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but the question bere is not deadly so pressing as the county bozords, which are the pat es recable disease.
In the excher part oss aridie we oorsidered a scese for simpefying cartral pr-5tic bealth a nnistration to transjaring the wided the soiectific and statistical work of the difierent deartments to a Ministry of Heala laring, boneve, criana adozisistrative fractices stto be performed by the Local Government Board and other ca. We are now in a position to see hos central al ministratica could be still further simplified, by transferring some of the remaining functions to the unified Local Health Council which it is proposed to create. It would der and too much space to consider in detail the distribution of these functions between local and central authorities, but broadly speaking the principle should be that what is uniform over the whole country should be administered by a central depertirent, and what varies from district to district by a local authority. Thus while we take medical and sanatorium benefit away from the Insurance Commission, we find no reason against leaving that body as the ultimate authority over Approved Societies in regard to regulations governing sickness benefit, since there is but one criterion for the payment of this benefit in the Shetland Islands or Shoreditch, víz. incapacity to work. For similar reasons it is unnecessary to interfere in any way with the work of the Central Midwives Board, which examines and registers midwives, and lays down regulations for their conduct of cases; or the General Medical Council, which exercises disciplinary control over the medical profession and keeps the medical register; or the duties of the Home Office in prescribing sanitary conditions in factories and regulations for dangerous trades. On the other hand, the medical functions of the Board of Education, and of the Poor Law branch of the Local Government Board, would be transferred to local authorities.
The determination of what infectious diseases should be notified, and the prescribing of regulations to control any epidemic, must still be centralised, for it is clear that with any threatened epidemic it might be necessary to enforce special precautions simultaneously over a wide area. These duties might with advantage be assigned to the Ministry of Health. Regulations intended to ensure the purity of milk and to prevent adulteration of food and the sale of unsound
meat must be made by a central authority, and our laws for these purposes require both strengthening and simplifying. At present adulteration of food is widespread, and the penalties inflicted upon dishonest vendors are often far too light. Failure to repress undesirable practices results partly from the complexity of the law, and partly from the existence of different standards in different localities, and variations in magisterial opinion as to what constitutes unfitness of food for human consumption. Again and again the Local Government Board has called attention to the fact that an emaciated beast, which would not be allowed to be sold for food in one area, is driven into a contiguous district, where vigilance is less strict, and there disposed of. Control of the sale and advertisement of patent and proprietary medicines was advocated by the Select Committee on Patent Medicines, which issued its report in 1914. Such control if established should be exercised by the Ministry of Health.
One effect of the above proposals should be noticed. They would increase the responsibility of each locality for the cost of its own sickness, a principle to be encouraged, since it tends to stimulate local activity in the prevention of disease. At the present time healthy localities are paying part of the cost of sickness in unhealthy districts both through taxation and through contributions under the Insurance Act; and since death-rates are higher and practically all forms of disease are more prevalent in urban areas, particularly industrial towns, than in rural districts, the ultimate effect of grants from imperial funds is to impose a tax upon rural industries for the benefit of towns, and this though agriculture is the worst paid form of labour, and rural industries those which of all others we ought most to encourage. A good instance is afforded by the recent arrangements for the treatment of venereal disease, 75 per cent. of the cost of which is to be borne by the Treasury. These diseases, as we have seen, are most prevalent in seaports and industrial towns; nevertheless rural districts, which are almost free from them, are compelled through taxation to pay part of the cost of their treatment. Treasury grants for the erection and part maintenance of sanatoria, and the special parliamentary grant of a millions for medical benefit, afford other examples.
Again, Approved Societies find that sickness rates are very
considerably lower in rural than in urban districts. Hence the flat rate of contribution invalidates the whole principle of insurance, which demands equality of payment for reasonable equality of risk. Rural dwellers pay an unfair share both directly through their own contributions and indirectly through the Government additions to the contributions which are derived from taxation. Broadly speaking, it may be said that in England the rural south is paying for excessive sickness in the industrial north. The fact that most large Societies consist of both rural and urban members does not affect the argument, for it is the gain on the rural members which compensates for the loss on town members and helps to keep the Society solvent. By taking medical and sanatorium benefit out of the Insurance Act, and making each locality pay the cost of its medical service, we should do much to correct this unfairness, and we should give ratepayers a direct interest in securing healthy conditions in their locality in order to reduce the cost of the medical service.
The objection most frequently urged against increasing the powers of local authorities is that these bodies are apt to be neglectful of public welfare, and unduly mindful of vested interests. As a general charge this cannot be substantiated. Most of the larger local authorities are now fully alive to their responsibilities, and in many county boroughs are displaying marked zeal and energy in attacking the causes of disease and improving the conditions of health. The necessity they are under of having to obtain approval from a central authority before they can initiate various schemes of reform often hinders rather than assists their progress. It is true that some local authorities—more frequently the smaller onesare supine in public health matters, but we most emphatically do not avoid this evil by centralising the services, for a central authority may display neglect and incompetence as great as that of any rural district council, and its influence is far more widespread. If the provision of medical treatment under the Insurance Act had been assigned to local authorities, we should have had good services in some areas and bad in others. As it is, with the administration subject to central control, we have an inadequate service all over the country.
To sum up then: we picture in the future a Ministry of Health-preferably to be formed by enlargement of the Registrar-General's office-constituting a great public health
statistical department, continually investigating the causes and distribution of disease, and subjecting to expert criticism all public health measures before they are introduced in Parliament. Centrally administered also-preferably by the Ministry of Health, but possibly by the Local Government Board and other departments—we have Acts for the prevention of food adulteration, for notification of infectious diseases, regulation of sanitary conditions in factories, and other matters which should be uniform over the whole country. Locally, we have in each county borough a single health authority responsible for maintaining sanitary conditions within its area, and charged with the duty of providing for all classes of the communitya medical service, including hospitals, sanatoria, treatment by general practitioners, lying-in homes, midwives, nurses, pathological laboratories, and other adjuncts necessary to secure treatment consonant with the present high level of medical science.
It has not been possible to give more than an outline of the above proposals, and the writer is well aware that they are open to adverse criticism in various directions, but no scheme can be suggested which is free from difficulties. The proposals here made seem to the writer those most calculated to reduce bureaucratic control to the minimum, and to give the people themselves a direct interest in improving local conditions. Sweeping reform of the public health services cannot be long delayed, for the paramount importance of securing a healthy population is now realised by all. But whatever scheme be adopted, let us beware of anticipating too much from mere administrative changes. The best medical service possible is but a palliative, and permanent improvement in the nation's health will only be achieved by destroying the great environmental causes of disease. We do not need a Royal Commission or Ministry of Health to tell us what these are. By far the most malign influence is overcrowding and bad housing in London and the large industrial towns. By all means let us have an improved system of public health services, but do not let us forget that no number of volumes of statistics or of hospitals and health visitors will compensate for lack of sunshine and fresh air in slums. A healthy people can only be bred in a healthy environment.
WILLIAM A. BREND.
THE WAR AND THE NAVAL OFFENSIVE
La Guerre Navale et L'Offensive. By CONTRE-AMIRAL DEGOUY.
Paris : Librairie Chapelot. 1917.
AFTER more than three years of war at sea we are in
1 a position to estimate the amount of the success, or the depth of the failure, which has been the reward, or the punishment, of the use we have made of our naval resources. For a reason to be shortly stated in its proper place I do not say only 'the use we have made of our Fleet.' Yet the fleet goes in the forefront of the war. We see it plainly before us. We know that without it there can be no safety, and will be no victory. The question whether we have employed it to the best purpose stands as a preliminary in any attempt to make a survey of the war at sea so far. It is notorious from newspaper comment, parliamentary debate, and the freedom of private discussion that there are many who answer the question in the negative. Mr. Kennedy Jones spoke for no inconsiderable body of opinion when he asked a certain question and made a certain statement in the House of Commons during the debate on the adjournment for the Autumn Recess on August 16th last.
'Assuming Germany's determination to continue, do you believe, in the face of the submarine menace, that the passive pressure your Fleet now exerts is the best help it can give to achieve victory in a reasonable time? Is not some change in your present scheme of naval operations desirable ? . . . Let me make my first question perfectly clear. At present the submarine has broken down our traditional naval strategy. The Fleet existed, as I conceive it, not merely to win battles. The ultimate purpose of the Fleet was to make blockade possible for us and impossible for the enemy. All that has gone. To-day we are in the position of a Power with overwhelming naval strength, unable to obtain that command of the sea which our preponderance ought to give us.'
Though there is no necessity to show that Mr. Kennedy Jones does not speak for himself alone, his statement of the case may be supported by a reference to a noteworthy article contributed to the 'Revue des Deux Mondes' of July 15th by