Great Britain

GREAT BRITAIN (sanitary condition and organization of public health). Great Britain (excluding its colonies, i.e., England and Wales) covers an area of 151,052 sq. km, with a population in 1926 estimated at 39,067,000 inhabitants (this does not include the population of Scotland—4,897,000, and Ireland—4,229,000). Its sanitary structure, the successes achieved in protecting the health of the population, and the problems that are posed in this country as the next steps in the further improvement of health—all this is of great interest. Of all European countries, Great Britain can rightfully be considered the country where health issues first became an object of state influence and entered the sphere of state legislation; the country where those branches of public health in which the task of state and public prevention of diseases, i.e., sanitary measures, is placed in the foreground, are most broadly established. Limited by the conditions of a specific economic (bourgeois) system, these measures nevertheless, due to their planned and systematic application on the basis of broad sanitary legislation, have yielded major results, and Great Britain, by its sanitary indicators, currently stands in one of the first places among all countries of the world. Demographic data. The total population growth of Great Britain over the last 50 years in absolute figures can be seen from the following table: Table 1. Population of Great Britain. Years: 1871-80, Population: 24,225,271; 1881-90, Population: 27,384,934; 1891-900, Population: 30,643,316; 1901-10, Population: 34,180,052; 1911-20, Population: 35,682,500; 1911-15, Population: 36,257,600; 1916-20, Population: 35,107,400; 1921-25, Population: 38,416,740; 1926, Population: 38,890,000; 1927, Population: 39,067,000. The natural movement of the population of Great Britain during the same period shows a picture of a gradual, steady decline in general mortality and, at the same time, a gradual decline in the birth rate—a phenomenon, as is known, common to all European countries in the second half of the 19th and early 20th centuries. Below is the corresponding table in absolute and relative figures (see Table 2). Birth rate figures are falling both in absolute terms, and the birth rate indicators in 1926-27 (17.8 and 16.7) are the lowest for all years after the imperialist war. Table 2. Population movement of Great Britain. Years: 1871-80, Births (abs): 858,878, Birth rate (per 1,000): 35.4, Death rate (per 1,000): 21.4; 1881-90, Births (abs): 889,024, Birth rate (per 1,000): 32.4, Death rate (per 1,000): 19.1; 1891-900, Births (abs): 915,515, Birth rate (per 1,000): 29.9, Death rate (per 1,000): 18.2; 1901-10, Birth rate (per 1,000): 27.2, Death rate (per 1,000): 15.4; 1911-20, Birth rate (per 1,000): 21.8, Death rate (per 1,000): 14.3; 1921-25, Birth rate (per 1,000): 19.9, Death rate (per 1,000): 12.2; 1925, Birth rate (per 1,000): 18.3, Death rate (per 1,000): 12.2; 1926, Birth rate (per 1,000): 17.8, Death rate (per 1,000): 11.6; 1927, Birth rate (per 1,000): 16.7, Death rate (per 1,000): 12.3. The general mortality figures (11.6) in 1926 are the lowest ever recorded in Great Britain. Of these deaths, 38% occur at an age below 50 years. An analysis of mortality figures indicates a sharp decline in infant mortality. As the report of the Ministry of Public Health of Great Britain for 1926 points out, "the decrease in the birth rate is compensated by a significant number of children whose lives have been saved." Here, too, data for the same period (1871-1926) speak of a steady decline in infant mortality. Table 3. Mortality of infants under 1 year (per 1,000 born). 1871-80: 149.0; 1881-90: 142.0; 1891-900: 153.0; 1901-10: 128.0; 1911-20: 100.0; 1921-25: 76.0; 1925: 75.0; 1926: 70.0; 1927: 63.0. If we compare the data of 1926 with the corresponding infant mortality indicators for at least 1901-10, this reduction represents the saving of the lives of 40,000 children. Among the causes of mortality in Great Britain, the following five main groups of diseases are in the foreground: Table 4. Main causes of population mortality. 1. Diseases of the heart and vascular system (53,220 deaths); 2. Diseases of the respiratory organs (pneumonia, bronchitis) (46,569 deaths); 3. Cancer and other malignant neoplasms (37,525 deaths); 4. Diseases of the nervous system; 5. Tuberculosis of all forms. In total, these five groups of diseases account for 64% of all causes of death in Great Britain. "Against these diseases, the main efforts in the fight for public health must be directed," says the same ministry report. Among infectious diseases in this list of causes of death, influenza is in first place, followed by childhood infections; but the significance of acute infections in the total mortality figures is very small. In recent years, an interesting dynamic has been observed in the ratio of causes of death, with childhood diseases (of infants), acute infections, and tuberculosis—the decline of which has been marked since the second decade of the 20th century—playing an ever-smaller role, and conversely, increasing mortality figures from diseases of the vascular system and heart, and then malignant tumors (cancer), playing an ever-greater role. It is sufficient to compare the mortality figures from tuberculosis and cancer in 1926. In absolute figures, mortality from all forms of tuberculosis in 1926 was 37,525 (including pulmonary tuberculosis 30,108); at the same time, mortality from cancer was 53,220. Calculating per 1,000,000 population, we have mortality from tuberculosis of 961 and from cancer of 1,362. The growth of cancer diseases in Great Britain can be seen from the following table: Table 5. Mortality from cancer and other malignant tumors (per 1,000,000 inhabitants). 1850-55: 129; 1861-65: 371; 1871-75: 455; 1881-85: 563; 1891-95: 717; 1901-06: 885; 1911-15: 1,055; 1916-20: 1,200; 1921-25: 1,300. The fight against malignant neoplasms is therefore one of the pressing problems in Great Britain (as in the U.S.A.). Tuberculosis diseases, on the contrary, are now beginning to occupy a more subordinate place, which serves as obvious proof (among other reasons) of the successful activity of the state in the fight against this social evil. Below are the figures for morbidity and mortality from tuberculosis. Table 6. Morbidity and mortality from tuberculosis (abs. figures). [Table data omitted in source]. Furthermore, the figures for the incidence of venereal diseases deserve attention. In 1926, 22,550 new cases of syphilis were registered, and 35,052 of gonorrhea; the total number of venereal diseases was 81,506. Finally, the total number of cases of infectious diseases registered in 1926 in Great Britain was 300,892 cases (i.e., forms subject to mandatory registration). Here, diphtheria, scarlet fever, influenza, and tuberculosis are in the first place. The following table indicates the figures for diseases with the most dangerous acute infections: Table 7. Morbidity of acute infectious diseases in 1928 (abs. figures). Scarlet fever: 81,672; Diphtheria: 51,069; Smallpox: 10,141. It should be noted that smallpox, which was previously little noticeable, has taken on the character of an epidemic in recent years (since 1923) due to the absence of a law on mandatory vaccination in Great Britain. The diseases, however, are of a very benign nature: in 1926, out of 10,141 cases of smallpox, only 11 deaths were recorded. Table 8. Smallpox diseases (abs. figures). [Table data omitted in source]. The figures for typhoid fever and intestinal infections in general are extremely low, and parasitic typhus is almost completely absent. These indisputable successes in protecting the health of the people of Great Britain depend on a number of reasons, among which, along with the general high culture of the country, the high sanitary culture of the latter stands in one of the first places. In the not-so-distant past—in the first half of the 19th century—Great Britain was, like other countries, the scene of major cholera outbreaks. In 1837, an act on the registration of causes of death was issued, and a Central Statistical Bureau was created for the registration of births and deaths. In the 1840s, a special Royal Sanitary Commission was created, which studied the epidemics of past years and proposed a number of concrete projects for the organization of sanitary affairs. In 1848, a "General Board of Health" was created, and then local boards (Local Board of Health). A number of other laws of the same time introduced into the practice of English sanitary life a special concept—the so-called "nuisance." This term refers to all those harmful conditions in life and environment that can have a bad effect on health (poor housing, damaged pavements, unmaintained yards, poor-quality food, smoke, noise, etc.). Laws on nuisance give the right to any person who has suffered from any "nuisance" to prosecute the guilty party in court (lawsuit). The same rights are also granted to sanitary authorities. In 1871, instead of the General Board of Health, a special Local Government Board was created. The administration of all local affairs (public health, municipal affairs, finance, poor relief, etc.) was concentrated under the latter. This institution existed until 1919, when it was transformed into the Ministry of Public Health.

The main functions of the public health authorities, which were created in the middle of the last century, were sanitary, namely the fight against epidemics and the improvement of populated areas (communal sanitation), to which food hygiene was later added. Separate laws in these areas of sanitary affairs were consolidated in 1875 into the famous classic sanitary law (The Public Health Act, 1875), which even at the present time remains the fundamental law on public health in Great Britain. This law (its text occupies 157 printed pages; there is a textual Russian edition by the Rein Commission, 1914) precisely defined the composition and duties of local authorities in charge of health protection, established basic sanitary requirements for the improvement of cities (water supply, sewage, garbage collection, the layout of streets and buildings), for the fight against epidemics, for the supervision of food products, etc. At the same time, the law also established forms of liability for the violation of these sanitary rules. Subsequently, a number of additional laws were issued: in 1889-90, a new law on infectious diseases; in 1907, an amendment to the 1875 law; in 1890, the Housing Act; in 1909, the Town Planning Act, etc. Thus, already in the pre-war period, Great Britain had developed broad sanitary legislation, on the basis of which the entire business of sanitary improvement of the country was built. After the imperialist war, with the formation of the Ministry of Health, the matter of sanitary legislation received further development in the sense of expanding the sphere of its influence to other new branches of sanitary-preventive work. In 1919, the law on the fight against tuberculosis was issued, followed by the publication of laws on the fight against venereal diseases, on the protection of infancy (1918), and a number of new laws on housing (1919, 1924), town planning, and food matters (the Milk Acts of 1915 and 1926, etc.). Every new task in a new branch of sanitation and prevention in Great Britain is, therefore, based on a corresponding central law. The organization of public health in Great Britain currently consists of the following parts. At the center, there is the Ministry of Health, which includes, in addition to public health functions, a number of functions of a different, broader order: a) in the field of social security—social insurance, the fight against unemployment, pensions, etc., and b) in the field of communal affairs—water supply, sewage, improvement, roads, and the general financing of the local economy. Thus, in the hands of the Ministry of Health in Great Britain are powerful means and opportunities, both financial and legislative, for the guidance and organization of sanitary affairs in the country. The Ministry possesses an extensive staff with a large number of specialists (sanitary doctors, engineers, and architects). However, such functions as school-sanitary supervision (which is under the Ministry of Education), industrial-sanitary supervision (under the Home Office), and military sanitation (War Office) have not yet come under the jurisdiction of this Ministry. Locally, the authorities responsible for the organization of public health are the county and city councils. Attached to them are 'Public Health Committees'—special elected bodies of local self-government, sanitary bureaus (Health Department), and within the latter, sanitary doctors of various specialties (Medical Officers of Health). Attached to the sanitary doctors there is usually a staff of assistants—sanitary inspectors (non-doctors) with good technical training, and then an institute of health visitors. The latter work in the field of fighting tuberculosis, venereal diseases, child protection, etc. The functions of the sanitary bureaus usually include general sanitary supervision, veterinary supervision, the fight against epidemic and social diseases, and the protection of maternity and infancy. As institutions upon which the work relies, there are infectious disease hospitals, dispensaries, clinics, sanatoriums, etc. The total number of institutions for maternity and infancy in 1926 in Great Britain (excluding Scotland and Ireland) was 2,324 (an increase of 129 from 1925). Of these, 1,489 institutions are under the jurisdiction of local authorities and 835 are charitable. The total number of tuberculosis dispensaries was 442, the total number of sanitary doctors for tuberculosis was 367. The number of tuberculosis beds in sanatoriums and hospitals was 22,202 (of which 14,165 were in local authority facilities). The number of so-called venereological centers was 190, with 1,904,063 visits. Regarding food supervision, the total number of product samples taken was 120,617 (of which 7,044 were found to be adulterated—6.5%). The total number of houses inspected was 1,114,504; of these, defects were found in 279,407 cases. From 1919 to 1927, 104 projects and plans for the improvement of unimproved quarters were drawn up locally, of which 85 were completed with 11,227 houses. The capital laws on housing construction, which are currently being implemented, albeit with significant limitations, have provided a large increase in living space. The total number of houses built in recent years is determined by the following figures: 1923/24—86,210; 1924/25—136,889; 1925/26—173,426; and 1926/27—217,629. A characteristic feature of Great Britain in the matter of its public health is the insignificant participation of the state in medical care. All of Great Britain's widely spread public health system is directed, mainly, along the lines of sanitary affairs, along the lines of preventive measures. Such is the historical development of this matter—the fight against epidemics, improvement and sanitary supervision, the fight against social diseases, the protection of infancy. Recently, new problems have been put forward, again of a mass, preventive nature (the fight against cancer, mental illnesses, rheumatism). Medical care, however, was built in Great Britain, like in almost all European countries, as a personal matter for each individual patient (private practice), as charitable aid (poor laws, etc.), and, finally, as voluntary organizations for health insurance. Therefore, until very recently, all medical aid to the population of Great Britain was extremely insufficient from the point of view of its social organization and qualitative value. The National Health Insurance Act of 1911 introduced compulsory insurance for workers (this law provides for various types of social insurance, including against diseases). It is built on the type of ordinary insurance laws. In 1926, there were 14,102,000 insured persons. Contributions are made by workers, employers, and the state. The insurance organizations do not have any of their own medical institutions; the insured apply (at their own discretion) to any of the insurance doctors, who, in the order of private practice, also have a clientele from among the insured. The number of such doctors in 1926 was 14,432. Insurance organizations pay for the work of doctors and free pharmaceutical assistance. The total number of prescriptions issued was 51,081,684. For bed care, beds are rented in various hospitals. The state (the Ministry of Health) has general control over this entire matter. Likewise, hospitals in Great Britain are to a lesser extent owned by any public or state organizations (infectious disease hospitals, sanatoriums, and psychiatric hospitals); usually, they are either charitable or exist on the basis of the poor law (special boards of guardians). The number of beds (excluding infectious ones) was 150,090. Medical aid is provided only during employment; in case of unemployment, it is retained for only 26 weeks. The public health budget in Great Britain is composed of various sources, indicated above. For 1927/28, the budget of the Ministry of Health was about 20 million pounds sterling (of which 9 million for housing construction, 3.5 million for subventions to localities for preventive measures, 6 million for social insurance, etc.). The budget of local authorities amounted in 1924/25 to about 92 million pounds sterling (of which 18 million for housing construction, 15 million for improvement, etc.). School-sanitary supervision cost 1,300,000 pounds sterling. Public health in Great Britain is a reflection, on the one hand, of its high culture, and on the other hand, of its economic structure. Its extremely imperfect organization of medical care, the lack of connection between medical work and prevention, and the insufficient and weak development of such branches of public health as the fight against occupational diseases and sanitary labor protection (a few dozen sanitary doctors under the Home Office) depend to a significant extent on the general economic structure, and not only on the known traditions of the population. The role of the state is nevertheless growing here as well, and the organization of general sanitary affairs deserves careful study and attention.