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In "Ethical Responsibility in Medicine" by Edmunds and Scorer,
published by E. & S. Livingstone Ltd., 1967.
Chapter on "Responsibility in Preventive Medicine"
by W.G. Swann, M.D., M.O.H., Port & City of London.
The road to achievement in social and preventive medicine is not hard to see; to build it is
quite another matter. Not only are there entrenched vested interests bestriding the primitive
tracks, there is also the natural unwillingness of human nature to have to take the extra trouble
needed. In addition, at some points, political, religious, social and individual freedom may seem
to be, or actually is, at stake. Some authority and ultimately some person must take
responsibility for the planning and carrying out of such measures as seem desirable. Therefore,
before discussing the basic problems it will be necessary to outline some of the varied and
complicated tasks which concern environmental and preventive medicine in this country, and to
indicate who is primarily responsible for the applications.
The fundamental aim of a reformer in public health is to alter the 'environment' of the social
group whom he seeks to serve. This must be done in such a way as to rid that environment of
what is injurious to physical or mental health or, alternatively, to add what will work effectively
for health. The varieties and complexities which these alterations may take is best appreciated
by summarising the work of a Public Health Department.
THE SPHERE OF PUBLIC HEALTH
Local Government through its many services works to protect people against all that might
cause disease. In the environmental division of the Health Department the epidemiological
section deals with the notification of disease, preventive immunisation and vaccination, control
by quarantine of disease at ports, food hygiene in all its aspects, health aspects of housing
and factories, smoke abatement, and such like. This work was traditionally developed in
connection with the control of infectious disease, but modern epidemiology is equally concerned
with non-communicable diseases in an endeavour to unmask the causative factors in the
aetiology of diseases such as bronchitis, cancer and coronary thrombosis. The environmental
work of the Public Health Medical Officer also includes the abatement of 'statutory nuisances',
which means a concern for slum clearance and other housing problems, offensive trades, rodent
and insect pest control.
In addition, the Medical Officer of Health has powers and duties (under the Food and Drugs
Act and subsidiary regulations) to ensure that food is of the nature, substance and quality
demanded by the purchaser and that it is free from contamination and fit for human consumption.
This has wide ramifications in the field of food production and technology, and concerns such
commodities as meat, home slaughtered and imported; production, transportation, pasteurization
and distribution of milk supplies; inspection of catering establishments and, in some instances,
their registration; and many other aspects of food control dealing with labelling, preservatives
and other permitted additives.
The history of public health discloses many instances of the way in which disease has
been controlled by altering the environment. The introduction of a pure water supply and of
various water-borne sewage disposal systems led to the eradication of epidemics of cholera
and typhoid in this country, even before the bacterial causation of these diseases was known.
In traditional Public Health the practitioner was concerned primarily with material factors
in the physical environment which should be eliminated, that is those which were injurious to
health. The history of the conquest of infectious diseases in this country illustrates how harmful
agents, which were a menace to the health of the public, were at first controlled and later
largely conquered. The various statutory provisions for the control of the spread of infectious
diseases encroached on the liberty of individuals because the welfare of the community as a
whole was the overriding consideration. Doctors by law were and are required to notify certain
infectious diseases—a responsibility which a few forget, even in this enlightened age! The
Medical Officer of Health may become aware of the outbreak of communicable diseases and he
then has the responsibility to determine the source of the infection bv epidemiological
investigations. He seeks to discover the mode of transmission of the disease ana takes
adequate measures to prevent its spread in the community. At this point the history of
preventive medicine shows how necessary it has been to give powers to local authorities to
limit the freedom of individuals. This has been done by restricting the movements in public
places of persons suffering from notifiable infectious disease and, if necessary, by compulsorily
removing them to, and retaining them in, hospital by a magistrate's order, for their own welfare
or to protect the health of the public. This compulsion was extended into the realm of preventive
treatment as in the case of vaccination against smallpox. However, where the directive
involves the freedom of the individual and his right to refuse medical treatment, safeguards
were introduced to allow for genuine conscientious scruples as well as exemptions on medical
certification of conditions considered as contra-indications to vaccination.
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