AC439(1) SOUTH GATE BOROUGH OF SOUTHGATE ANNUAL REPORT if of the Medical Officer of Health for the Year 1957 Wm. CLUNIE HARVEY, M.D., D.P.H. Medical Officer of Health BOROUGH OF SOUTHGATE ANNUAL REPORT of the Medical Officer of Health for the Year 1957 Wm. CLUNIE HARVEY, MD., D.P.H. Medical Officer of Health TO THE MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF SOUTHGATE Madam Mayor, Ladies and Gentlemen, I beg to present the Annual Report for 1957. The year under review was again relatively uneventful. Apart from the two-yearly epidemic of measles, which duly arrived in 1957, the year was free from epidemics or even what might be termed more than the most limited outbreaks of infectious disease. This matter will receive more detailed attention in the section of the report dealing with the prevalence and control of infectious diseases. The vital statistics for 1957 were also satisfactory, with the usual proviso that the figures for one year in respect of a population of less than one hundred thousand cannot be regarded as in any way conclusive. The birth rate rose from 11.2 to 12.1. The death rate was 10.5, as against 9.9 for 1956. There were again no deaths from puerperal causes. The infantile mortality rate, i.e., the number of infants who died during the first year of life for every thousand live births, rose from 13.8 to 20.1. This is a striking example of the fact that, quite literally, two or three additional infant deaths will raise the infantile mortality rate substantially, and tend to create a quite erroneous impression. These matters will be discussed more fully in the section of the report dealing with the statistics and social conditions of the area. Work under the Housing Acts continued during the year, and will be fully dealt with in the section of the report covering this important field. It may suffice here to say that work under these Acts, commonly but not always correctly known as slum clearance, has been temporarily halted, as it did not seem either politic or even useful to continue the condemnation of unfit houses until the obvious difficulties in the way of providing alternative accommodation could be overcome. It is hoped that this obstacle will shortly be removed and that we will be able to proceed with maximum speed towards the completion of our programme. The position in regard to the setting up of Smoke Control areas in Southgate was fully explored. After very careful deliberation, it was decided that a further report should be made to the 3 Public Health Committee in 1958, when the area to be chosen could be finally delineated and the necessary work put in hand to prepare the preliminary scheme which must be submitted to the Ministry of Housing and Local Government. Meantime, the principle that a Smoke Control Area should be established in the Borough has been agreed. The coming into force of the Rent Act, 1957, placed a certain amount of extra work on the shoulders of the Public Health Inspectors. So far as the department itself is concerned, this work has proceeded without incident. As work under the Rent Act only came into being in the latter part of 1957, the present Annual Report is not, of course, the proper place in which to discuss the final implications of such a far-reaching piece of legislation. Altogether the year 1957 has not presented any significant problems, other than those problems which we have come to know so well. Housing still remains one of our fundamental difficulties, and will surely remain an obstacle to the establishment of what we know as positive health, until we are satisfied that the entire population of Southgate is adequately housed. Few if any facets of what we know as environmental health have such urgency and significance. The social effects of inadequate housing, in whatever guise they appear, are too obvious to require repetition ; the latent effects are unfortunately equally far-reaching and fraught with infinite harm. The problem of our old folk increases year by year, not only those problems associated with the admission of the elderly chronic sick to hospital, but also the more general problems affecting loneliness, chiropody and other matters too numerous to mention. The Public Health Department has endeavoured in every way possible to play its part in this truly human work, and is prepared to offer its services to an even greater extent. The increasing responsibilities brought about by the new Food Regulations have also been accepted and implemented throughout the Borough. Unhappily, our staff of Public Health Inspectors, upon which the routine work of the department will always depend, was never up to full strength during 1957. As the Council will be aware, however, this defect was remedied during 1958. It is also particularly pleasing to report that Mr. R. L. Burkill, who came to Southgate in 1944 and who has given excellent service as a Public Health Inspector throughout his period with us, was appointed deputy to Mr. Gooday during the year. Mr. Burkill has deputised for Mr. Gooday on numerous occasions, during Mr. Gooday's absence on holiday or for any other reason. The official recognition 4 of Mr. Burkill as Deputy Chief Public Health Inspector is a welldeserved honour and regularises a position which, as I have already stated, has been in unofficial being for many years. The closest liaison is maintained between the Public Health Department and the Area Health Office, which is very fortunately situated in the Southgate Town Hall. After ten years of acting as Medical Officer of Health for Southgate and the Area Medical Officer for Health Area No. 2 County of Middlesex, it is more than ever obvious that the close and harmonious liaison which exists between these two departments, both of them engaged in the work of preventive medicine, has at least done something to obviate the difficulties which arose following the splitting up of the health functions between the local health authority and the local authority. It is indeed fortunate that our relations with the County Council in the field of Public Health are close and harmonious, and even that many members of the Area Health Staff have worked in Southgate for very many years and are therefore familiar with the conditions which exist, both from the standpoint of environmental health and personal health. Although this may not seem a very important point, I am convinced that it is none the less significant. It cannot be emphasised too often or too strongly that, unless and until the personal health services return to the control of the local authority, in this case Southgate Borough Council, the closest liaison should be maintained between the local authority and the local health authority. Happily, as indicated above, the relationship in Southgate could scarcely be improved. The Borough Council might be the authority directly concerned with the personal health services, but it is none the less vitally interested in all matters which affect the health, not only of the community but of the individuals making up the community. For this reason, I have always tried to keep the Public Health Committee fully informed of all the steps, e.g., inoculation against poliomyelitis, being taken in Southgate to provide an efficient and comprehensive personal health service. There is one other matter which I would particularly mention. During the years which have passed since 1948, when the new regime came into being, it has become increasingly obvious that the fact of my being Area Medical Officer for Area No. 2 in addition to Medical Officer of Health for the Borough has been of the greatest possible value. In this way, I am able to correlate the personal and communal health services, to integrate the work of the Public Health Department with the work of the Area Health Office ; in a word to view the whole field of preventive medicine as it affects Southgate. I am very happy to think that 5 our relations with the County Council have always been most happy, and that all members of my staff work in the closest harmony. The same remarks must also apply to the close and cordial co-operation which exists between the Public Health Department and voluntary organisations. We always try to make ourselves acquainted with the work of voluntary organisations and to assist them in every possible way. I am entirely convinced that this side of our work is extremely significant. I would again express my grateful thanks to the Public Health Committee and to the Borough Council for the help and courtesy extended to me as Medical Officer of Health during the year. I would also express my thanks to the members of the Public Health Staff for their continued service. I would particularly mention my Deputy, Dr. Janet Campbell, and Mr. Gooday, Chief Public Health Inspector, although every member of the department has given wholeheartedly of his or her service throughout the entire year. I am, Madam Mayor, Ladies and Gentlemen, Your obedient Servant, W. C. HARVEY, Medical Officer of Health. Town Hall, Palmers Green, N.13. 6 PUBLIC HEALTH COMMITTEE From 1st January to 13th May, 1957 Councillor G. D. Payne (Chairman) Councillor H. S. Beardow (Vice-Chairman) Councillor R. A. Clarke Councillor R. A. Gray Councillor P. W. Lansten Councillor A. V. Stapleton From 21st May, 1957, to 31st December, 1957 Alderman R. Prior (Chairman) Councillor G. D. Payne (Vice'Chairman) Councillor F. J. V. Brown Councillor R. A. Gray Councillor S. C. Jenner Councillor P. W. Lansten Councillor A. V. Stapleton PUBLIC HEALTH STAFF Medical Officer of Health : W. Clunie Harvey, M.D., Ch.B., D.P.H. Deputy Medical Officer of Health : Janet R. Campbell, M.B., Ch.B., D.P.H. *Chief Public Health Inspector : A. E. Gooday, M.R.S.H., F.A.P.H.I., Cert. R.S.H. Meat Inspection. *Deputy Chief Public Health Inspector : R. L. Burkill, A.R.S.H., M.A.P.H.I., Cert. R.S.H. Meat Inspection, Cert. R.S.H. Smoke Inspector. *Public Health Inspector : E. T. Jephcott, M.A.P.H.I., Cert. R.S.H., Cert. R.S.H. Meat Inspection (resigned 10th June, 1957). *Public Health Inspector : W. Shackcloth, A.R.S.H., M.A.P.H.I., Cert. R.S.H., Meat Inspection. *Public Health Inspector : J. C. Noble, M.A.P.H.I., Cert. R.S.H., Cert. R.S.H. Meat Inspection (appointed 22nd July, 1957). Senior Typist : Miss E. W. Barratt. Clerk : Miss A. G. Alcock. Junior Clerk : S. Fenn. General Assistant : B. Latter. Driver : J. L. Arnold. Rodent Operator : W. Dowsett. *These Officers' salaries are repaid to the Council in part by the Middlesex County Council. 7 STATISTICS AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 3,765 Registrar-General's Estimate of Resident Civilian Population, 1957 71,250 Number of houses and flats assessed to General Rate (as at 1st April, 1957) 22,085 Effective rateable value on 1st April, 1957 £1,439,069 Sum represented by Id. Rate (1957) Revised Estimate £5,885 8 EXTRACTS FROM VITAL STATISTICS OF THE YEAR Male Female Total Live Legitimate 386 385 771 Births Illegitimate 14 13 27 400 398 798 Birth rate per 1,000 of the estimated population 11.2 Still Legitimate 7 4 11 Births Illegitimate 1 — 1 8 4 12 Rate per 1,000 live and still births 14.81 Deaths from all causes and at all ages 901 Death Rate per 1,000 of the estimated population 10.5 Deaths from puerperal causes nil Deaths From Puerperal Sepsis nil From other causes nil Deaths of Infants under 1 year of age : Male Female Total Legitimate 8 7 15 Illegitimate 1 — 1 9 7 16 Infant Death Rate : All infants per 1,000 births 20.1 Legitimate—per 1,000 legitimate live births 19.46 Illegitimate—per 1,000 illegitimate live births 37.0 Deaths from Measles—all ages 0.01 Deaths from Pertussis—all ages nil 9 The births and birth rates for the past five years were as follows : Birth Rates Year No. of Births Southgate England and Wales 1953 760 11.48 15.5 1954 815 12.3 15.2 1955 776 11.8 15.0 1956 800 11.2 15.7 1957 798 11.2 16.1 POPULATION The Registrar-General's estimated population of the Borough at the middle of 1957 was 71,250, a decrease of 420 as compared with 1956. BIRTHS—BIRTH RATE The total nett births for the year accredited to the district was 798, a decrease of 2 on the preceding year. Of these, 400 were males and 398 females (14 males and 13 females being illegitimate). The birth rate for the year was 11.2 per 1,000 of the population. The birth rate for England and Wales for 1957 was 16.1. During the year, the number of births recorded was 103 less than the number of deaths, as compared with 44 less in 1956. 10 MORTALITY General Mortality and Death Rate. The nett number of deaths accredited to the district was 901, 57 more than in 1956. This gives a crude death rate of 12.6 per 1,000 of the population and a corrected death rate of 10.5 (the rate for 1956 being 9.9). Death Rates Year No. of Deaths Southgate England and Wales 1953 838 9.18 11.4 1954 813 8.80 11.3 1955 809 11.30 11.7 1956 844 11.80 11.7 1957 901 12.60 11.5 Apart from the fact that the major causes of death as shown by the Registrar-General's return are still deaths from diseases of the heart and circulation and lung cancer, I would comment on two specific death rates : The tuberculosis death rates for Southgate have not altered a great deal over the past four years, the number of yearly deaths varying from 9 in 1957 to 2 in 1956. In 1957, the death rate from tuberculosis was 0.08 per thousand of the population, the third highest rate in Middlesex. In 1956, the death rate from tuberculosis was the third lowest in Middlesex ; while in 1955 the death rate (0.11 per thousand population) was exactly the average for the County. In 1954, the Southgate rate was somewhat below the average. In other words, although the death rates from tuberculosis in a district such as Southgate might be expected to be low, this is not always the case. The reasons are not difficult to find. It must be obvious that persons suffering from tuberculosis move into Southgate from Inner London because of the very fine amenities available and the absence of industrial development. The fact that a very few of these patients die—and I need scarcely say that the death rate from tuberculosis is declining year by year— must never be taken to imply that that is a bad area so far as tuberculosis is concerned. One must consider, above everything else, the number of new cases recorded in the Borough, especially among what might be termed the indigenous population. The fact that our death rates from tuberculosis are relatively high, however, does indicate the urgent need for the adequate housing of all families from which a case of tuberculosis has been reported. So far as the tracing of contacts and the care of actual patients is concerned, the work of our Chest Clinics is particularly important. 11 In 1957, the death rate from cancer (2.8 per thousand population) was the highest in Middlesex. In 1956, the rate for Southgate was the second highest in the County. In 1955 the rate was the third highest in Middlesex, while in 1954 the rate was again the second highest in the County. In short, year after year, the number of deaths from cancer in Southgate, which varied from 168 in 1955 to 202 in 1957, remained high when compared with figures from other County districts. The reason is again not far to seek. The population o.f Southgate is weighted in the over-60 group and is becoming increasingly weighted as the years go by. This means that more and more Southgate inhabitants are living to the age when cancer used to be considered a major killing disease. Although one cannot describe any cause of death as satisfactory, it is at least pleasing to think that the conditions which prevail within the Borough are such as to promote longevity. Unfortunately, we know only too well that a portion of these deaths occur in persons who have only reached late middle life. None the less, the over-all fact remains that, in the absence of any factor which might increase the prevalence of cancer—and no such factor seems to exist—we must assume that the high rates in Southgate are primarily due to the long life of its burgesses. Infant Mortality. There were 16 deaths of infants under 1 year of age, which gives an infant death rate of 20.1 per 1,000 births, as compared with 11 deaths and a rate of 13.8 in the preceding year. The infant deaths and rates for the past five years were as follows : Death Rates Year No. of Deaths Southgate England and Wales 1953 21 27.63 26.8 1954 13 16.00 25.5 1955 15 19.30 24.9 1956 11 13.80 23.8 1957 16 20.10 23.0 As already indicated, the Infant Mortality Rate rose from 13.8 in 1956 to 20.1 in 1957. These figures are perhaps seen in more accurate perspective when it is remembered that the number of infants who died before the age of one year in 1956 was 11, while the corresponding number in 1957 showed only an increase of 5, making a total of 16. In other words, as has been explained, a few infant deaths will appreciably raise the infantile mortality rate for a district with a population such as Southgate's. We also know, that most of our infant deaths occurred during the first few weeks of life, indeed, during the first few days of life. This mortality, 12 known as the neo-natal mortality, comprises the type of fatalities which, so far as the work of the local health authority is concerned, are largely non-preventable. Each neo-natal death is, however, very carefully investigated, whether the child died at home, or as happens in most instances, in hospital. The Council will remember that, in my Annual Report for 1956, I mentioned that we were endeavouring to arrange a postmortem examination of infants who died before the age of twelve months in as many cases as possible. This is never an easy matter, for very obvious reasons. We are nevertheless continuing our efforts, in the hope that the additional information which postmortem examinations still provide will afford a clearer insight into the cause of death, especially those deaths which should be preventable. The greatest care is also being exercised in the field of ante-natal welfare, since it is known that a number of infant deaths are due to causes which arise during pregnancy and which lead, if not to a stillbirth, to early death of the newly born infant. Deaths in England and Wales of infants between the age of six and twelve months has dropped by approximately 92% since the beginning of the century. As a contrast, the mortality of infants immediately after birth has fallen by approximately 30% during the same period, a much less satisfactory figure. In other words, more work is still required to ascertain the true cause of early infant deaths, and to ensure that, wherever possible, these causes are eliminated. Still-births. Twelve still-births, 11 legitimate and 1 illegitimate, were accredited to the Borough for 1957. This is equal to a death rate of 14.81 (live and still-births), the corresponding figures for 1956 being 11 still-births with a rate of 13.44. The rate per 1,000 of the population was 0.16, the rate for England and Wales being 22.4. Maternal Mortality. No maternal deaths were reported during 1957. Mortality of Persons over the Age of 65. Six hundred and twenty-eight, or 69.7, of the total deaths during the year occurred in persons over the age of 65 years. Of these 216 died between the ages of 80 and 90, while a further 33 females and 10 males were over the latter age, the oldest being 101. Following the trend of recent years, diseases of the heart and circulation were responsible for more deaths in this age group than any other cause. 13 TABLE I. Causes of Death during the year 1957. Causes of Death Male Female Total Rates per 1,000 of population All causes (civilians only) 414 487 901 12.60 1. Tuberculosis, Respiratory 7 2 9 0.12 2. Tuberculosis, Other 1 1 2 0.02 3. Syphilitic Disease 1 1 2 0.02 4. Diphtheria — — — — 5. Whooping Cough — — — — 6. Meningococcal Infection — — — — 7. Acute Poliomyelitis — 1 1 0.01 8. Measles 1 - 1 0.01 9. Other Infective and Parasitic Diseases 1 — 1 0.01 10. Malignant Neoplasm—stomach 7 9 16 0.22 11. Malignant Neoplasm, Lung, Bronchus 39 9 48 0.67 12. Malignant Neoplasm, Breast — 25 25 0.35 13. Malignant Neoplasm, Uterus — 17 17 0.23 14. Other malignant and lymphatic Neoplasms 42 54 96 1.36 15. Leukaemia, Aleukaemia 1 4 5 0.07 16. Diabetes 1 9 10 0.14 17. Vascular Lesions of Nervous System 50 72 122 1.71 18. Coronary Disease, Angina 87 56 143 2.00 19. Hypertension with Heart Disease 7 14 21 0.29 20. Other Heart Disease 39 80 119 1.67 21. Other Circulatory Disease 16 22 38 0.53 22. Influenza 4 2 6 0.08 23. Pneumonia 20 22 42 0.58 24. Bronchitis 27 14 41 0.57 25. Other Diseases of Respiratory System 4 3 7 0.09 26. Ulcer of Stomach and Duodenum 3 4 7 0.09 27. Gastritis, enteritis and Diarrhoea 3 3 6 0.08 28. Nephritis and Nephrosis 6 5 11 0.15 29. Hyperplasia of Prostate 9 — 9 0.12 30. Pregnancy, Childbirth, Abortion — — — — 31. Congenital Malformation 3 2 5 0.07 32. Other Defined and Ill-Defined Diseases 19 37 56 0.78 33. Motor Vehicle Accidents 4 1 5 0.07 34. All Other Accidents 7 12 19 0.26 35. Suicide 5 6 11 0.15 36. Homicide and Operations of War — — — — 14 TABLE II. Deaths from all causes, divided as to sex and certain age groups, and showing a percentage of total deaths and death-rates per 1,000 of population for each age group. 1957 FEMALES MALES TOTALS Age No. %of total deaths Rate per 1,000 No. % of total deaths Rate per 1,000 No. % of total deaths Rate per 1,000 0-1 year 7 0.78 0.09 6 0.67 0.08 13 1.45 0.17 1-5 years 1 0.11 0.01 1 0.11 0.01 2 0.22 0.02 5-15 years 1 0.11 0.01 1 0.11 0.01 2 0.22 0.02 15-25 years 1 0.11 0.01 3 0.33 0.04 4 0.44 0.05 25-45 years 26 2.89 0.37 14 1.55 0.20 40 4.44 0.57 45-65 years 105 11.66 1.47 107 11.87 1.50 212 23.53 2.97 65-75 years 121 13.43 1.69 108 11.98 1.52 229 25.41 3.21 Over 75 years 225 24.97 3.15 174 19.32 2.44 399 44.29 5.59 T otals 487 54.06 6.80 414 45.94 5.80 901 100.00 12.60 15 TABLE III. INFANTILE MORTALITY 1957: Nett deaths from stated causes at various periods under 1 year of age. Causes of Death Under 1 week 1—2 weeks 2—3 weeks 3—4 weeks Total under 1 month 1—3 months 3—6 months 6—9 months 9—12 months Total under 1 year 1. Smallpox 2. Chickenpox J. Measles 4. Scarlet Fever 5. Pertussis 6. Diphtheria and Croup 7. Erysipelas 8. Tuberculous Meningitis 9. Abdominal Tuberculosis 10. Other Tuberculosis 11. Meningitis (not Tuberculous) - - 1 _ 1 - - - - 1 12. Convulsions 13. Laryngitis 14. Bronchitis — — — — 1 — 1 15. Pneumonia - - - - - - - 1 — 1 16. Diarrhoea 17. Enteritis 18. Gastritis • 19. Syphilis 20. Rickets 21. Suffocation 22. Want of Attention and Injury at Birth 23. Atelectasis 2 — — — 2 — — — — 2 24. Congenital Malformation 8 — — — 8 — — 1 — 9 25. Premature Birth 1 — — — 1 — 1 26. Atrophy, Debility and Marasmus - - - - - - - - 1 1 27. Other Causes Total 11 — 1 — 12 — 1 2 1 16 16 TABLE IV. Vital Statistics of Whole District during 1957 and Eight Previous Years. Year Population estimated at Middle of each Year Nett Births belonging to District Nett Deaths belonging to the District At all ages Under 1 year of age Number Rate per 1,000 population Number Rate per 1,000 population Number Rate per 1,000 population 1949 74,350 944 12.69 820 11.04 24 25.42 1950 74,180 860 11.46 868 11.70 20 23.25 1951 72,840 839 11.17 951 11.09 13 15.49 1952 72,480 775 10.37 900 10.55 9 11.61 1953 72,110 760 10.54 838 11.62 21 27.63 1954 72,290 815 11.30 813 11.20 13 16.00 1955 71,870 776 10.80 809 11.30 15 19.30 1956 71,670 800 11.20 844 11.80 11 13.80 1957 71,250 798 11.20 (crude) 12.10 corrected) 901 12.60 (crude) 10.50 (corrected) 16 20.10 17 GENERAL PROVISION OF HEALTH SERVICES Hospitals. The situation as it relates to the availability of hospital beds has not altered appreciably from that recorded in my Annual Reports for the last few years. The problem is still most acute in regard to the provision of beds for the chronic sick, especially the elderly chronic sick. As I stated in my Annual Report for 1956, difficulties have also tended to arise in the provision of maternity beds. This is specifically the case in so far as the provision of a hospital bed on social rather than medical grounds is concerned. This matter—a very important matter when existing housing conditions are remembered—has been taken up with the maternity hospitals serving the Borough. It is hoped that the difficulties will at least be alleviated, if not substantially removed. The admission to hospital of old people who are suffering from what might be described as the normal infirmities of old age, presents a problem which grows in size and in intensity year by year, almost month by month. Unfortunately, the situation so far as Southgate is concerned is by no means clear. After considerable negotiations, Highlands Hospital, the general hospital which serves the Borough, has agreed to accept geriatric cases from as much of the N.14 and N.21 postal districts as can be accommodated. This is certainly a considerable improvement on the state of affairs which existed not so long ago, when it was virtually impossible to secure the admission of a geriatric case to Highlands Hospital because of the hospital's commitments in Inner London. Although the position has certainly improved, it is still by no means satisfactory. The whole of the Borough is not yet covered, while accommodation, even for those parts of the district specified above, is not always available. I hasten to add that Highlands Hospital is always cO'Operative, and has done everything possible to fulfil and to extend its obligations. The geriatric service at Highlands Hospital has been appreciably extended, so that we look forward eagerly to the day when a full geriatric service will be at our disposal and when geriatric cases from the whole of the Borough can be freely admitted to Highlands Hospital. Geriatric cases from Southgate are also received into St. Michael's Hospital, Enfield, the North Middlesex Hospital and, on occasion, into Chase Farm Hospital. On paper, this arrangement may appear adequate. But this is very far from being the case ; not because of any lack of goodwill on the part of the hospitals concerned, but by reason of the increasing demand for geriatric beds, not to mention the appalling shortage of staff. It is tragic in the extreme to find an elderly and infirm person who is either not suffering from any specific disease or who has 18 reached a stage where anything resembling a permanent or even a partial cure is out of the question, and to be told that there is no bed available in any hospital for their needs. Such tragedies are very definitely increasing, and present what is virtually an insuperable problem. The Health Services provided by the County Council in Area No. 2 certainly afford as much amelioration as is possible. Health visitors regularly visit these old people ; home nurses are available for daily or even more frequent visits ; while the home help service can also help. But two things must be remembered. These measures, helpful though they be, are only palliative. A time must come when the answer, and the only answer, is admission to a hospital or to an Old Persons' Home. And even here, it must never be forgotten that persons can only be admitted to an Old Persons' Home if they are able to look after themselves. And it is precisely the type of old person who is quite incapable, by reason of age and infirmity, to fend for himself or herself who presents the real, the quite appalling problem. The second point is the fact that the County staff available to look after old persons in their own homes is extremely limited ; while I need scarcely say that they have many other very important duties to perform. This is particularly so in the case of the Home Help Service, where old people can only be catered for when the urgent needs of maternity cases, cases of tuberculosis and urgent illness in the family have been fully covered. Altogether, although the personal health services provided by the County Council are designed, at least in part, to reduce the number of cases which might otherwise have to go to hospital, they are only able to cope with the aged infirm to an extremely limited extent. What is obviously required is a much fuller geriatric service which will adequately cater for the desperate needs of a Borough such as Southgate where the population, as I have stated elsewhere, is heavily weighted in the older age groups. Such a geriatric service should be able to secure the admission to hospital of elderly people before the stage has been reached when rehabilitation is out of the question. This would permit a much quicker turn-over of beds, and would solve at least part of our problem. Considerable discussion, in which I have played a part, has already taken place on this subject. Here again, we can only hope that these discussions will bear fruit, and that the disturbing state of affairs which exists today will become a nightmare of the past. When it is remembered that the number of persons over the age of 65 in Middlesex is estimated to rise by 30% in the appreciable future ; and when it is also remembered that Southgate is particularly unfortunate in this respect, the need for immediate action will be appreciated, if the nightmare is not to assume psychotic proportions. There is another aspect of the problem of the admission of old people to hospital which urgently requires attention. When 19 it is impossible, as is so often the case, to secure the admission to hospital of an old person who is either very infirm or suffering from some chronic ailment, the position of the relatives, where there are relatives, requires consideration. Quite apart from those old people who are living alone, there are many old people who are being looked after in their own homes by relatives. The Home Nursing and Home Help services provided by the County Council are certainly able to help, but the strain will always remain with the relatives, both by day and by night. When a relative accepts this responsibility in the fullest possible measure, and where the infirmity or illness of the elderly person continues for months and sometimes for years, it need scarcely be said that an enormous strain is placed upon the health of those who are doing their best to look after the old person at home. Very often, these relatives have a breakdown in health, sometimes so severe that admission to hospital is required. If the geriatric services provided locally were such that old people could be got into hospital at an early date, and if there were even some arrangement whereby old people could be admitted to hospital for a short period, in order to give the person looking after them a break or even a short holiday, this would undoubtedly ease the burden. This is yet another matter which is being stressed with the appropriate Regional Hospital Board, in an effort to discover whether something along these lines can be arranged as a matter of very real urgency. Care of the Aged. The remarks which I made in my Annual Report for 1956 regarding care of the aged generally apply equally today. Here is a field in which so very much can and should be done. As I write this report it is highly probable that the Southgate Old People's Welfare Committee will be strengthened and in a position to undertake much wider functions in the very near future. From what I know of the Old People's Welfare Committee, of which I have the privilege to be a member, I am convinced that these extended duties will be eagerly accepted. An attempt is at present being made to endeavour to assess the needs of old people living in the Borough, to place these needs in some order of priority, and to take such steps as are practicable to ensure that the needs are met. It need scarcely be said that the Borough Council has always taken the greatest interest in the welfare of its old folk. This is an almost classic example of the way in which a statutory body such as a Borough Council can co-operate with a voluntary committee, to improve the lot of those members of the community who are in such dire need of assistance. Much, of course, is already being done. The great work carried out by the Old People's Welfare Committee has already been mentioned. One must also remember the magnificent 20 tribution made by the Southgate Division of the British Red Cross Society, the W.V.S. "Meals on wheels" and other activities, and the Southgate Social Service Council, together with many other bodies, not to mention individuals. When all these efforts have been fully co-ordinated, when our old people can know where to obtain assistance when gaps have been filled and new amenities and services provided, we can honestly say that the problem of the aged is being adequately tackled in Southgate. Need I stress that the sooner this is done, the more can we rest content. Laboratory Facilities. I would again record my appreciation and thanks to the staff of the Central Public Health Laboratory, both at Colindale and at Edmonton for their unfailing assistance during the year. Once again, we did not have to call upon the Laboratory to any great extent during 1957 owing to the absence of major outbreaks of infectious disease. It is, however, very satisfactory to remember that the Public Health Laboratory Service is available to us, and that any calls we make upon it will be readily and sympathetically met. Summary of Work carried out at the Central Public Health Laboratories for the year : Positive Negative Swabs for diphtheria bacilli 1 210 Sputa for tubercle bacilli 1 71 Throat and Nose 503 Faeces 423 Blood 52 Urine 66 Others 126 Mortuary. The position in regard to the Council Mortuary at the rear of the Town Hall is still as set out in the Report for 1946, except that we now have a firm agreement with the Prince of Wales Hospital to accept Southgate bodies. Up to the present, no difficulties have arisen. Scabies and Lice. I reported fully on this aspect of our work in the Report for 1951. The remarks set out in that Report still apply. During 1957, three Southgate patients received treatment at St. John's Hospital. NATIONAL ASSISTANCE ACT 1948 Section 47—Removal to suitable premises of persons in need of care and attention. No action was taken by the Council in 1957 under this Section. 21 SANITARY SERVICES Summary of Visits. Visits re housing defects (Public Health Act, 1936) 2,967 Visits re housing defects (Housing Acts 1936/57) 306 Visits re drainage and building works 256 Visits re dustbins (Public Health Act, 1936) 50 Visits re housing conditions and overcrowding (applications for housing accommodation) 36 Visits re Rent Act, 1957 168 Visits re food premises (including butchers, bake' houses, confectioners, restaurants, grocers and fish shops) 1,050 Visits re milk and ice-cream sampling 102 Visits re food hawkers 4 Visits re Shops Act, 1950 624 Visits re factories 92 Visits re Infectious Diseases 786 Visits re Prevention of Damage by Pests Act, 1949 952 Visits re Smoke Observations 16 Visits re places of public entertainment 39 Visits re other matters 3,077 10,525 Service of Notices. Informal Notices served : re Housing repairs 395 re Dustbins 49 re Food premises 63 re Shops and Factories 115 Total Informal Notices served 622 Total Informal Notices complied with 520 Total Statutory Notices served 38 Total Statutory Notices complied with — 34 Repairs to Houses. Considerable work has been carried out by the Public Health Inspectors during the year in connection with repairs to houses. Their efforts have resulted in repairs being carried out at 431 houses, the repairs varying from those of a major character to minor repairs necessary to abate specific nuisances. It is, I think, worthy of note that the repairs referred to were carried out mainly as a result of informal action on the part of the Inspectors. Only in 36 instances was it found necessary to followup informal notices by the service of Statutory Notices. 22 Non-compliance with one of the above-mentioned Statutory Notices necessitated legal proceedings being instituted against the owner. A Nuisance Order was made by the Court and the necessary repairs were subsequentily carried out. Unfit Houses. During 1957, following reports of unfitness for habitation, the Council made two Closing Orders under the Housing Acts, one in respect of the basement rooms at 17 Upper Park Road, N.ll, and the other in respect of 56 High Street, N.14. Further to the reference in my Annual Report for 1956 regarding the Council's five-year programme for dealing with unfit houses, approval was received in 1957 from the Minister of Housing and Local Government to a Compulsory Purchase Order in respect of 38 houses in two Clearance Areas in New Southgate. The Council, during 1957, declared a further three areas, comprising 20 houses, to be Clearance Areas under the Housing Acts, and resolved to deal with two areas by way of acquisition by agreement with the owners and to deal with the third area by way of a Clearance Order. Certificates of Disrepair. The following is a summary of the action taken by the Council during 1957 in respect of Certificates of Disrepair under the Housing Repairs and Rents Act, 1954, and the Rent Act, 1957. In the period 1st January to 6th July, the Council revoked four Certificates of Disrepair issued to tenants under the Housing Repairs and Rent Act, 1954, on the completion of the necessary repairs. On 6th July, the Rent Act, 1957, came into operation. The provisions of this Act in respect of the granting and cancellation of Certificates of Disrepair superseded those of the Housing Repairs and Rents Act, 1954. The action taken by the Council under the Rent Act, 1957, is set out below : APPLICATIONS FOR CERTIFICATES OF DISREPAIR 1. Number of applications for certificates 27 2. Number of decisions not to issue certificates Nil 3. Number of decisions to issue certificates (a) in respect of some but not all defects 17 (b) in respect of all defects 8 4. Number of undertakings given by landlords under graph 5 of the First Schedule 12 5. Number of undertakings refused by Local Authority under proviso to paragraph 5 of the First Schedule 1 6. Number of Certificates issued 13 23 APPLICATIONS FOR CANCELLATION OF CERTIFICATES 7. Applications by landlords to Local Authority for cellation of certificates 8 8. Objections by tenants to cancellation of Certificates 3 9. Decisions by Local Authority to cancel in spite of tenants objection 2 10. Certificates cancelled by Local Authority 5 In accordance with a request by the Ministry of Housing and Local Government in Circular 32/57 that local authorities should give information to the general public concerning the provisions of the Act, the Public Health Department dealt with 113 enquiries relating to certificates of disrepair. Housing Applications. Visits by the Public Health Inspectors to applicants for housing accommodation and the preparation of reports as to living conditions were continued in 1957. The number of visits for this purpose was 36, as against 44 in 1956. The close liaison between the Public Health Department and the Housing Department has been maintained in 1957, as in previous years. On many occasions, I have been asked by the Town Clerk to advise as to the degree of urgency on medical grounds applicable to particular applications. Food Hygiene. During the whole of 1957, the campaign towards improvement in the standards of food hygiene and the implementation of the Food Hygiene Regulations, 1955, which featured prominently in the work of the Public Health Inspectors in 1956, was actively continued. Largely due to the concentrated efforts of traders and Inspectors alike in 1956, a great deal of the work carried out in this field during 1957 was in the nature of a "mopping up" operation, i.e., dealing with the relatively small hard core of traders who were resistant to the implementation of the Regulations. In all, the Inspectors made 1,156 visits in connection with food hygiene during 1957, and 63 notices were served to secure compliance with the Regulations. As a result, the following improvements were achieved : Regulation 9. (Personal Cleanliness). Warnings re smoking while handling food were given in two separate instances. 24 Regulation 14. (Sanitary Conveniences). At nine food premises it was found necessary to effect improvements to the sanitary conveniences in order to bring them into compliance with this Regulation. Regulation 16. (Washing facilities for food handlers). In compliance with this Regulation, wash-hand basins with constant hot and cold water were provided at ten food premises. At one food premises a defective wash-hand basin was renewed. At another, constant hot water was provided to an existing wash-hand basin where previously only a cold water supply had been available and where means of providing hot water were inadequate. Nail brushes, towels, soap, etc., were provided at seven food premises. Regulation 17. (First-aid materials). Adequate first-aid equipment was provided at four food premises. Regulation 18. (Accommodation for clothing, etc.). Adequate accommodation for clothing and footwear, not worn during working hours, of persons engaged in the handling of food was provided at four food premises in compliance with this Regulation. Regulation 19. (Facilities for washing food and equipment). In compliance with this Regulation it was found necessary to require the provision of sinks with constant hot and cold water for the washing of equipment at five food premises. In addition, it was necessary to require the provision of constant hot water to existing sinks, used for the washing of equipment, at twelve food premises where previously only a cold water supply had been available and where means of providing hot water were inadequate. Regulation 23. (Cleanliness and repair, etc., of food rooms). Improvements in the cleanliness and repair of food rooms in compliance with this Regulation were required at eleven food premises. I think it is fair to say that a great deal has been achieved in the 475 privately-owned food premises in the Borough by the implementation of the Food Hygiene Regulations in 1956 and in the year under review. In order, of course, to ensure that the 25 ments are kept up to standard and that full use is made of the additional facilities provided, I am convinced that routine inspection work by the Public Health Inspectors is invaluable. In fact, I regard their work in this connection as a most important contribution to our Health Education Programme. In addition to the above, visits have been made by the Inspectors to the school kitchen/dining rooms and mobile dining centres, together with the Council's cafes in the parks and sports grounds. Food inspection. The following is a summary of the food condemned during the year as unfit for consumption. The method of disposal was by incineration at the Council's Destructor Works. Fish 31½ stone Poultry 45 lbs. Carcase meat 472 lbs. Offal 75½ lbs. Bacon 35 lbs. Ham 18 lbs. Canned Meat (various) 451 lbs. Canned foods (various) 186 cans Dried fruits 291 lbs. Potatoes 128 lbs. Number and Classes of Food Premises in the Borough. Below is a summary of the food premises classified under type of business: Bakers and Confectioners 32 Butchers 60 Grocery and Provisions 114 Fruit and Greengrocery 60 Wet Fish 16 Fried Fish 8 Restaurants and cafes (including school canteens, works canteens, clubs, etc.) 109 Confectionery and Sweets 76 475 In the Borough there are 299 premises registered under Section 16 of the Food and Drugs Act, 1955, 207 in respect of ice-cream and 92 in respect of preserved foods. There is one dairy in the Borough registered under the Milk and Dairies Regulations, 1949-54. 26 Under the provisions of the Middlesex County Council Act, 1950, relating to hawkers of food and their premises, there were 87 hawkers on the register at the end of 1957. Of these, 21 have storage premises in the Borough, and 66 have their storage premises in other areas. Post-Mortem Inspection of Animals. No slaughtering of animals took place in the Borough during 1957. Milk Regulations and Milk Sampling. During the year under review, 53 samples of milk were obtained and submitted to the Public Health Laboratory for bacteriological examination. All the samples gave satisfactory results. Ice-Cream Sampling. During the year under review, 52 samples of ice-cream were obtained and submitted for bacteriological examination. The results were : Grade 1 50 „ 2 2 „ 3 nil „ 4 nil It is, I think, worthy of note, that none of these samples were in Grades 3 or 4. This is the first occasion on which I have been able to report such satisfactory results. All samples were obtained as sold to. the consumer, 23 of the 52 being samples in the loose state from bulk. Whilst it is true that these samples represent a relatively small proportion of the ice-cream sold in the Borough, it is equally true that they were taken at random, without prior notice of any kind to the vendor. In my view, therefore, the results indicate an upward trend in the handling and distribution of icecream in the Borough. Two samples of ice lollies were obtained and submitted for bacteriological examination. The results were satisfactory. Establishments for Massage or Special Treatment. Under the Middlesex County Council Act, 1944, 15 existing licences were renewed, and 1 new licence was granted. Pet Animals Act, 1951. Two licences were granted by the Council during 1957 under the above-mentioned Act in respect of two pet animals shops in the Borough. 27 Swimming Bath. The figures for attendances at the Barrowell Green Open Air Swimming Bath for the last two years were:— 1956 1957 Adults (Mixed and Spectators) 8,242 17,791 Children (Mixed and Spectators) 21,632 31,756 From Schools 3,092 3,042 Season Tickets 9,456 8,729 42,422 61,318 Costumes, etc., hired 39 84 As in the past, samples of water were taken at regular intervals from the swimming bath. The results were uniformly satisfactory. In order that the public might be reassured as to the quality of the water, reports on the samples taken, couched in general terms, were displayed at the Bath. Attendances at the Bath of members of the St. John Ambulance Brigade during crowded sessions and hot week-ends has been continued. The assistance is very greatly appreciated. As hitherto, the Superintendent of the Swimming Bath and her staff have shown a very keen appreciation of their duties in relation to public health. The condition of the Bath was always found to be excellent on inspection, while Co-operation has been close and cordial as in past years. Altogether Barrowell Green Swimming Bath provides the district with a valuable amenity which must have an appreciable effect on health, particularly on the health of children. Rivers and Streams. During the year under review, seven complaints were received concerning minor nuisances from streams in the Borough. These were immediately dealt with. Prevention of Damage by Pests Act, 1949. During 1957, 414 complaints of rats and mice were received and dealt with, as against 382 in 1956. In March, 1957, a baiting and poisoning treatment was carried out by the Borough Engineer's Department in the Council's soil sewers. 279 manholes were baited. In 132 of these, complete or part takes of bait were noted. In October, 1957, test baiting was carried out by the Borough Engineer's Department to 201 manholes, representing approximately 28 11.5 per cent. of the total manholes on the Council's soil sewers. On the results obtained from this test, a baiting and poisoning treatment followed, during which 301 manholes were baited. Of these, 83 showed complete or part takes of bait. All work done in the sewers was carried out in accordance with the recommendations of the Ministry of Agriculture and Fisheries (Infestation Control Division). An official of the Ministry visited the Borough on both occasions and was given facilities for inspecting the work while in progress. He expressed himself entirely satisfied with the way in which the work was carried out. Public Conveniences. 17 public conveniences are available in the Borough, situated as follows: Broomfield Park (3). Arnos Park. Bramley Sports Ground. Oakwood Park. Tottenhall Sports Ground. North Circular Road, Palmers Green. Triangle, Palmers Green. Fords Grove, Winchmore Hill. "Cherry Tree" Hotel, N.13. "Crown," Chase Side, N.14. "White Hart," Chase Road, N.14. "Kings Head," Wades Hill, N.21. "Orange Tree," Highfield Road, N.21. " Fox " Hotel, Green Lanes, N.13. Grovelands Park. Conveniences provided by London Transport Executive at Southgate and Oakwood Underground Stations are also available to the public. All public conveniences in the district are inspected by members of the Public Health Department Staff. This inspection includes conveniences provided for the use of the public in publichouses and hotels. Defects are brought to the notice of the Borough Surveyor's Department, or are notified to the proprietors of the premises in which the public conveniences are situated. Ponds and Rubbish Dumps. These continue to be kept under observation. During the summer months spraying was carried out where and when necessary to prevent insect breeding. 29 As in 1956, improvements in respect of the dumping of rubbish on undeveloped land was effected. Water Supply. The water supply of the district, which is almost entirely supplied by the Metropolitan Water Board, remains satisfactory in quality and quantity. The supply is from high-pressure mains. All the houses in the district are provided with a direct pipe supply, the few wells which previously existed having now been discontinued. It was not considered necessary to carry out any bacteriological or chemical examination of drinking water during the year. There is no evidence of any plumbo-solvent action in the water. Refuse Collection and Disposal. The Borough Engineer and Surveyor reports that a weekly collection service was maintained throughout the year. Tonnage of refuse dealt with at the Refuse Disposal Works amounted to 20,204 tons, an increase of 217 tons on last year. I reported last year that a scheme to convert the Refuse Disposal Works at Barrowell Green into a Transfer and Salvage Depot was being considered. I am now able to report further on this matter. The Minister duly gave approval to the scheme submitted by the Council, and disposal of refuse by incineration ceased to operate with effect from 31st December, 1957. When the reconstruction work is completed later this year, the unloading of collection vehicles, extraction of salvage and re-loading of refuse into large capacity vehicles for transporting to a tipping site in Hertfordshire will be carried out entirely within closed buildings. Dust extraction plant will be installed at essential points further to reduce the dissemination of fine dust into the atmosphere, and to improve working conditions for the staff. At the time of writing, the demolition work, including the taking down of the 140 ft. chimney, is nearing completion, and the building work to house the new handling plant is under way. During the period of reconstruction, the refuse collection vehicles are unloaded on open ground adjoining the works, and the refuse is then re-loaded by mechanical shovel on to large capacity vehicles and transported to the tipping site in Hertfordshire. 30 The following table gives the tonnages of the materials sold : Tons Paper 947 Cullet 2 Non-ferrous metals 2 Rags 21 Carpet 18 Tins 656 Bottles 9 Scrap Iron 104 Kitchen Waste 95 Miscellaneous 25 Sale of salvage recovered from the refuse during the year realised an income of £14,309. Fumes and Noise. Work in this field occupied the Public Health Inspectors to a greater extent than usual during 1957. Complaints continue to be received relating to alleged noise nuisance and nuisance from fumes emanating from the Metal Box Company's factory in Chequers Way, N.13. As this matter is still being actively pursued, this report would not appear to be the proper place in which to make anything in the nature of a final statement. It might, however, be said that the number and extent of observations kept on this factory and on the immediate vicinity thereto has been, to say the least, extensive. Conferences have been held between the Public Health Committee, the Metal Box Company itself and local residents, at which the complaints made by residents were fully ventilated and discussed. As I have just said, the matter is still being actively pursued. In view, therefore, of the fact that possible action in the future might be prejudiced by a statement made at this juncture, it need only be repeated that everything possible has been done by the Public Health Committee and, indeed, by the Public Health Department to establish the true facts of the case and to ascertain what, if any, remedies might be applied. In addition to the Metal Box Company, sixteen complaints were received from residents alleging nuisance from fumes and/or noise from various other industrial premises in the Borough. Careful investigation was made into all these complaints, involving in some instances long and continued observations by the Inspectors. Where, as a result of observations it was proved there was justifica' tion for the complaints, the Inspectors were able to effect improve' ment by obtaining the co-operation of the firms concerned and making constructive suggestions as to what could be done to abate or mitigate the nuisance. 31 FACTORIES ACTS, 1937 AND 1948 Details of Work Carried Out During the Year 1957 1. INSPECTIONS for purposes of provisions as to health (including Inspections made by Public Health Inspectors). Premises M/c. line No. Number on Register Number of M/c line No. Inspections Written Notices Owners Prosecuted. (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 1 67 29 1 — 1 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 2 171 63 9 — 2 (iii) Other premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) 3 — — — — 3 Total 238 92 10 — 2. Cases in which DEFECTS were found. (If defects are discovered at the premises on 2, 3 or more separate occasions, they should be reckoned as 2, 3 or more cases.) Particulars M/c. line No. No. of cases in which defects were found Number of cases in which prosecutions were instituted M/c. line No. Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of Cleanliness (S.l) 4 7 7 — — — 4 Overcrowding (S.2) 5 — — — — — 5 Unreasonable temperature (S.3) 6 — — — — — 6 Inadequate Ventilation (S.4) 7 1 1 — — — 7 Ineffective drainage of floors (S.6) 8 — — — — — 8 Sanitary Conveniences (S.7) (a) Insufficient 9 — — — — — 9 (b) Unsuitable or defective 10 6 6 2 — — 10 (c) Not separate for sexes 11 — — — — — 11 Other offences against the Act (not including offences relating to Outwork) 12 — — — — — 12 Total 60 14 14 2 — — 60 32 33 OUTWORK—(Sections 110 and 111) Nature of Work Section 110 Number of prosecutions for failure to supply lists Section 111 M/c Line No. Number of Outworkers in August list required by Section 110(1)(c) Number of cases of default in sending lists to the Council Number of instances of work in unwholesome premises Notices served Prosecutions M/c Line No. Wearing Apparel— Making, etc. 13 73 — — — — — 13 Cleaning and Washing — — — — — — — — Fur Pulling 22 1 — — — — — 22 Artificial Flowers 28 2 — — — — — 28 Making of boxes or other receptacles or parts thereof made wholly or partially of paper 34 1 — — — — — 34 Carding, etc., of Buttons, etc. 38 22 — — — — — 38 Stuffed Toys 39 1 — — — — — 39 Lampshades 44 1 — — — — — 44 Total 70 101 — — — — — 70 PREVALENCE AND CONTROL OF INFECTIOUS DISEASES From the table of infectious diseases set out on page 43, it will be seen that 1,216 cases of infectious disease were notified during the year, as against 349 in 1956. The Infectious Sickness Rate for the district was therefore 16.92 as compared with 4.87 during the previous year. As I have mentioned on previous occasions, the Infectious Sickness Rate for any district has lost most of its significance. This rate is almost entirely governed—at least during any normal year— by the fact of the period under review being or not being a year during which measles was prevalent. It need scarcely be said that 1957 was, in fact, a "measles" year, 973 cases being reported, as against 43 during 1956. Apart from the fact that scarlet fever notifications rose from 19 in 1956 to 69 in 1957, the year's totals for individual infectious diseases require no elaboration. I do not think I can do better here than to quote the remarks which I included in my report to the meeting of the Public Health Committee held on the 25th February, 1958, These remarks apply to the infectious diseases picture as it applied to 1957: "It must be frankly admitted that, so far as measles notifications are concerned, we merely receive these notifications and do little more, unless we are specifically asked to do so by a general practitioner or by a parent. And this, it may be observed, is an extremely rare occurrence. "In the case of scarlet fever notifications, we do, of course, control the contacts of food handlers; while we still carry out disinfection when and where this is requested or required. But here again, it must be appreciated that what we do now is more or less infinitesimal compared with what we did not so very many years ago. Indeed, in my submission, having regard to all the circumstances, the only justification for continuing the notification of the disease which we know as 'scarlet fever' is the fact that, at any time, the more severe type may arrive back in this country, and will then require rigorous super' vision. The notification of 'scarlet fever' seems even more illogical when it is remembered that streptococcal infection of the throat without a rash is not notifiable but is generally assumed to be more infectious. It must also be borne in mind that many cases of the present mild type of scarlet fever are never notified at all. Indeed, in quite a number of instances, it would seem that the existence of the disease is never even suspected. 34 "So far as the remainder of the table of infectious diseases notified during the year is concerned, it is pleasing to note that the number of cases of pertussis (whooping cough) fell from 150 in 1956 to 73 in 1957, an indication, we hope, of the extensive immunisation programme being carried out in South' gate. Cases of dysentery fell from 39 to 13, but here the classification of 'dysentery' as set out on notification forms is so wide as to have limited practical significance. Cases of poliomyelitis rose very slightly from 7 to 9, a satisfactory outcome in view of the fact that polio was particularly prevalent throughout the country in 1957. "Whenever I study infectious diseases tables, I am more than ever convinced that our whole system of notification should be completely overhauled. At the moment we receive notifications of diseases such as measles, where we act virtually as a post office only; erysipelas which has little or no clinical import these days; puerperal pyrexia which may very well be due merely to constipation or a slight cold during the puerperium; malaria whose significance entirely escapes me ; and several other diseases which, although admittedly infectious, have extremely little communal or epidemiological significance. One must admit that the collection of information is always valuable. But when the collection of this inform' ation means that other work must either be neglected or pushed aside, when the cost involved might very well be devoted to other, more important projects, it would seem that the time has come to act. And there is yet another aspect of the problem to consider. The diseases which I have just mentioned are no longer killing agents, with the possible exception of pertussis (whooping cough) in very young children and paralytic poliomyelitis. Even here, the death rate is not at all high. Yet the death rate for such diseases as coronary thrombosis and lung cancer is steadily rising among important age groups in the population, while the aggregation of diseases commonly grouped under the term 'rheumatism' continues to take an extremely heavy toll, not perhaps of life, but of well-being and the ability to carry on a useful even a bearable existence. But in none of these instances is notifica' tion required. This would surely seem a fruitful field in which the modern epidemiologist might play a truly significant part." Diphtheria. For the tenth year in succession, no case of diphtheria was notified in the Borough. The last death took place approximately fifteen years ago. 35 The remarks set out in my Annual Report for 1956 relating to immunisation apply with equal force today. We have now implemented the suggestion which I set out in my Report for 1956, replacing immunisation against diphtheria and pertussis (whooping cough) combined by immunisation against diphtheria and vaccination against pertussis (whooping cough) separately. It must be admitted that our new system calls for more visits to clinics or to private doctors by mothers who wish their infants protected against diphtheria and pertussis (whooping cough) as well as being vaccinated against smallpox. Although we are keeping very careful records, it is not yet possible to state the precise impact which the change-over from combined inoculations to separate inoculations has had. Our own belief, however, is that mothers are accepting the advice given at our clinics, to the effect that a few additional visits are much more than offset by the very full measure of protection afforded their children. In this connection, the Council might be interested to know that our records show that 86% of Southgate children who attained the age of 2 years by the end of 1955 had been immunised against diphtheria. By the end of 1957, the latest figures available, this percentage had risen to the almost unprecedented level of 91. It is indeed hard to believe that this percentage will ever be improved, although we must obviously do our utmost to see that the level is maintained. It is to be hoped that, when vaccination against poliomyelitis assumes the proportions which immunisation against diphtheria has now reached, it will be safe to resume protection against diphtheria and pertussis (whooping cough) by the combined method. Indeed, one might even hope that a triple or even a quadruple antigen will eventually be available, affording protection against diphtheria, pertusis (whooping cough) poliomyelitis and possibly tetanus, in a single series of inoculations. A very careful time-table was drawn up in 1957 to allow us to offer immunisation and vaccination to mothers at properly spaced intervals. This time-table has been working very well : Month of age 1st No injections 2nd Pertussis vaccine—first dose 3rd „ ,, —second dose 4th No injection 5th Smallpox vaccination 6th 7th No injections 8th 36 Month of age 9th Formol diphtheria toxoid (F.T.)—first dose 10th „ „ „ „ —second dose 11th No injections 12th Pertussis vaccine—third dose. 5th year — Formol diphtheria toxoid (F.T.) first reinforcing dose. 10th year— Formol diphtheria toxoid (F.T.) second reinforcing dose. Scarlet fever. 69 cases of scarlet fever were notified during the year, as against 19 cases in 1956 and 30 cases in 1955. It must again be stressed that the character of scarlet fever has altered materially, so much so that the disease is now mild in almost every instance, no complications or sequelae having been reported. We must always bear in mind, however, the possibility of the more serious type of scarlet fever returning. To be perfectly frank, this is the sole reason which I can see for scarlet fever continuing to figure in the list of notifiable infectious diseases. In view of the extremely mild character of the cases of this disease now being met, it is no longer considered necessary to exclude contacts of scarlet fever from school. Here again, of course, this procedure would have to be amended if a different type of scarlet fever made its appearance. We no longer consider it necessary to exclude home contacts of scarlet fever from school. This is in keeping with modern practice which is based on the known fact that the exclusion of home contacts of most infectious diseases from school makes little or no difference to the infectious sickness rate for the district. Thus, virtually the only common infectious disease for which there is still an exclusion period is poliomyelitis. One must, of course, continue to exclude contacts of such dangerous contagious diseases as smallpox, where the role of the intimate contact is rather different. We also continue to exclude known 'carriers' of diseaseproducing germs, after this fact has been definitely established. Acute Anterior Poliomyelitis. 9 cases of paralytic poliomyelitis were notified during the year, as against 5 paralytic and 2 non-paralytic cases during 1956. There were no cases of non-paralytic poliomyelitis during 1957. In all but one of the nine cases, the disease occurred in chidren ranging from 2 to 14 years of age. Fortunately in all these cases the illness was not too severe, although three of the children had eventually to be 37 transferred to the orthopaedic unit at Highlands Hospital for treatment to aid recovery. The remaining one of the nine cases occurred in a woman of 28 years of age. This patient had a particularly severe type of poliomyelitis from which unfortunately she died on admission to hospital. Four of the nine cases reported during the year occurred in July, 1957. Three of these children attended Arnos School and one attended Bowes Road School. At the same time, three cases were reported from the adjoining part of the Borough of Wood Green, thus involving a total of seven children developing poliomyelitis within a period of a few weeks in the New Southgate portion of the Borough and the adjoining portion of Wood Green. At the time it looked as though we might be at the outset of an outbreak or even an epidemic. The strictest measures of hygiene were therefore undertaken in all the schools concerned, while a most careful watch was kept on all known contacts. Fortunately no more cases of poliomyelitis were reported from this part of the Borough and only one from the corresponding part of Wood Green after August. The most careful enquiries did not bring to light any connection between the individual cases reported. The Council will be aware of the programme of vaccination against polio which continued throughout 1957. The Council will also be aware of the interruptions which have taken place in our schedule of inoculations owing to the hold-up in vaccine which occurred early in 1958. Although this is a matter which more properly belongs to the Annual Report for 1958, it can be said that vaccine is now becoming available in increasing quantities. During 1957, approximately 1,948 Southgate children have been given two injections of British polio vaccine, as the American vaccine was not then being used officially in this country. A further 472 children have received one injection and should have received their second during the early months of 1958. Much of the American vaccine, although tested and licensed in the country of origin, has not been re-tested again in this country. It will be appreciated that the figures set out above must, of course, be approximate, as we have very limited information relating to children who attend boarding schools outside Southgate and who received their inoculations in other parts of the country. It is also much too soon to estimate the effect which the programme of vaccination will have on the incidence of polio; or, indeed, whether a third inoculation will still be required. This is a matter which must rest with the future, although we are all sanguine of the benefits which we sincerely hope will accrue. 38 Measles. As noted elsewhere, 973 cases of measles were notified during the year, as against 43 cases in 1956. These facts indicate that 1957 was a "measles" year. Once again, the disease itself was mild in the extreme. Pertussis. 73 cases of pertussis (whooping cough) were notified during the year, as against 150 cases in 1956. As noted elsewhere, we are continuing our policy of offering immunisation against pertussis (whooping cough). Again, as noted elsewhere, these injections are being given quite apart from immunisation against diphtheria. As pertussis (whooping cough) is most serious during the first six months of life, our programme is aimed at protecting children as soon as possible after birth, having due regard to the need for vaccination against smallpox during the same period. Smallpox. No case of smallpox occurred during 1957. 1957, however, did see the occurrence of 3 cases of smallpox in the neighbouring Borough of Tottenham. This produced 20 Southgate contacts, none of them, fortunately, close contacts of the Tottenham cases. It was, however, necessary to keep these contacts under the closest surveillance and to ensure that, should a case arise, the necessary steps to prevent spread of the disease could be taken without delay. It was also necessary to request the services of the smallpox consultant for the Area on two occasions. In both instances, the cases which the Consultant was asked to see proved to be rather unusual types of chicken-pox. I would take the opportunity here of expressing my sincere thanks to the Public Health Inspectors, who did a great deal of useful work during this period in tracing contacts and keeping a watch on the houses from which contacts had been reported. The occurrence of definite contacts of a disease such as smallpox requires urgent and immediate attention. Nothing can be left to chance; no gaps must be left in our defences. Fortunately, as I have already stated—and this was very largely due to the excellent way in which the limited outbreak in Tottenham was handled— the smallpox interlude passed without incident. During this period, we pursuaded eleven persons, either definite contacts or members of households in which contacts had been reported, to accept vaccination. 39 The incidence of the Tottenham smallpox cases shows all too clearly that the risk of smallpox is still with us. When one remembers that the state of vaccination in Great Britain as a whole is anything but satisfactory, the danger will be more clearly appreciated. It is not so many years ago that the percentage of infants being vaccinated in Southgate was less than 10. By the end of 1955, records prepared in the Area Health Office show that 68% of Southgate children reaching the age of two years were protected against smallpox by vaccination. By the end of 1957, this figure had risen to the very satisfactory level of 80%. This, of course, is almost entirely due to the constant advice given to parents attending our clinics, by our Area Assistant Medical Officers and Health Visitors, who by their efforts and by their persuasion have encouraged mothers to take the fullest advantage of the vaccination facilities now provided at all our clinics. Food Poisoning, including Sonne Dysentery. One might say that the figures relating to the incidence of food poisoning (including Sonne dysentery) reported in the Borough over the past few years indicate that this type of infection can now be regarded as virtually endemic among the resident population. Having regard to the increasing number of food poisoning outbreaks which are being reported each year throughout the country, even when the much more accurate system of recording is taken into account, it must be realised that the commoner organisms which cause food poisoning, especially the salmonella group, seem to have established themselves throughout the population, especially the urban population of these islands. Fortunately, we can at least say that the simpler, non-fatal form of food poisoning has now taken the place of such diseases of the gastro-intestinal tract as cholera and the enteric fever group. In other words, killing diseases which formerly swept the population in vast, overwhelming waves have now been replaced by comparatively mild attacks of food poisoning caused by germs apparently introduced within comparatively recent years into this country. This, of course, is satisfactory when the picture less than 100 years ago in regard to such diseases as cholera and typhoid fever is placed against the food poisoning and dysentery situation as we know it today. But this is only part of the story. So long as outbreaks or even individual cases of food poisoning are occurring, so long must it be recognised that these attacks are neither haphazard nor the result of some unfortunate coincidence. Food poisoning is the logical result of faulty methods in the preparation, handling, selling and cooking of food. The fact that the number of outbreaks of food poisoning, however small these outbreaks may be, reported each year from England and Wales, is very much 40 higher than was apparently the case before the war, continues to give rise to concern. As I have just said, it means that conditions are being allowed to exist which act to the prejudice of the public, and which place the health and sometimes even the life of our people in danger. It would be dangerous to argue that food poisoning today is mild, that drastic action is not required, that an illness lasting a few days need cause no one much concern. That is surely a policy of despair. This country, which has a history second to none in the realm of promoting health, should not rest content until our reputation in the world of food hygiene has been completely re-established. In Southgate, with our limited number of Public Health Inspectors, all of whom have many other duties to perform, we do our best by periodic visits, selected inspections, advice and guidance, and, where necessary, legal action, to improve the standard of food hygiene in food premises operating within the Borough. This is a never-ending task, as it must be admitted that we are still far from approaching that ideal which all of us so fervently desire. The staff of the Public Health Department also takes as many opportunities as possible to address local organisations on the matter of clean food, what part the housewife can play in this great effort, what attitude the ordinary ratepayer should adopt. It is impossible to say what impact these talks, very often accompanied by one or more sound films, have. But it is hoped that a beneficial cumulative effect will eventually be felt. I am happy to be able to report that, during 1957, I was invited by the Secretary of the Northern Hospital Group to visit the kitchens at Highlands Hospital, Grovelands Hospital and the Wood Green and Southgate Hospital. These visits are of the greatest importance, establishing that cordial relationship which is so essential between the Public Health services and local hospitals. It also gives the Medical Officer of Health the opportunity of seeing, at first hand, conditions which prevail in hospital kitchens, and, when invited to do so, as I was, to make suggestions. As I write this report, I have just agreed to a suggestion made by the Central Public Health Laboratory that Southgate should co-operate in a scheme for the investigation of all cases of salmonella food poisoning occurring within the Borough. This investigation is being carried out, not only in Southgate but in many other districts, in an effort to establish the reason why salmonella food poisoning has become so much more prevalent over the past few years. It is certainly the type of investigation in which I know the Borough Council will be only too happy to play a part. Tuberculosis. Forty-two cases of tuberculosis (38 pulmonary and four nonpulmonary) were notified during the year, as against 49 in 1956. 41 Distribution of cases notified among the various wards was as follows: North-east North-west Middle South 9 7 8 18 A broad classification of the cases notified during the past five years in relation to employment was:— 1953 1954 1955 1956 1957 Clerical 17 7 12 5 1 Housewives 12 6 5 3 5 Children 3 1 4 1 2 Manual Labour 8 6 — 8 5 Factory Workers 5 2 1 5 5 Professional Classes 2 1 3 6 8 Armed Forces — — 1 1 1 Domestic Service — 3 — — — Food Trades — — 2 — — Students 1 3 2 2 1 Shop Assistants 1 — 3 4 2 Nurses 2 1 2 1 1 Non-manual Trades other than Food 7 9 7 4 1 Teachers — — — 2 — Unclassified 7 3 5 7 10 65 42 47 49 42 It must again be stressed that the totals which make up the tables set out are not sufficiently large to warrant any significant conclusions being drawn. The figures merely allow us to keep a careful watch on trends so that we can take or suggest any action which might be considered necessary. The scheme for the B.C.G. vaccination of children in the 13 age group, referred to in my Annual Report for 1956, is making excellent progress. This work is, of course, carried out by Middlesex County Council staff as part of the personal health and school health services provided by the local health authority in Southgate. No difficulties have been encountered in administering or in carrying out the B.C.G. scheme, which undoubtedly marks a very definite step in the protection of our susceptible adolescents against tuberculosis. Mass Radiography Unit 5B did not visit Southgate during 1957. Arrangements have, however, been made for the Unit to visit the Borough during the early Autumn of 1958. 42 NOTIFICATION OF INFECTIOUS DISEASES, 1957 Disease Jan.— March April— June July— Sept. Oct.— Dec. Totals Scarlet Fever 26 28 7 8 69 Measles 476 468 29 — 973 Pertussis 42 23 6 2 73 Pneumonia 4 3 4 5 16 Erysipelas 1 4 — 2 7 Food Poisoning 2 1 4 1 8 Dysentery 9 3 1 — 13 Puerperal Pyrexia 1 2 — — 3 Meningitis 1 — — 1 2 Encephalitis — 1 — — 1 Poliomyelitis: Paralytic 1 — 8 — 9 Non-paralytic — — — — — Tuberculosis: Pulmonary 7 9 17 5 38 Non-Pulmonary 1 2 1 — 4 Total 571 544 77 24 1,216 REGISTER OF TUBERCULOSIS CASES Pulmonary NonPulmonary Totals M. F. M. F. Cases on Register at 1.1.57 315 276 40 33 664 Cases notified for the first time in 1957 27 11 — 4 42 Cases Restored to Register 1 1 — — 2 Other Cases Added 13 12 — 1 26 Cases Removed from Register 87 77 13 18 195 Cases Remaining on Register at 31.12.57 269 223 27 20 539 TUBERCULOSIS—1957 *New Cases Deaths Pulmonary NonPulmonary Pulmonary NonPulmonary M. F. M. F. M. F. M. F. Under 1 year 1 — — — — — — — 1-5 years — 1 — 1 — — — — 5-10 years — — — 1 — — — — 10-15 years — — — — — — — — 15-20 years 2 2 — — — — — — 20-25 years 11 2 — — — — — — 25-35 years 10 12 — 2 1 — — — 35-45 years 4 1 — — — 1 — — 45-55 years 5 5 — — 1 1 — — 55-65 years 4 1 — 1 2 — — — Over 65 years 5 — — — 3 — — Unknown — — — — — — — — Total 42 24 — 5 7 2 — — * These figures Include all cases previously notified and noted by the Tuberculosis Officer and others as having removed into the district. 43 APPENDIX 1 MISCELLANEOUS (a) Letters to Doctors. Letters on the following subjects were circulated to Southgate practitioners during 1957, some being sent under my signature as Medical Officer of Health, others either as Area Medical Officer, District School Medical Officer or jointly. As all the matters covered in these letters have a direct bearing on the health of at least a section of the community and as it is extremely difficult to divide one's responsibility in such a vital matter as that of health, I have included all the topics covered : Antitoxins and Antigens. Infectious Disease Regulations. Collection of Laboratory Specimens—Easter Holiday. Addresses of Practitioners. Collection of Laboratory Specimens—Whitsun Holiday. Outbreaks of Influenza. Influenza. Smallpox. Poliomyelitis and Smallpox. Poliomyelitis. Collection of Laboratory Specimens—August Holiday. Poliomyelitis. Asian flu. Collection of Laboratory Specimens—Christmas Holiday. The remarks set out in my Annual Report for 1956 relating to the value of close co-operation with general practitioners holds as firmly today as it did then. I am still very happy to think that the relationship of the Public Health Department with the family doctor is close and cordial and that this cordial bond is playing a truly significant part in maintaining the health of the district. (b) Medical Examinations. During 1957, forty-four medical examinations were carried out in respect of entrants to the Council's services. In addition, two medical reports were issued to employees absent from duty for more than a short period through sickness. 44