school life; they are taught to value and look after their teeth; and much of the "spade work" of introducing the child to dentistry is done by the hygienist. All this results in more co-operative patients for conservative dental work at a later date. It has been noticed that many of these patients request re-appointments at regular intervals for a check-up without being approached in any way by the clinic staff. Orthodontic Treatment. This work continues to be much appreciated by parents, and the one special session a week devoted to it is well attended. The main difficulty, as in any under-staffed dental scheme, is to be certain that too much time is not devoted to this work to the detriment of conservative dental surgery. A certain amount of selection of cases is therefore justified in order (a) to ensure that the maximum amount of benefit is obtained for the time expended on the work, (b) to undertake the treatment of only such pupils as can have the dental work brought to a successful conclusion before school leaving age, and (c) to avoid undertaking orthodontic work for known bad attenders or where there is the slightest lack of appreciation for the work. Items of work under this heading for which no provision is made in Table IV (page 164) are— Impressions taken 108 New appliances fitted 35 Attendances for treatment 365 Advice and adjustment of appliances 363 X-rays 22 Finished cases 29 Additional operations not tabulated in Table IV (page 164). Dental space retainers fitted 23 Local anaesthetics 2,468 Application of silver nitrate 1,076 Scalings 1,084 X-ray films taken 189 Orthopaedic Clinic. First attendances 150 Subsequent attendances 162 144 X-Ray Examinations. Nine cases were referred to Whipps Cross Hospital for radiological examination. Physiotherapy. Fifty-four children were referred to Whipps Cross Hospital for corrective exercises. Admissions to Hospital. Eight children were admitted to hospital for operative treatment. Surgical Appliances and Footwear. Appliances supplied 29 Alterations to footwear 113 Aural Clinic. It is now three years since the local Hospital Management Committee assumed responsibility for the provision of Consultants for the specialist branches of the School Health Service. Unfortunately the work of the special Aural Clinic has suffered from the fact that in the short period of two years there have been at least six changes in Consultant. Such frequent changes disturb the continuity of specialist supervision and treatment, and are unsatisfactory from the point of view of both specialist and patient. Twenty-three sessions were held in 1954. New cases seen and dealt with by the Ear, Nose and Throat Specialists were:— Deafness 28 Acute and chronic otitis media 27 Catarrhal otitis media 4 Sinusitis 10 Referred for antral lavage 7 „ „ X-ray 10 Cases referred for pure tone audiometry 14 Follow up after removal of tonsils and adenoids 7 Referred for operation 15 Other conditions 20 No treatment required 14 Cases discharged during the year 73 HANDICAPPED PUPILS Delicate Pupils. Boys Girls Total No. of Delicate Pupils ascertained 8 18 26 No. admitted to Knotts Green Day Open Air School 3 3 6 No. admitted to Residential Open Air School 5 16 21 No. awaiting admission to Residential Open Air Schools at 31/12/54 - 2 2 145 Physically Handicapped. Fortunately the number in this category is small, and attention is drawn to those receiving residential treatment, which is two at the end of 1954. There were none awaiting admission to either Day or Resident Schools. Boys Girls Total No. attending at Knotts Green Open Air School 4 6 10 No. attending at Residential Schools 1 1 2 No. ascertained in 1954 4 1 5 No. recommended Knotts Green Day Open Air School 1 - 1 No. recommended Residential School 3 1 4 No. recommemnded to continue at Ordinary School - - - Educationally Sub-normal. Boys Girls Total No. of Educationally Sub-normal Pupils ascertained 9 7 16 No. admitted to Harrow Green 9 5 14 No. admitted to Residential School 0 1 1 One child is awaiting admission to a residential school. Four children who were ascertained in 1954 will attend Harrow Green E.S.N. School in January 1955. Maladjusted Pupils. Before these children are ascertained as maladjusted the help of the local Child Guidance Clinic has usually been sought and treatment instituted there. Six children were ascertained as maladjusted in 1954. Admitted to Residential School 3 Waiting for a vacancy 2 Refusal to accept a vacancy 1 Deaf Pupils. These are pupils who have no hearing, or whose hearing is so defective that they require education by the methods used for deaf pupils without naturally acquired speech or language. No child was ascertained to be totally deaf in 1954. There are five children of school age attending residential deaf schools. Four children are at day schools for the deaf. Partially Deaf Pupils. These are children whose hearing is so defective that they require for their education special arrangements or facilities, but not all the educational methods used for deaf pupils. They usually learn speech in a normal fashion, with or without hearing aids. 146 One child was ascertained as partially deaf in 1954 and was placed in a day school for the partially deaf. There were four children at residential schools for the partially deaf. There is one child at a day partially deaf school. Hearing aids have been supplied to four children who are able to carry on at ordinary schools satisfactorily. Blind. These are children who are blind, or whose sight is so defective that they cannot be educated by methods involving the use of sight. One child was ascertained as blind in 1954. One child attends a residential school for the blind. One child is waiting for admission to a residential school for the blind. Partially Sighted. These are children who cannot follow the ordinary curriculum without detriment to their sight or to their educational development, but can be educated by methods involving the use of sight. One child was ascertained during 1954. There was one boy in this category attending a school for partially sighted pupils. Epileptic Pupils. No child was ascertained as epileptic during 1954. One child is attending a residential school and one child is attending a day school. Section 57, Education Act, 1944. Under Sub-section 3 of this section of the Education Act children found to be ineducable have to be notified to the Mental Welfare Authority. One child was so notified and one other child (Forest Division) was referred for notification. Under Sub-section 5 of Section 57 children who require supervision by the Mental Welfare Authority have to be notified. Two boys and seven girls were so recommended in 1954 from Leyton and two boys and three girls from Forest Division attending Harrow Green School were referred for notification. Section 48 of the Education Act. Under this Section of the Act it is possible to send children in need of a short recuperative holiday to a Convalescent or Holiday Home. This is an excellent method of dealing with children who are very debilitated either after a severe illness, such as pneumonia, or after a series of infections, such as whooping cough, measles and influenza. They quickly improve with four weeks at the seaside or in the country, and thereby reduce the number of cases which might have to spend a long time in a day open air school. In 1954 some 43 children were sent away for from four to six weeks—16 girls and 27 boys. 147 Section 56 of the Education Act. Under this section the Local Authority is empowered to provide education for children who are unable to attend a day or residential school. During 1954 one child received education at home, and on the 31st December, eighteen children were receiving tuition while long-term in-patients of Whipps Cross Hospital. REPORT ON HARROW GREEN EDUCATIONALLY SUB-NORMAL SCHOOL Leyton Forest Total Number on Roll 88 60 148 Number admitted, 1954 14 8 22 Number left, 1954 16 8 24 Reasons for Leaving. Leyton Forest 1. Attained age of 16 years and (a) Notified under Section 57(5) 8 3 (b) Not requiring supervision 3 1 (c) Notification not proceeded with - 1 2. Number returning to Secondary Modern School 3 - 3. Notified as Ineducable after trial - 1 4. Removed to another area 2 1 5. Notified as unsuitable for education in mixed school and recommended residential E.S.N. - 1 Children admitted on trial as "borderline ineducable" 2 4 Report by Dr. Mary Gilchrist. Children attending an E.S.N. School tend to suffer from physical handicaps more than other scholars and there is at present rather a preponderance of children with one particular handicap—epilepsy. Nine children are under active treatment for major epilepsy; one had been clear for five years, but had one slight recurrence recently and has resumed treatment. Another, a girl of 12 years, has just recently developed the disability. One boy is considered to be cured; three cases of minor epilepsy are probably cured; and a boy considered as cured of "petit mal" has recently had a recurrence of attacks and is under hospital care. Hearing Defects. One girl and one boy have a hearing aid. There is doubt about the boy as to his educability and he is in school on trial. Six children have recurrent attacks of deafness of minor degree, have special places in class and have treatment when required. Eight children are under observation for possible hearing difficulties. 148 Children with Eye Defects. One girl and one boy have a special position in class as their eyesight is poor and glasses cannot improve the vision. Twenty-four children wear glasses, and six others are under observation for defective eyesight. Heart Lesions. Three children have congenital heart lesions, of whom two suffer no handicap, but one must not over-exert himself. None are suitable for surgical operation. Progress. The great majority of children are making progress. Eight are on trial as to their suitability for education in an E.S.N, school. One child (a Mongolian) is awaiting transfer to an Occupation Centre. One boy is awaiting admission to a residential E.S.N, school because of poor home circumstances. Several boys are making very good progress and may be able to return to an ordinary school after a further stay at the school. Three girls in the junior age group may be able to go back to a junior school. Three boys, because of social and behaviour problems, are under consideration for transfer to residential E.S.N, school. One boy is under treatment for a speech defect, and may ultimately be transferred to Moor House School for speech difficulties. KNOTTS GREEN SPECIAL SCHOOL A comprehensive report on this School was given in my Annual Report for 1952, and no special alterations have taken place since that time. Removals from Roll. Attained the age of 15 years 2 Found fit to return to ordinary school (1 Forest, 19 Leyton) 20 Transferred to a school for educationally sub-normal children 4 Removed to other areas (1 Forest) 1 27 Admitted to the Roll. Delicate (2 Forest, 6 Leyton) 8 Physically handicapped (2 Leyton) 2 Maladjusted (1 Forest) 1 11 At the end of the year there were 38 children on the Roll. 149 REMEDIAL READING CLASSES—LEYTON SESSION 1953-54 Report by Miss M. Marshall, Educational Psychologist. The remedial reading classes in Leyton have now completed their second whole year's work. All the Junior Schools in Leyton now have groups of children receiving this extra help, except St. Joseph's R.C. Primary School, where the Group has been selected but so far no teacher has been found to undertake the work. Numbers of Children. It has now become established practice that the number of children in a Group should be six. This seems to be the best number from the point of view of the remedial teacher, who finds it impossible to give every child some individual help in the hour's lesson if there are more than that number in the Group. Since Mayville Road Junior School came into the scheme after Christmas 1953, and the numbers were increased at Cann Hall Road and Downsell Road, there were more children in the reading classes this year than last. Total number of children given remedial teaching during the year :— Boys, 92 ; Girls, 17. Total 109. Average age at beginning of Teaching 9 years 10 months Average Reading age at beginning of Teaching 6 years 1 month Average age at end of Teaching 10 years 8 months Average Reading age at end of Teaching 8 years 8 months These results are considered to be very good, as the average gain in reading ability was well over two years, though many of the children had less than a year's special teaching. The number of children going on to Secondary Schools at the end of the summer term, who had had some special help with reading was 47. The average reading age of this group was 9.0 years (highest 12.6 years and lowest 7.0 years). This is a slight improvement over last year. The following table will show in more detail the gains made during the year. No. of Children with their Gains in Reading Ages (in months) Number of Children Number of Months Remedial Teaching Gains in Reading Age (in months) 0-6 7-12 13-18 19-24 25-30 31-36 37-42 43-48 48 + 56 Whole year 1 3 11 15 18 4 3 — 1 39 Two Terms 4 3 17 8 2 2 1 — 2 14 One Term or less 6 5 2 — 1 — — 109 — 11 11 30 23 21 6 4 — 3 150 As in previous years there were some outstanding successes, and all the remedial teachers have now had the pleasure of at least one pupil who has suddenly grasped the whole idea of reading and forged ahead from failure to success in a matter of a few months. Again the head teachers spontaneously report on the striking improvement in general behaviour and attitude of these successful ones and the same can be said of the great majority, though perhaps to a lesser degree. Co-operation with the School. The value of the work done in the remedial reading class is certainly appreciated in the schools and in some instances more use is being made of the special class as a source of inspiration and reference. One class teacher reported that a 10 year-old boy had now become so absorbed in learning to read that he could be seen at all times of the day poring over a book and calling on his neighbours for assistance in reading a " hard word This had inspired the rest of the class with equal enthusiasm and now everyone had begun to copy him—to the great benefit of their reading ability. There are still teachers who feel that the special reading class should take all the worst "reading failures" regardless of intellectual ability, but the policy of restricting this special help to children of average or above average still seems to be the best one. It must be remembered that these special lessons are long ones (1 ½ to 1 hour in duration) and only occur twice in the school week. Children of duller mentality need shorter and more frequent lessons if they are to make progress. Selection of Children. Satisfactory ways of selecting the children who may be expected to benefit the most from this special help have not yet been found with certainty. The best way seems to be for the educational psychologist to select by means of individual tests from a list of possible candidates prepared by the school. However, this becomes a formidable task when it is remembered that perhaps 20 tests will have to be given in order to select 12 children, and each test takes from 40 minutes to 1 hour to give. At the meeting of Head Teachers held during the Spring Term, alternative methods of selection were discussed and certain schools are now making their own selections on the basis of group tests. The remedial teachers will be asked to report on any child they feel to be a " misfit" in the group, and the estimate of the success of the school's selection will have to await the end of the year results. Remedial Teachers. As before, the success or otherwise of the scheme depends very largely on the remedial teachers themselves, and Leyton is fortunate in finding five teachers (four of them retired after many years' service in the schools) who have proved themselves to have the necessary talents for this interesting but arduous work. It can truthfully be said that not one child of the 109 did not look forward eagerly to the next lesson with " the reading teacher ", and the impatient queue waiting at the door, books and pencils in hand, is the best testimony that can be found for the value of the scheme to the children. It is to be hoped that other teachers, as they approach retiring age, will begin to think of this special work as something to look forward to. More volunteers are needed. i5i PROVISION OF MEALS (a) Average daily number of children fed under the Education Authority's arrangements during 1954 was :— Dinners. Milk Meals Free 290 11,717 For payment 3,831 4,121 11,717 (b) Number of Meals supplied :— Free 63,417 2,313,498 For payment 757,164 820,581 2,313,498 PREVENTION OF FOOD POISONING IN SCHOOL CANTEENS (Report by the Medical Officer of Health and School Medical Officer—1954) In another scction of this Annual Report (pages 48-51), will be found a special report on "Hygiene in Catering Establishments "submitted by me as Medical Officer of Health to the three Committees responsible for catering establishments—one of which is the Committee for Education. Along with that report submitted to the Education Authority, in my capacity as School Medical Officer, the following report under the title " Prevention of Food Poisoning in School Canteens ". EXTRACTS FROM MINISTRY OF EDUCATION CIRCULAR 272. (JANUARY, 1954). The Minister believes that Local Education Authorities and others concerned will welcome some information on the possible risks and on the measures which should be taken to avoid them. Following are some typical examples of outbreaks of food poisoning in school canteens : (a) 329 Children and staff were affected in several schools after a meal of savoury mince. An intestinal organism was the cause ; it is liable to be transmitted to food by failure of canteen staff to wash their hands after using the water-closet. (b) 321 Children in one school became ill after eating custard that contained staphylococcus aureus. A food handler was found to have this infection in the skin of his hands. Such outbreaks result almost always from contamination of food by food handlers who harbour the organism in their nose, throat or ears, or who have uncovered sores on their hands, arms or face. (c) 219 Children and staff in four schools became ill following a meal of minced meat, which was cooked and covered with pastry the day before it was eaten. The infection was apparently due to heat-resistant strains of cl. welchii, which has been responsible for several outbreaks of food poisoning in schools. If foods, especially large joints of meat, containing this heat-resistant organism are allowed after cooking to cool slowly and are not eaten on the same day, rapid multiplication of the organism can occur. (d) 250 Children and staff became ill after eating fruit salad stored in a zinc bath for 20 hours ; 260 parts of zinc per million were found in the salad. Although chemical food poisoning is rare, it has to be remembered. It has also to be rememberd that typhoid and paratyphoid infections, although strictly not forms of food poisoning, have been spread by school meals. 152 Suggested Action. The Minister asks authorities to review the measures they have taken to prevent food poisoning in schools, in particular : (a) Co-operation between Medical, Teaching and Kitchen Staffs. There should be close co-operation between the Principal School Medical Officer, the Head Teachers, the Meals Organiser, the staff of the kitchens and the borough or district Medical Officer of Health. This does not exempt the borough or district Medical Officer of Health from his statutory responsibility in regard to hygiene in all food premises in his area, including school canteens. (b) Health of Food Handlers. There would be a big reduction in food poisoning if all who work in canteens observed the simple, elementary rules of personal hygiene. (c) Hygienic Conditions in the Kitchen. Every kitchen should have a wash-basin separate from the sink, hot water, soap and clean towels. All crockery and utensils must be thoroughly washed and rinsed ; rinsing water must be changed frequentiy. Where it is practicable to provide rinsing water maintained at a temperature of about 18o°F., as, for instance, where there is a double sink with a thermostatically controlled supply of hot water for rinsing, crockery and utensils will be sterilised and will dry quickly without a drying cloth. The need for cleanliness for all working surfaces (that should be impervious to liquids and without open cracks), fittings, walls and floors cannot be over-emphasised. The staff should wear clean overalls and caps. (id) The Preparation and Cooking of Food. In school canteens it ought not to be necessary to cook food the day before it is to be eaten. If all food were kept cold till it was cooked, if the cooking were done thoroughly, if all cooked food were eaten immediately after cooking or cooled down at once and kept cool till it was to be used, there would be very little food poisoning in school canteens. (e) Domestic Animals and Pests. All food should be protected and all waste food should be kept in bins with closely-fitting lids. Rodents on the premises should be exterminated. 153 Survey of Schools. During the summer school term I made arrangements with the Borough Education Officer and Head Teachers for a comprehensive survey by the Chief Sanitary Inspector of all schools and school departments in the Borough. Scope of Survey. Each school and school department was inspected with regard to the methods employed in the preparation, cooking, handling, serving and distribution of school meals and the observance of sanitary and clean conditions and practices in connection therewith. Standard Adopted. The standard of hygiene of school catering arrangements was judged in the light of requirements contained in the Food and Drugs Act (1938), the Clean Food Byelaws (1950) and other relevant legislation. Results of Survey. In general the standard of hygiene in the preparation, cooking, distribution and serving of school meals was found to be reasonably satisfactory, and compared favourably with the general standard found in commercial establishments and industrial canteens. The following recommendations were made. Recommendations. Not all school kitchens and washing-up rooms were equipped with facilities for sterilising utensils and crockery so as to promote drying without the use of cloths ; and the installation of such facilities should be adopted when and where practicable. Water for culinary purposes should be taken direct from the main supply, and not from a storage cistern. Whenever renewal of kitchen equipment is necessary, consideration should be given to the advisability of providing stainless steel for sinks and draining boards, and of smooth impervious plastic material for table tops where food is prepared. When structural alterations are contemplated attention should be given to the siting of kitchen equipment and the coving of floor and wall junctions to facilitate easy cleaning ; to the collection of strong smelling effluvia by the provision of metal hoods over cooking equipment and to their dispersal by means of ducts and extraction fans. It was realised that the most carefully designed and equipped food premises are not proof against the unclean or careless food handler, and for that reason it was recognised that the most urgent need was for the health education of all persons engaged in the preparation and service of school meals. 154 SPEECH THERAPY Boys Girls Total Children at present undergoing treatment 47 18 65 Children discharged during 1954 30 7 37 On waiting list Nil Average number of cases treated daily 13 Homes visited 50 School Departments visited 37 Parents interviewed 198 Children referred to other clinics 21 Number of new cases 50 Children re-admitted 1 Number of children who left before cured or discharged 14 Total number of attendances 1,778 Number of children referred who were found not to require treatment 3 CHILD GUIDANCE Report of the Educational Psychologist to the Forest and Leyton Divisions— (Miss M. Marshall). The Educational Psychologist in the Forest Division and Leyton Borough in Essex has continued her work along the lines already established and to expand when opportunities arise. The school population in the combined area has now reached the figure of approx. 41,000. There have been 10 new Schools opened during the year. The great difficulty is to keep up with work already started, such as the remedial reading groups in the Leyton Primary Schools, while continuing to keep in touch with other Schools and answer all the requests that are now coming in from new Schools. Work in the School Psychological Service. The greater part of this work consists in the help given to Schools and parents over the problems of individual children. Requests come from the School Medical Officers, Head Teachers, parents and sometimes from other services, such as the Children's Department, or the Juvenile Employment Officers. Number of children interviewed individually by the Psychologist. Boys Girls Total Total Forest 199 90 289 465 Leyton 122 54 176 Of these 465, 70 children were seen by two Trainee Educational Psychologists, supervised by the L.E.A. School Psychologist, as part of their practical training. At the end of the year there were still 31 children on the Psychologist's waiting list, and four Schools whose Heads had asked for a visit. 155 The reasons for referral to the Psychologist were :— Backwardness, including backwardness in reading only 250 Educational advice other than for backwardness 61 Behaviour problems at home 84 Behaviour problems at School 61 Requests from other agencies 8 Children with physical symptoms, e.g., enuresis, tics, stammer, etc 33 Some children, of course, show more than one symptom of disturbance. An analysis of the figures shows :— Forest Pre-School Infants Juniors Secondary Boys 3 61 102 33 Girls 4 29 45 12 Total 7 90 147 45 Leyton Pre-School Infants Juniors Secondary Boys 1 17 84 20 Girls — 6 40 8 Total 1 23 124 28 Of these 465 children seen in School, 141 were referred to the Child Guidance Clinic for further help. Thus 324 children, who are presenting some problem in their development in School or home, have been seen only by the Psychologist and not by the full Child Guidance team. In many of these cases the Psychologist interviews the parents also, and in every case individual reports have been sent to the Schools, so that whatever is suggested or done for the child shall be as well co-ordinated as possible. Consultation with the School Medical Officer is a regular part of this work in the Schools. The range of intelligence of the children tested individually is fairly evenly distributed. The Psychologist continues to find more retarded children needing special educational treatment in the Forest Division than in Leyton, as is to be expected since there is a well-established E.S.N. School in Leyton and none in the Forest Division. I.Q. Range Below 70 71-90 91-110 111-130 130 + Forest 20 108 115 36 9 Leyton 6 48 78 34 11 Total 26 156 193 70 20 During the year the Psychologist made 218 School Visits, of which 80 were to Leyton Schools and 138 to Forest Schools. 156 The scheme for assisting children who are backward in reading has continued to flourish in the Leyton Primary Schools. A separate report has been made on this. During the Autumn a similar scheme has begun to emerge in the Forest Division. Six Primary Schools in Harlow, Loughton and Chigwell now have the help of a part-time teacher, who is giving small groups of children extra help with reading two or three times a week. The Psychologist has not had time to make the selection of children for the groups, but has discussed the organisation of the scheme and supply of suitable books, etc., with the Head Teachers and with the Teachers appointed to do the work. During the year the Psychologist has received more requests for lectures than ever before. In the day-time 7 lectures were given, either at Teachers' Refresher Courses, or at a Home Office Course for House Mothers at Wansfell. In addition, 14 lectures were given in the evenings to a great variety of groups, about half of them being Parent-Teacher meetings in School. In 1954 for the first time the Psychologist has undertaken work with " migrant" pupils who move into the area with " Central School" placements obtained previously in their home district. Each of these children has to be seen and tested individually and recommendations made for suitable Schools in Essex, after discussion with the parents. Nine such reports were prepared in 1954. The Psychologist has also investigated and reported on five children in Leyton Schools and one in Cooper's School, Bow, who were reported to be " misfits " in Technical or Grammar Schools. Work of the Educational Psychologist in the Child Guidance Clinic. The Psychologist has continued to act as liaison between the Clinic and the School on behalf of individual children receiving treatment at the Clinic. 73 special visits were made to Schools during the year for this purpose. The Psychologist also continues to take individual children for remedial teaching at the request of the Psychiatrist. During the year 12 children (6 from Leyton and 6 from Forest Division) have received this help and altogether there were 157 remedial teaching sessions. Children are not taken on for this help at the Clinic where there is a remedial reading group in their school, except in exceptional cases. CHILD GUIDANCE CLINIC TABLE I. Analysis of Figures for 1954. Leyton Number of cases referred to the Clinic 72 Number of cases diagnosed at the Clinic 46 (a) Psychiatrists. Diagnostic Interviews 46 Cases taken on for treatment 28 Treatment Interviews 172 Other Interviews 5 Number of Psychiatric Sessions per week 4 157 (b) Psychologists. Clinic cases tested 55 Cases given remedial education 6 Treatment Interviews (remedial education) 8o School visits on behalf of Clinic cases 26 Other Interviews at Clinic — (c) School Psychological Service. Individual cases seen 176 Number referred to Clinic 22 (d) Play Therapists. Cases treated 7 Treatment Interviews 121 (e) Psychiatric Social Workers. Interviews at Clinic 408 Interviews elsewhere 30 (f) Waiting List. Cases for Diagnosis 23 Awaiting Treatment 1 (g) Total cases treated during year 70 TABLE II. Primary Reasons for Referral. Leyton I. Nervous disorders, e.g., fears; depressions ; apathy; excitability 23 II. Habit disorders and physical symptoms, e.g., enuresis ; speech disorders ; sleep disturbances ; tics ; fits, etc 10 III. Behaviour disorders, e.g., unmanageable ; tempers ; stealing; lying ; sex problems, etc. 31 IV. Educational, e.g., backwardness ; failure to concentrate 4 68 TABLE III. Analysis of Cases Diagnosed. I. Nervous disorders, e.g., fears ; depression ; apathy; excitability 17 II. Habit disorders and physical symptoms, e.g., enuresis ; speech disorders ; sleep disturbances ; tics ; fits, etc. 9 III. Behaviour disorders, e.g., unmanageable ; tempers ; stealing ; lying ; sex problems, etc. 12 IV. Educational, e.g., backwardness ; failure to concentrate 5 V. No basic disturbance of child, i.e., mainly parental over-anxiety 3 46 158 TABLE IV. Analysis of Cases Closed during the Year. (Including cases referred in previous years) Improved and recovered after treatment 13 Improved after partial service, i.e., before diagnosis 12 Diagnosis and advice only 4 Interrupted, e.g., on parents' initiative 18 Closed for Miscellaneous Causes (removed from area, placement at E.S.N. School, etc.) 4 No change 1 52 B.C.G. VACCINATION. In 1949 the Ministry of Health approved proposals by Local Health Authorities of schemes for the protection by B.C.G. Vaccination of persons known to have been in contact with tuberculous infection, and in my last Annual Report I dealt with the arrangements whereby Dr. Ethel Emslie has been undertaking the preliminary testing, the immunisation by B.C.G. vaccine, and the subsequent testing and following-up of Leyton contacts of tuberculosis under school leaving age. In November, 1953, the Minister of Health signified his intention of approving the extension of these arrangements so that authorities may offer B.C.G. vaccination to older school children on the understanding that the former scheme for the vaccination of contacts will continue, and that the vaccination of school children should be carried out by designated Medical Officers on the responsibility of the Medical Officer of Health and School Medical Officer. No child was to be vaccinated without the prior consent of the parent in writing, and before the scheme was put into operation steps were taken to acquaint parents of children, general medical practitioners and school teachers of the arrangements. Some idea of the nature and purpose of B.C.G. vaccination may be gained by a perusal of the following letter distributed to parents :— " It is known that a slight infection with the germ of tuberculosis does not always cause the disease, and that in the majority of cases no signs or symptoms are experienced. Following this infection however, a greater resistance to any subsequent attack of the disease is developed. Many people have, without knowing it, already had this infection and have so developed a natural resistance, but some have not. It is possible to distinguish between those who have and those who have not by a simple skin test. For those who have not had the infection it is now possible to induce a similar kind of resistance by injection of the vaccine known as B.C.G. This vaccine is not harmful to health at any age. The local reactions which follow its use are seldom severe. " The age group for both males and females which shows the highest susceptibility to the contraction of tuberculosis is 15-25 years. It has therefore been decided to offer B.C.G. vaccination to children in Leyton at the age of 13 with the object of giving some protection before they leave school. The selection of children of this age has the further advantage that an opportunity will be provided for observation of the children for a year before they leave school. " The vaccination will be carried out by approved medical officers at the Health Service Clinics for those children whose parents wish it to be done ; and, since the vaccine has to be obtained from Copenhagen, it will take place about a month after consent is given. 159 " The procedure will be to carry out an initial tuberculin test to find out which children are already ' positive ' to tuberculin and who do not, therefore need to be done, since only those who are ' negative ' will be given B.C.G. vaccine. This may be done at either school or clinic. " If the B.C.G. ' takes ' a small ' pimple ' will begin in two to three weeks and this will slowly increase in size for another two to three weeks and may develop into a small shallow sore for which no dressing would be required and which should heal in a few weeks leaving only a small scar. Any result more severe should be reported to the family doctor or to me. " A further tuberculin test will be carried out not earlier than six weeks after the B.C.G. is given. If the latter has been effective then the previous ' negative ' result will be ' converted ' into a ' positive ' and some protection against tuberculosis will have been given. " If a child who is to be given B.C.G. vaccine is living in close contact with an infectious case of tuberculosis, then if ' negative ' to the test he/she should as far as possible not come into contact with the patient for six weeks before the B.C.G. is given." After the completion of the necessary " preliminaries ", the scheme for the B.C.G. vaccination of school leavers was able to be commenced in Leyton in August, when two school Medical Officers began to carry out the vaccinations. The following list shows in statistical outline the numbers of children dealt with and the results obtained. Number of pupils who Are " Leavers " 1,112 Accepted 337 Attended 292 Mantoux positive without vaccination 34 Vaccinated 258 Mantoux positive after vaccination 198 Mantoux negative 14 Not re-tested 46 The figures show clearly the unexpectedly poor response to the offer of vaccination and the unexpectedly low percentage of " leaver " pupils found to be Mantoux positive before vaccination. I give below Dr. Emslie's observations on the progress of the scheme :— " Response to the offer of vaccination has not been very satisfactory, although perhaps one could not expect a very good response to the first invitation. Some parents may have doubts or fears which could be removed, and it might be considered whether personal explanation to parents at a meeting would produce a better response. As vaccination is done before the routine medical examination of school leavers, there is no opportunity of discussing the matter with the parents at that examination, and in any case parents do not attend well at school leavers' examinations. " The percentage of Leyton children Mantoux positive without vaccination, which is 13 per cent., is much lower than the figure quoted in the National Tuberculin Survey by the Medical Research Council in 1949 and 1950, which was 35 per cent. The figures are not comparable for the following reasons :— " 1. The age of Leyton children was slightly less, which might make a slight difference. " 2. The National Survey figures include cases positive to a Flour Paper Jelly test only, without a Mantoux test. Personal experience and reports from other sources have convinced me that a very high percentage of positive Flour Paper Jelly tests are false positives, even with standard technique. Caplin and others recorded (Brit. Med. J., 16th October) that two ' experts ' Jelly tested 361 children who were Mantoux negative (1 in 1,000), and one expert found 34 per cent, and the other 9 per cent, to be Jelly positive. There have been a number of reports with similar findings. 160 "3. The M.R.C. Mantoux dose was 100 units, not 10 units as in our cases. It is generally agreed that Mantoux testing with 100 units probably gives a few false positives. "4. Most of the positives might be expected to be among contact cases, and most known contacts had already been vaccinated in Leyton, and in any case were not invited to apply for vaccination as school leavers. "Of a proportion of the number of vaccinated (183) only one case failed to convert and has been re-vaccinated. Six others were negative when first re-tested after vaccination but either converted late or were more sensitive to the old tuberculin (10 units) with which they were re-tested than they had been to the P.P.D." RESEARCH WORK Anti-tuberculosis Vaccine (B.C.G.). In collaboration with the Medical Research Council, there is still being undertaken in Leyton schools the investigation into the efficiency of B.C.G. vaccine to which reference was made in my last Annual Report. The trial involved at the outset children leaving Secondary Modern Schools at the age of 15, and it was proposed to follow them up by regular examinations for at least three years. Participants in the trial were volunteers. The trial is still going on, and the results will not be available for some time. The following observations on its progress are submitted by Dr. T. M. Pollock, Physician-in-Charge. " The investigation into the efficacy of Anti-tuberculosis vaccines, in which Leyton Public Health Authority is co-operating with the Medical Research Council, continued during 1954. It is hoped to determine the degree and duration of protection afforded by vaccination, and thus the contribution which the vaccines can make to the prevention of tuberculosis in young people. "Over 50,000 volunteers from North London Boroughs, as well as from areas in Birmingham and Manchester, joined the scheme during their last terms at school between 1950 and 1952. Some of the volunteers were given the vaccines, and all who entered the scheme are now being followed up. 628 volunteers joined in Leyton, and during the year many of them were visited by the Health Visitors. The Medical Research Council's Mass X-ray Unit visited Dawlish Road Clinic during May, and three-quarters of the volunteers invited, attended for X-ray. "Co-operation between the Leyton Public Health Authority and the Medical Research Council, in all matters relating to the investigation, was very close throughout the year." STATISTICAL APPENDIX TABLE I. Medical Inspection of Pupils attending Maintained Primary and Secondary Schools. A. Periodic Medical Inspections. Number of Inspections in the prescribed Groups :— Entrants 1,298 Second Age Group 1,127 Third Age Group 1.365 Total 3,790 B. Other Inspections. Number of Special Inspections 4,225 Number of Re-inspections 9,748 Total 13,973 i6i C. Pupils Found to Require Treatment. Number of individual pupils found at Periodic Medical Inspection to require treatment (excluding dental diseases and infestation with vermin). Group For Defective Vision (excluding Squint) For all other Conditions Total individual Pupils Percentage of children found to require Treatment Entrants 32 158 181 12.17 Second Age Group 56 104 152 9.23 Third Age Group 70 112 171 8.20 Total (Prescribed Groups) 158 374 504 9.89 Routine Inspections (Junior Occupation Centre) 1 6 7 12.28 TABLE II. A. Return of Defects Found by Medical Inspection in the Year Ended 3 ist December, 1954. Defect or Disease Routine Inspections Special Inspections Number requiring Treatment Observation Number requiring Treatment Observation (1) (2) (3) (4) (5) Skin 14 7 19 1 Eyes—(a) Vision 159 89 292 19 (b) Squint 23 10 19 5 (c) Other 19 8 113 3 Ears—(a) Hearing 5 97 16 7 (b) Otitis Media 10 52 8 3 (c) Other 42 21 85 3 Nose or Throat 7i 114 60 3 Speech 6 17 31 5 Cervical Glands — 23 4 1 Heart and Circulation 19 31 4 1 Lungs 19 74 32 19 Developmental—(a) Hernia 1 3 — (b) Other 10 63 11 — Orthopaedic—(a) Posture 4 21 3 — (6) Flat Foot 36 35 11 — (c) Other 92 80 78 4 Nervous System—(a) Epilepsy 1 6 4 1 (6) Other 6 4 9 1 Psychological—(a) Development — 8 25 — lb) Stability 4 15 30 7 Other 28 33 634 17 162 TABLE II—contd. B. Classification of the General Condition of Pupils Inspected during the Year in the Age Groups. Age Groups No. of Pupils Inspected A Good B Fair C Poor No. % No. % No. % Entrants 1,298 427 32.9 816 62.86 55 4.24 Second Age Group 1,127 403 35.76 705 62.56 19 1.68 Third Age Group 1,365 594 43.55 761 55.74 10 0.71 Other Routine Inspections 57 6 10.5 51 89.5 — — Total 3,847 1,430 37.17 2,333 60.64 84 2.19 TABLE III. Return of Defects Treated during the Year ended 31st December, 1954. TREATMENT TABLE. Group I.—Minor Ailments (excluding Uncleanliness, for which see Table V). Disease or Defect Number of Defects treated or under treatment during the year By the Authority Otherwise Skin— Ringworm— Scalp — — Body — — Scabies 1 1 Impetigo 20 1 Other skin diseases 108 4 Minor Eye Defects— (External and other, but excluding cases falling in Group II) 169 6 Minor Ear Defects 210 26 Miscellaneous— e.g., minor injuries, bruises, sores, chilblains, etc. 1,235 67 Total 1,743 105 163 TABLE III—contd. Group II.—Defective Vision and Squint (excluding Minor Eye Defects treated as Minor Ailments.—Group I). Defect or Disease Number of Defects dealt with By the Authority Otherwise Errors of refraction (including squint) — 599 Other defect or disease of the eyes (excluding those recorded in Group I) — Total — 599 Number of Pupils for whom Spectacles were— (a) Prescribed — 1,114 (6) Obtained 1,068 Group III.—Treatment of Defects of Nose and Throat. Total number treated By the Authority Otherwise Received operative treatment:— (a) for adenoids and chronic tonsilitis — 202 (b) for other nose and throat conditions — 5 Received other forms of treatment 210 — 210 207 Group IV.—Orthopaedic and Postural Defects. (a) Number treated as in-patients in hospitals or hospital schools 9 (b) Number treated otherwise, e.g., in clinics or out-patient departments 215 Group V.—Child Guidance Treatment and Speech Therapy. Number of pupils treated— (a) Under Child Guidance arrangements 176 (b) Under Speech Therapy arrangements 149 164 TABLE IV. Dental Inspection and Treatment. (1) Number of pupils who were :— (a) Inspected by the Dentist 2,810 Specials (Casuals) 832 Grand Total 3,642 (b) Found to require treatment 2,784 (c) Actually treated 3,327 (2) Half-days devoted to Inspection 25 Treatment 1,646—Total 1,671 (3) Attendances made by children for treatment 11,322 (4) Fillings, Permanent Teeth 4,895 Temporary Teeth 1,912—Total 6,807 (5) Extractions, Permanent Teeth 954 Temporary Teeth 4,074—Total 5,028 (6) Administrations of general anaesthetics for extractions 1,420 (7) Other operations, Permanent Teeth 3,313 Temporary Teeth 1,690—Total 5,003 TABLE V. Infestation with Vermin. (i) Total number of examinations in the Schools by School Nurses 29,364 (2) Number of individual pupils found to be infested 197 (3) Number of individual pupils in respect of whom cleansing notices were issued 31 (Section 54 (2) Education Act, 1944.) (4) Number of individual pupils in respect of whom cleansing orders were issued (Section 54 (3) Education Act, 1944.) —