PROVINCE OF BRITISH COLUMBIA Fourth Report of the DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH) (Fifty-third Annual Report of Public Health Services) YEAR ENDED DECEMBER 31st 1949 VICTORIA, B.C. : Printed by Don McDiarmid, Printer to the King's Most Excellent Majesty. 1950. Office of the Minister of Health and Welfare, Victoria, B.C., February 28th, 1950. To His Honour C. A. Banks, Lieutenant-Governor of the Province of British Columbia. May it please Your Honour: The undersigned has the honour to present the Report of the Department of Health and Welfare (Health Branch) for the year ended December 31st, 1949. GEO. S. PEARSON, Minister of Health and Welfare. Department of Health and Welfare (Health Branch), Victoria, B.C., February 28th, 1950. The Honourable Geo. S. Pearson, Minister of Health and Welfare, Victoria, B.C. Sir,—I have the honour to submit the Fourth Report of the Department of Health and Welfare (Health Branch) for the year ended December 31st, 1949. I have the honour to be, Sir, Your obedient servant, G. F. AMYOT, M.D., D.P.H., Deputy Minister of Health. DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH). Hon. G. S. Pearson - Minister of Health and Welfare. SENIOR PUBLIC HEALTH TECHNICAL STAFF. G. F. Amyot, M.D., D.P.H. - J. A. Taylor, B.A., M.D., D.P.H. Geo. Elliot, M.D., CM., D.P.H. - A. H. Cameron, B.A., M.P.H. - - R. Bowering, B.Sc. (C.E.), M.A.Sc F. McCombie, L.D.S. - - - - Miss M. Frith, R.N., B.A., B.A.Sc, M.P.H. - Miss M. Campbell, R.N., B.A.Sc, M.P.H. - - Mrs. K. Beard, B.Sc, M.S.P.H. - - - - Miss E. M. Yvonne Love, B.Sc. (H.Ec), C.P.H. Miss Doris Noble, B.Sc. (H.Ec), C.P.H. - - C. E. Dolman, M.B., B.S., D.P.H., Ph.D. - - W. H. Hatfield, M.D. J. D. B. Scott, B.A., B.Com. - C. L. Hunt, M.D., M.R.C.S., L.R.C.P. Deputy Minister of Health and Provincial Health Officer. Deputy Provincial Health Officer and Director, Bureau Local Health Services. Assistant Provincial Health Officer. Administrative Assistant. Public Health Engineer. Acting Director, Division of Preventive Dentistry. Director, Public Health Nursing. Consultant, Public Health Nursing. Consultant, Public Health Education. Consultant in Nutrition. Consultant in Nutrition. Director, Division of Laboratories. Director, Division of Tuberadosis Control. Director, Division of Vital Statistics. Director, Division of Venereal Disease Control. _ TABLE OF CONTENTS. Page. Introduction 11 General— Accommodations 12 Arthritis 13 Cancer Control Services 13 Summaries of Activities in the Bureaux, Divisions, and Services of the Provincial Department of Health 14 Longevity and Causes of Death in British Columbia 23 Report of the Health Branch Office, Vancouver Area— Introduction 26 Bureau of Special Preventive and Treatment Services 26 Federal Health Grants 26 Report of the Bureau of Local Health Services— Introduction 35 Preventive Dentistry Services 35 Changing Concepts in Community Health Services 35 School Health Services 37 Services of Part-time Medical Health Officers 38 Health Unit Development 38 Interdepartmental Relationships 42 Morbidity Statistics 42 Table I.—Incidence of Notifiable Diseases in British Columbia 45 Table II.—Table showing Return of Notifiable Diseases in the Province of British Columbia for the Year 1949 46 Report of the Division of Public Health Nursing— Introduction 49 Personnel 49 Service Analysis 51 Public Health Nursing Supervision 53 Special Services 54 Table III.—Length of Service of Public Health Nurses with Provincial Health Department as shown in 1949 50 Table IV.—Comparison of Total Time in per Cent, spent on Specified Activities by Public Health Nurses in Period 1946-49 as indicated by Time Studies 51 Table V.—Per Cent, of Total Time spent by Public Health Nurses in Selected Activities as indicated by Time Study in 1949 52 Report of the Nutrition Service— Introduction 57 Consultant Service to Local Public Health Personnel 57 Consultant Service to Institutions 58 Consultant Service to other Departments and Organizations 59 Comments 59 Report of the Division of Preventive Dentistry— Introduction 60 Establishment of the Division 60 Personnel 61 Dental Health Education 61 Advisory Service to Local Public Health Personnel 62 Dental Programmes 62 Dental Health Committee of the British Columbia Dental Association 63 KK 8 BRITISH COLUMBIA. Report of the Division of Public Health Engineering— Page. Introduction 64 Water-supply 64 Sewerage and Sewage-disposal 65 Stream-pollution Control 66 Milk Sanitation 66 Shell-fish Sanitation 66 Industrial-camp Sanitation 67 Sanitation of Tourist Resorts 68 Summer Camps 68 Environmental Sanitation of Schools 69 Sanitation of Eating and Drinking Places 69 Frozen-food Locker Plants 69 Training Programme for Personnel 70 General Observations 70 Report of the Division of Vital Statistics— Introduction 71 Completeness of Registration 71 District Registrars' Offices, Inspection, etc 76 Vital Statistics Information for Health Units 78 Statistical Services 79 Vital Statistics Council for Canada 81 Administration of the "Marriage Act" 82 Administration of the "Change of Name Act" 83 Administration of Sections 34-40, inclusive, of the " Wills Act " 83 General Office Procedures 84 Problems outstanding at the End of the Year 87 Report of the Division of Public Health Education— Introduction 91 Local Health Services 91 Visual Aids 92 Materials 93 School Health 93 Pre-service Training 94 In-service Training _: 94 Staff Changes 95 Report of the Division of Laboratories— Introduction 96 Tests for Diagnosis and Control of Venereal Diseases 96 Tests relating to Tuberculosis Control 97 Food-poisoning and Gastro-intestinal Infections 98 Bacteriological Analyses of Milk and Water Supplies 100 Other Types of Tests 102 Branch Laboratories 104 General Comments 106 Table VI.—Division of Laboratories Statistical Report of Examinations done during the Year 1949 109 Table VII.—Number of Tests performed by Branch Laboratories in 1949 110 DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 9 Report of the Division of Venereal Disease Control— PAGE. Introduction 111 Treatment 111 Epidemiology 112 Social Service 113 Education 113 General 115 Report of the Division of Tuberculosis Control— Introduction 116 Clinics 117 Institutions 118 Nursing Service 119 Social Service 119 Budget 120 Conclusion , 120 Fourth Report of the Department of Health and Welfare (Health Branch) YEAR ENDED DECEMBER 31st, 1949. G. F. Amyot, Deputy Minister of Health. INTRODUCTION. Health has been defined as a state of complete physical, mental, and social well-being' and not merely the absence of disease or infirmity. In helping the people of British Columbia to work toward this state, the Health Branch and its many specialized Divisions and Services on the Provincial level render service to the citizens of the Province through the public health physicians, public health nurses, sanitary inspectors, and clerical workers who constitute the staffs of local health services. The most efficient administrative organization for providing health services on the local level is the health unit, which is, in effect, a modern local health department staffed by full-time public-health-trained personnel serving one or more population centres and the rural areas adjacent to them. It has long been a prime objective of public health officials in British Columbia to provide such full-time" professional service in all parts of the Province. Although this goal has not yet been reached, the year 1949 was marked by success in establishing three new health units. This brought to eleven the number of units in operation. These eleven units, together with the city health departments serving the Greater Vancouver area and the Victoria- Esquimalt area, provide complete public health services to 81.3 per cent, of the population of the Province. When the more limited services provided by those public health nurses and sanitary inspectors working in non-health unit areas are included in the calculation, it is revealed that local public health services are available to 94.9 per cent, of the population. During the course of the year just ended, the Health Branch also met with success in the establishment of a Division of Preventive Dentistry. Although it was not possible to begin actual service to the citizens during the year, a well- formulated programme and policy were established and accepted, and personnel to form the nucleus of a trained staff were appointed. Closely associated with all other advances was the programme of postgraduate training for professional personnel. Made possible largely through funds from the Federal health grants, this is a continuing programme which provides not only for complete university courses on the postgraduate level but also for short-term refresher courses. An important change in general organization was the transfer of the Provincial Infirmary from the jurisdiction of the Health Branch to the jurisdiction 11 KK 12 BRITISH COLUMBIA. of the British Columbia Hospital Insurance Service in January, 1949. This transfer was made because the Infirmary, as an institution providing bed-care, may be grouped more logically with hospitals than with public health facilities. Details of these and the many other achievements and changes are presented in this Fourth Annual Report, the body of which is comprised of the following major sections:— (a) General: A description of those matters which affected the Health Branch as a whole. (b) Summary of activities in the bureaux, divisions, and services of the Health Branch. (c) Detailed reports presented by the heads of these bureaux, divisions, and services. CO-OPERATION WITH OTHER DEPARTMENTS OF GOVERNMENT, PROFESSIONS AND VOLUNTARY AGENCIES. The responsibilities of the Health Branch are closely related to those of other departments of Government, and in some measure to almost every other department. The close co-operation of other departments during this year, as in other years, has made possible the furthering of plans involving joint responsibilities. Outstanding examples during 1949 included the joint planning between this Department and the Department of Fisheries in the drafting of the " Regulations for the Sanitary Control of the Shell-fish Industry," joint discussions between the Department of Agriculture and this Department in matters concerning milk production, and co-operation with the Department of Education in planning the revision of the health section of the curriculum for high schools. Similarly, co-operation between this Department and voluntary agencies interested in public health has furthered projects to improve services to the public, particularly in the programmes for the control of cancer and arthritis. Without the interest and support expressed by the public through voluntary activities, the high standard of public health services of this Province could not be maintained. GENERAL. ACCOMMODATIONS. There has been no improvement during 1949 in the matter of accommodations. The Provincial Laboratory continues to be housed in totally unsuitable and inadequate quarters which make the maintenance of their high standard of achievement extremely difficult. Other divisions in the Vancouver and Victoria offices are crowded into cramped and inconvenient quarters to such an extent that efficient conduct of their work is greatly hindered. Every director of a division in the Victoria offices is forced to share an office with other senior staff members, who must frequently vacate their space so that meetings or interviews may be conducted. In some offices accommodation for clerical staff is likewise so inadequate that efficiency is seriously affected. Storage and filing space is quite inadequate. In many instances files must be stored in remote corners of the building or in other buildings, with result that much time is spent travelling between files. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 13 Washroom facilities are greatly overcrowded and inconveniently located. Overcrowding in the Health Branch offices for the Parliament Buildings has become so acute that additional temporary accommodation is urgently needed to relieve the congestion until the new permanent building, now under construction, is completed. ARTHRITIS. During 1949 the pilot centre for treatment of arthritis was established as a part of the Vancouver General Hospital's out-patient department. The programme is financed by Federal, Provincial, and voluntary funds. Treatment is provided to all patients eligible for admission to the out-patients' department. The British Columbia branch of the Canadian Arthritis and Rheumatism Society, organized in 1948, has progressed rapidly. The physiotherapy service established by the Society is now in operation in Vancouver. Four physiotherapists provide treatment and education at the clinic and in the home to patients referred to them by physicians. Toward the end of 1949 about 380 patients were receiving instruction and treatment from the physiotherapists. Many of these patients can, with this assistance, progress from a completely bed-ridden state to the point where they can again become wholly or partly self-supporting. At present this programme is limited to Vancouver, but plans for expansion are being considered. Branches of the Society have been organized in eight centres throughout the Province, and plans are under way in most of these centres for the establishment of similar physiotherapy services. CANCER CONTROL SERVICES. The provision of cancer control services for the Province has been maintained within the existing organization of the British Columbia Cancer Foundation, which was incorporated in 1935, and operates the main treatment centre known as the British Columbia Cancer Institute. Patients are accepted at the Institute upon referral by a physician, where they receive diagnostic and treatment services regardless of financial status. Patients in the lower income group are provided with travel and boarding-home expenses from the Cancer Aid Fund of the Canadian Cancer Society. In 1949 there were 1,130 new patients examined at the Institute, and 696 of these were definitely shown to have cancer. A total of 27,931 treatments and examinations were given at the Institute during the year. This included 19,611 X-ray treatments for 1,277 patients and 398 radium treatments for 253 patients, in addition to 1,445 X-ray diagnostic examinations. During the year expansion of services was made to provide consultative cancer services in Penticton, Kelowna, Vernon, and Kamloops. At the end of the year 56 new patients had been examined and 132 follow-up examinations had been performed. Negotiations are under way to provide similar services in Nelson, Trail, Prince Rupert, and Cranbrook. A consultant radio-therapist from the Institute makes regular visits to each centre to examine patients, to consult with physicians, to advise on treatment, and to check on patients treated or KK 14 BRITISH COLUMBIA. under treatment. These clinics have been set up in close co-operation with the local public health services. In December a building adjacent to the British Columbia Cancer Institute was opened as a nursing home to care for patients who have come from other parts of the Province for treatment and require a limited amount of nursing care. This new service will result in improved management of cancer patients and their earlier discharge from general hospitals. In order to improve X-ray facilities available to the cancer consultative services, X-ray diagnostic equipment at the Vernon Jubilee Hospital, Royal Inland Hospital, and St. Paul's Hospital was increased as a result of funds from the Federal health cancer grant. As the year closed negotiations were under way to provide a free biopsy service throughout the Province as an auxiliary to improved cancer diagnosis. This will be developed in co-operation with the Hospital Insurance Service to permit pathological tissue examination to be conducted in hospitals having approved pathological facilities in personnel and equipment. SUMMARIES OF ACTIVITIES IN THE BUREAUX, DIVISIONS, AND SERVICES OF THE PROVINCIAL DEPARTMENT OF HEALTH. Whereas this Annual Report contains detailed reports of the activities of the various bureaux, divisions, and services of the Provincial Department of Health, this summary includes only the outstanding features of each report. Longevity and Causes op Death in British Columbia. The trend of the death rate in the Province over the last twenty years has been very gradually upward. This is because of the increasing percentage of people in the older age-groups. The age specific death rates based on the mortality experienced during the first ten months of 1949 show improvement in each category over the preliminary figures for 1948. The infant mortality rate continued to be among the lowest in Canada, a fact which reflects the comparatively high level of health in this Province. The three leading causes of infant mortality—prematurity, congenital malformations, and injury at birth—accounted for over two-thirds of the infant deaths in the Province. Preliminary figures for the first ten months of 1949 indicate that the maternal mortality rate will be 1.3. The comparative figure for 1929 is 5.5. During the year a reduction was noted in the mortality rate of the three leading causes of death, namely, diseases of the heart and arteries, cancer, and accidents. The year 1949 marked the third successive year in which an improvement in the accident mortality rate has occurred. Health Branch Office, Vancouver Area. In January, 1949, the Health Branch office, Vancouver area, was opened at 2670 Laurel Street, Vancouver. Through this office the Assistant Provincial Health Officer performs the duties of Director of the Bureau of Special Preventive and Treatment Service, of administrator of Federal health grants, and DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 15 of liaison officer between the Divisions of Laboratories, Tuberculosis Control, and Venereal Disease Control. These three divisions are located in Vancouver. During the year the Provincial Government made substantial grants to such official non-government health agencies as the Western Society for Physical Rehabilitation, the British Columbia Division of the Canadian Arthritis and Rheumatism Society, and the British Columbia Cancer Institute. Through the Health Branch office the Government was kept informed on the administration of these organizations, and the integration of their services with the general public health services in the Province. The Health Survey Committee, as the central advisory committee on the Federal health grant programme for the Province, met three times during 1949. The most important development under the crippled children's grant was the initiation of the survey of crippling diseases in children. This survey is still being conducted. The survey will provide the basis for the formulation of a Provincial programme for crippled children. The professional training grant provided the means whereby personnel engaged in health work in the Province were given specialized training. As of September 30th, 1949, a total of seventy-six persons had been approved for advanced training under one of the Federal health grants. Projects approved under the venereal disease control grant included provisions for a survey of all phases of venereal disease control in British Columbia, for expansion of clinic services, for postgraduate studies, and for the visit to British Columbia of an outstanding authority on venereal disease control. Mental health diagnostic and treatment services in the Province are under the jurisdiction of the Provincial Secretary's Department. Through the mental health grant, diagnostic, treatment, occupational therapy, and teaching equipment was purchased for the Crease Clinic of Psychological Medicine, which was opened during 1949. Also under this grant, recreational and occupational therapy facilities at the Provincial Mental Hospital were increased, and psychiatric nurses' training was provided. X-ray equipment purchased under the tuberculosis control grant during the fiscal year 1948-49 was placed on loan in nine of the larger hospitals in the Province and in two strategic health units. The grant also provided the means whereby it was possible to institute a rehabilitation service and to increase the occupational therapy service. The public health grant is allocated by the Federal authorities on a project basis. During 1948-49 one project from this Province was approved. This project provided for an evaluation of the Wetzel grid in school health services. A second research project was approved during 1949-50, namely, evaluation of the antigenicity of cholera vaccine prepared in fluid media. The general public health grant made possible the establishment of a Division of Preventive Dentistry during 1949. Further expenditures under this grant provided other special services directed at improving the public health. The cancer control grant provided the means for implementing a survey of the cancer problem in British Columbia. As a result of this survey a programme was drawn up which provides for the extension of existing diagnostic and treatment services in Vancouver and Victoria, for the organization of diagnostic centres in other parts of the Province, for organization of a statistical KK 16 BRITISH COLUMBIA. section, and for continuation of lay and professional education. At the end of the year progress had been made on all phases of this programme. Local Health Services. Three new health units were established and the satisfactory negotiations toward the opening of a fourth were completed during 1949. Health unit directors were appointed to two of three units in operation at the end of the year; only one of these was without a qualified director. The comparative figures for 1948 are eight health units in operation, three without qualified directors. Another outstanding development during the year was the establishment of the Division of Preventive Dentistry. It is now possible to evolve a programme of dental education and preservation and restoration of the teeth of pre-school and school children. During the year increased emphasis was placed upon measures designed to control two of the chronic diseases, namely, cancer and arthritis. In this respect diagnostic and follow-up services were extended to certain key centres in the Province. The possibility of improving the methods of providing school medical services continued to be investigated during 1949. In this respect the results of the Wetzel grid survey, conducted during the past two years, are being carefully examined. Federal health grants made expansion possible in public health dentistry, mental hygiene, child welfare, public health education, public health nursing, sanitation, and nutrition services of the Metropolitan Health Committee. Similar expansion was also made possible in the Victoria-Esquimalt Health Department through Federal health grants. Quarterly meetings of the health unit directors, including the senior medical officers of the metropolitan areas, were held during the year to discuss changes in policies and services and to review present programmes and proposals for new services. An agreement between this Department and the Department of Agriculture during the year provided co-operative supervision of milk production. This agreement co-ordinated these services so that there would be no duplication or overlapping of services. There was an upward trend in the morbidity rate in the Province during the year. This seems to be due mainly to an increase in certain of the communicable diseases of children, and to a significant increase in the number of cancer cases reported. Very definite increases in rates were recorded for measles, mumps, poliomyelitis, and cancer. There were, however, marked decreases in the rates recorded for whooping- cough and diphtheria. Public Health Nursing. The shortage of qualified personnel continued during 1949, necessitating the appointment of a limited number of registered nurses who lack specialized training in public health. Eight such nurses, following a period of supervised field experience, were granted bursaries under the professional training grant to take a course in public health nursing. DEPARTMENT OP HEALTH AND WELFARE, 1949. KK 17 The public health nursing field staff at the end of 1949 totalled 111 members, an increase of four over the number at the end of 1948. The ratio of public health nurses to population in British Columbia is 1 to 4,000. Three new public health nursing districts were opened during 1949—Gibsons Landing, Howe Sound, and Kettle Valley. The percentage of the total population covered by public health services remained at 94.9, only slightly higher than last year. The fact that the increase in coverage is small is largely due to an increase in the population and to the small population in the new nursing districts. In-service educational programmes were effected through regular staff and regional study group meetings. The field staff continued to provide field training for a large number of undergraduate nursing students, and for thirty-two graduate nurses taking postgraduate courses in public health nursing. The senior nurses with supervisory responsibilities met twice during the year for special conferences. This group also received an advanced course in public health nursing supervision. A trial survey of the crippling diseases of children in one of the nursing districts provided the basis for a similar survey for the entire Province. As a part of the James A. Hamilton and Associates Report on Hospital Services in British Columbia, Miss Lucile Petry, Assistant Surgeon-General, United States Public Health Service, studied the adequacy of the public health nursing phase of local health services. Miss Petry reported, in part, that " The Health Branch of the Department of Health and Welfare has an exceedingly well-conceived plan for public health nursing services in the Province, and has succeeded in implementing the plan extensively." Nutrition Service. The consultants of the Nutrition Service continued to provide consultative services to local health staffs during 1949. Through the provision of technical data and direct assistance, the field staff were better able to deal with the problems of nutrition which were presented to them. Most of these problems were related to school lunch programmes and to low-cost meal planning. Public health nurses and teachers in an Okanagan district co-operated on a study of the school lunches. From information obtained from this study it was possible to make specific suggestions for improvement. A second study, several months later, showed that the suggestions were effective. A marked improvement in the school lunches was noted. Technical direction was supplied in a project involving the study of the foods eaten by the school children in another area. As a result of this study, a programme to improve food habits has been initiated. Two conferences were held with the senior public health nurses during the summer. The entire consultant programme was reviewed and certain extension of services resulted. Requests and specific problems from public health personnel were dealt with through correspondence and by articles in the staff bulletin. Consultant service to institutions continued, with the object of improving the food habits of the people in such establishments. KK 18 BRITISH COLUMBIA. A study of the diets, and related factors, was made at the Provincial gaols. Such a study is completed annually in accordance with recommendations outlined in the revised rules and regulations pertaining to such institutions. With the provision in 1949 of accommodation for patients at the British Columbia Cancer Institute, consultant services were provided to the Institute in the organization and supervision of meal services. Preventive Dentistry. The division was established during the year 1949 with the object of improving the dental health of the children of British Columbia. The programme is directed at prevention of dental ill-health. In this respect plans were formulated with particular emphasis on the care of younger children. The co-operation of the College of Dental Surgeons of British Columbia and of the British Columbia Dental Association was obtained. Dr. F. McCombie was appointed as acting director of the division early in 1949. He left in September for a year's postgraduate study in dental public health at the School of Hygiene, University of Toronto. Dr. W. G. Hall joined the division in August from the staff of the Faculty of Dentistry, University of Alberta. He deputized for the acting director during the absence of the latter. The division co-operated with the Division of Health Education in procuring audio-visual aids pertaining to dental health. Several types of dental programmes were evolved and finalized in consultation with the British Columbia Dental Association. In general these programmes were aimed at incorporating treatment services for pre-school and Grade I school children. Plans were formulated for the appointment of full-time dental directors to local health units, and for the use of the services of private dental practitioners working in their own offices. Two further programmes were established to provide dental services to those areas where there is no resident dentist. The first of these is a system of grants-in-aid to encourage dentists to locate in such areas. The other is the establishment of basically equipped dentist offices in these areas, and includes provision for payment of travel allowance to near-by dentists. Public Health Engineering and Environmental Sanitation. An estimated 835,960 people in the Province use water from public water- supply systems. One of the major responsibilities of the division is to ensure that these public water-supply systems provide safe water. During 1949 the division examined all plans for new water-supply systems, and in addition conducted sanitary surveys of a number of plans of new sewerage systems, pending the approval of such plans by the Deputy Minister of Health. In studying the plans submitted for approval, the sizes and grades of the sewers were carefully checked. The methods of sewage treatment and disposal were also carefully examined. Almost 500,000 people in the Province use private sewage-disposal systems. Standard plans were produced showing the proper method of constructing septic tanks and pit privies. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 19 There were no major milk-borne epidemics in British Columbia during the year. The continuous co-operation between the Department of Health and the Department of Agriculture, in the matter of milk sanitation, is definitely improving the quality of the milk sold in this Province. The Division provided consultative services cn milk sanitation to the local health services. The latter are responsible for the supervision and sampling of milk supplies. Each of the sanitary inspectors in the Province was provided with kits which enabled them to carry out resazurin and phosphatase tests. Many milk samples were sent to the Division of Laboratories for examination. A new set of regulations governing the sanitary control of the shell-fish industry was enacted during the year. In this respect the division performed a considerable number of surveys of oyster-beds. In Boundary Bay and in Esquimalt Harbour the surveys were especially thorough. Due to the increased staff of sanitary inspectors in the field during 1949, it was possible to devote much more time to the inspection of industrial camps. The sanitary inspection of tourist camps and summer camps was quite comprehensive during 1949. The responsibility for such inspections lies with the local sanitary inspectors. Detailed inspections of environmental conditions in and around schools were made by the local sanitary inspectors. The inspections were reported upon, and copies of these reports were sent to the appropriate school boards. The inspection of eating and drinking establishments is an important feature of the work of the local sanitary inspector. The increased staff in the field meant that many such establishments were inspected for the first time during 1949. The division hopes to have each food place inspected at least four times annually. In 1949 the biggest single job of the division was in connection with shellfish sanitation. Almost the whole of the time of the Assistant Public Health Engineer, and of two students during the summer months, was devoted to this work. Division of Vital Statistics. The Division of Vital Statistics is charged with two major responsibilities, namely, the registration of births, deaths, still-births, marriages, divorces, adoptions, and changes of name, and the provision of all the statistical data, studies, and analyses required by or stemming from the various services of the Health Branch. The efficient integration of these two complementary activities, both directed in the ultimate toward improving the health of the people, is an accomplishment unique in Canada. In the registration work of the division, particular emphasis has been placed during the year upon further improving the quality of the registrations accepted. Every registration is carefully scrutinized for legibility, clarity of statement, and accuracy and completeness of all items. During the year a considerable improvement was noted in the quality of the registrations of Indians, while continued progress was evidenced in the difficult problem of securing registrations amongst the Doukhobors. This latter gain is felt to be mainly due to the efforts of the special field representative assigned to Doukhobor work, and to careful planning of policy concerning the collection of vital statistics. KK 20 BRITISH COLUMBIA. The Vancouver District Registrar's office was opened in March of this year in the Provincial Government building at 636 Burrard Street. This was an important forward step in giving speedy and efficient service to the expanding population of the Greater Vancouver area, as well as in relieving the overburdened Government agency of a heavy responsibility. The division undertook to supply the Hospital Insurance Service with a monthly death index as from January 1st, 1949, and, in addition, a weekly death index as from May 1st, 1949. The microfilming of important records was continued during the year, and 15,650 files relating to delayed registration of birth were placed upon microfilm. Original files were subsequently destroyed and much-needed space was made available for more urgent requirements. The system of notification of births, deaths, and still-births to public health personnel was extended so that the Metropolitan Health Committee in Vancouver is now advised of events which occur to residents of the Metropolitan Health District who are temporarily in other parts of the Province. The division continued its important statistical obligations to all divisions of the Health Branch, particularly to the Division of Tuberculosis Control and the Division of Venereal Disease Control, in the processing and tabulation of service and treatment statistics, in the presentation of monthly, quarterly, and annual reports, and in the maintenance of Provincial case registers. Advice and assistance were given in the planning of the Province-wide survey of crippling diseases of children, in drawing up the associated questionnaire, and in setting up the recording and statistical procedures for summarizing and analysing the results. Consultative and statistical help was provided in a special study carried out jointly by the Provincial and Federal Health Departments on the use of the Wetzel grid in school health services. Assistance was also provided to the British Columbia Cancer Institute, to the British Columbia Division of the Canadian Arthritis and Rheumatism Society, and to other non-official health agencies. Considerable effort was expended in complying with statistical inquiries from Government, commercial, and private sources. Public Health Education. The efforts of the division were mainly devoted to providing consultative services and educational materials to local public health personnel. Through funds available from Federal health grants, a basic library of seven public health reference books was supplied to each public health office. Additional books were sent to each proposed or established health unit centre. Audio-visual equipment, including a film projector, a film-strip projector and a record-player, was supplied to each of the eighteen health unit centres. The central film library was increased to include eighty-five films and forty-nine film-strips. A series of demonstrations on the use of the above visual aids was presented at the annual Public Health Institute and classes were given to local staffs at some health unit centres. In 1949, as in other years, a large number of films was previewed. Those of value in the public health programme were purchased and added to the film . DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 21 library. The film catalogue was revised and brought up to date. It contains more complete descriptions of films than is usually found in such catalogues. As the result of an increased demand, more books and other reference materials were purchased. The increased demand was particularly noticeable in the fields of mental hygiene and child-development. All the books in the library were classified and catalogued during the year. The division co-operated with the Department of Education in planning the health phases of the revised curriculum in " Effective Living," which will include health, guidance, and family relations in one course. Articles on school health were prepared and distributed to schools in the Province. Kits of reference materials were assembled and provided to school health teachers through the local public health nurses. The division planned and conducted orientation courses for new appointees in the Department. Laboratories. Almost 380,000 examinations were made by the laboratories of the division during 1949. This represents an increase of about t per cent, over the number for the previous year. Roughly 80 per cent, of these examinations were made in the central laboratories in Vancouver. As in previous years, tests relating to venereal diseases accounted for about 75 per cent, of the total tests done. Most of the tests on blood specimens were submitted by practising physicians. There was an increase of over 1,100 in the number of cultures examined for M. tuberculosis. This substantial increase is largely attributed to a growing tendency to request repeat examinations at short intervals from the same patient. During the summer months a number of outbreaks of staphylococcal food poisoning were identified. There was another botulism episode—the third in British Columbia within the past five years. The number of acute gastro-enteritis infections, due to micro-organisms of the salmonella-shigella groups, increased by about 75 over 1948. There were no extensive epidemics. The infections were confined to individuals or to small familial groups. The upward trend in the number of bacteriological tests of milk- and water- supplies was maintained during the year. The number of milk samples examined increased by more than 50 per cent. The number of phosphatase tests for efficient pasteurization doubled. Tests of water samples for the presence of the coli-aerogenes group of micro-organisms increased from 6,930 in 1948 to 7,942 in 1949. Tests relating to diphtheria totalled nearly 20,000 for 1949, an increase of about 30 per cent, over the 1948 figure. The number of Paul-Bunnell tests for infectious mononucleosis increased from 739 in 1948 to 1,028 in 1949. Although requisitions for these tests are steadily increasing, there is no convincing evidence that the disease is prevalent in British Columbia. Cultures of throat-swabs for hemolytic staphylococci and streptococci continued to mount, 3,819 of these being reported on in 1949, as compared to 3,092 in 1948. KK 22 BRITISH COLUMBIA. Microscopic examinations for intestinal parasites also increased by over 25 per cent, over 1948. Venereal Disease Control. The incidence of venereal diseases in general showed a slight decrease during 1949. The greatest improvement appeared in relation to syphilis, where early infections showed a decline of over 50 per cent, over 1948. The figures for gonorrhoea remained fairly constant. Free diagnostic and treatment services continued to be given at all clinics of the division. The free consultative service to private physicians continued to be used to an ever-increasing extent. Free drugs for treatment of venereal diseases were again made available to all persons, through their private physicians. A new treatment schedule for syphilis was drawn up in 1949 and distributed to every physician and hospital in the Province. Penicillin became the drug of choice in the treatment of all stages of syphilitic infections. In most instances the penicillin treatment was followed by a short course of arsenic and bismuth. The shortage of hospital beds necessitated an increased use of the ambulatory form of treatment with " delayed absorption " types of penicillin. The results from this method appeared to have been as effective as the more inconvenient three-hourly injections of aqueous penicillin. Health unit directors and public health nurses in the field continued to carry an ever-increasing share of the epidemiological work for the division. Meetings were again held at intervals of three to four months for discussion of problems relating to the spread of venereal diseases. These meetings were well attended and included representatives from all interested groups. Two blood-testing surveys were conducted during the year. Out of 680 persons examined a total of sixty new syphilis cases were discovered. Social factors related to venereal diseases assumed an increasingly important part of the programme. Every new patient who reported to the Vancouver Clinic was granted an interview with a social service worker. This worker attempted to detect and assess any underlying social or psychological problems. The " Reference Manual for Clinic Physicians " was revised to include recent developments in treatment and diagnosis. The booklet " Procedures and Services in Venereal Disease Control " was also revised. Copies of the latter publication were sent to every practising physician in the Province. Tuberculosis Control. The programme of the division continued to be hampered by the inadequate number of beds available for treatment of tuberculosis patients. Despite this handicap, there was some improvement in the over-all tuberculosis picture in the Province. The greatest improvement in the division during the year was the opening of the new surgical and teaching facilities at the Vancouver unit. The problem of obtaining qualified medical personnel persisted in 1949, as in previous years. Plans were completed for a major change in the tuberculosis survey programme, whereby mass X-ray surveys will be reduced. Instead, X-ray equip- I DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 23 ment will be installed in general hospitals and local health units in most areas of the Province, where the service will be readily available to the people at all times. The rehabilitation programme which was initiated by the British Columbia Tuberculosis Society was transferred during the year to the division, using funds from the Federal health grant. No new clinics were opened but the volume of work performed in each clinic continued to grow. The new home for nurses at Tranquille was opened during the year. It proved a valuable addition. Also at Tranquille an alternating-current system was made available and a new telephone system installed. The epidemic of poliomyelitis during the summer months necessitated the removal of the division's patients from the Vancouver Isolation Hospital for a period of fourteen weeks. The Federal health grants made possible three major developments in the social service work of the division. A full-time rehabilitation officer and a full- time occupational therapist were appointed. A home-making service for tuberculosis patients was established, and at the end of the year there were seven full-time home-makers and four part-time home-makers in patients' homes. As in previous years, there was, during 1949, complete co-operation between the division and the British Columbia Tuberculosis Society. LONGEVITY AND CAUSES OF DEATH IN BRITISH COLUMBIA. As the establishment of health units throughout the Province progresses, there is a growing recognition of the value of quantitative data on morbidity and mortality. It is only by a consideration of this data that a comprehensive public health programme can be properly established and maintained. The statistics which are developed in this way will, over a period of years, help to indicate the strength and the weakness of the services provided and will also indicate where further activity may be best expended. Much has been done to increase the life-span of the people in the Province, but the mitigation of some of the more urgent health problems will also serve to emphasize those which remain. While progress in public health matters may appear slow when viewed from year to year, a comparison of the position to-day with that of twenty, or even ten, years ago brings out the advances very clearly. In some fields, such as cancer and heart-disease, the mere holding of the line indicates progress when the ageing of the population is considered. The mortality rate in the Province has shown very little fluctuation over the last twenty years. It has varied within a small range, with a low of 8.7 deaths per 1,000 population in 1933 and a high of 11.1 in 1943. The trend of the death rate has been very gradually upward because of the increasing percentage of people in the older age-groups. The crude mortality rate, based on preliminary figures for the first ten months of the year (excluding Indians), declined from last year's rate of 10.2 deaths per 1,000 population to 9.6 deaths in 1949. When the age specific death rates based on the mortality experienced during the first ten months of the year are considered, improvement is shown KK 24 BRITISH COLUMBIA. in each category over the preliminary figures for 1948. The provisional death rate last year in the 0-19 age-group was 3.2 deaths per 1,000 population while in 1949 it declined to 2.8. For the group 20-39 years of age, last year's figure was 1.9, this year's 1.7, and for the 40-59 group, the comparable figures were 7.6 in 1948 and 7.1 in 1949. A more substantial improvement occurred in the death rate of the group 60 years of age and over. The rate, based on the first ten months of 1948, was 47.8, while this year the rate has declined to 41.4. As an indication of the progress being made in public health a comparison between the infant mortality rate this year and that for 1929 is interesting. Twenty years ago the rate was 45.7 infant deaths per 1,000 live births; in 1949 it has decreased by more than 43 per cent, to 25.8 deaths per 1,000 live births. British Columbia's infant mortality rate has for some time had the distinction of being among the lowest in Canada, a fact which reflects the comparatively high level of health of the community. Premature birth was the leading cause of infant mortality, accounting for almost 40 per cent, of the deaths of children under one year. Next was congenital malformations, which caused 16 per cent, of the infant deaths. This was followed by injury at birth, responsible for 12 per cent, of the deaths. These three causes together accounted for over two-thirds of the infant deaths in the Province. A very marked improvement has occurred in maternal mortality in 1949 as compared with the period twenty years ago. Then, the number of deaths of mothers per 1,000 live births was 5.5. Preliminary figures for the first ten months of this year indicate that the rate will be 1.3, a reduction of over three- quarters from the 1929 figure. This year a reduction is noted in the mortality rate of all the leading causes of death. Preliminary figures show that diseases of the heart and arteries this year caused 386 deaths per 100,000 population, an improvement of 4 per cent, over the first ten months of 1948, when the rate was 401.9. Cancer, the second leading cause of death, shows a preliminary rate of 144.8 deaths this year as compared to 149.1 last year, a gain of nearly 3 per cent. Accidents maintained their position as third leading cause of death this year with a rate of 75.7 deaths per 100,000 people, which is slightly less than last year's figure of 76.3. This marks the third year an improvement has occurred in the accident mortality rate and it is hoped that this downward trend can be continued, for accidents represent the most easily preventable form of wastage of human life. Several changes have occurred in the order of importance of the various specific types of accidents. Deaths from falls or crushing last year were in second place, accounting for 14.7 per cent, of the deaths from all accidents. This cause has moved into first place in 1949, figures based on the first ten months of the year indicating that 26.6 per cent, of accidental deaths will arise from this cause. Motor-vehicle accidents, which were the leading cause of accidental death last year, accounting for 20.7 per cent, of such fatalities, this yea_r dropped to second place with 17 per cent. Drowning maintained its third place as a cause of death by accident, preliminary figures showing it to have claimed 13.3 per cent, of the lives lost accidentally in 1949, compared to 11.6 per cent, last year. The three leading causes of death accounted for over 60 per cent, of the deaths from all causes. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 25 Intra-cranial lesions of vascular origin (without mention of arteriosclerosis) ranked fourth as a cause of death, with a rate of 38.3 deaths per 100,000 people, an improvement over last year's rate of 45.7. The death rate from pneumonia, the fifth leading cause of death, was 36.5 per 100,000 population this year, while last year it was 40.7. Diseases of early infancy has moved up into sixth place as a cause of death this year, and nephritis has fallen back to seventh place. Tuberculosis, diabetes, and premature birth, in that order, fill the last three places among the first ten major causes of death. A study of the comparative effect of the leading causes of death within each age-group is interesting as it reveals the changing importance of the various causes as age progresses. In the first year of life, as noted before, prematurity caused the greatest number of deaths, followed by congenital malformations, and injury at birth. Accidents caused the greatest number of fatalities at all ages between 1 and 39 years, but as the age progresses their importance as the leading cause decreased. They were responsible for 44.2 per cent, of the deaths in the 1-9- year age-group, 42.5 per cent, in the 10-19 group, 38.6 per cent, in the 20-29 group, and 25.4 per cent, in the 30-39 group. Drowning caused the greatest percentage of accidental deaths in the 1-19 age-group, and this was followed by motor-vehicle accidents. In the two groups 20-39 years, motor-vehicle accidents moved up to first place, forestry accidents occupying second place in the 20-29 group, and drowning in the 30-39 group. Leukemia and pneumonia followed accidents as causes of death in the 1-9 age-group. In the next two age-groups, tuberculosis held second place. Cancer and tuberculosis were second and third in importance as fatal diseases in the 30-39 age-group. From 40 years of age onward, heart-disease accounted for an increasing percentage of deaths in each age-group up to 90 years, when it declined in effect slightly, but retained its position as the leading cause of mortality. In the 40-49 age-group, heart-disease caused 24.1 per cent, of the deaths; this increased to 31.9 per cent, in the next age-group, and to slightly over 41 per cent, in the following two age-groups. It took the greatest toll in the 80-89 age- group, where nearly one-half of the deaths which occurred were charged to this cause. In the last age-group, the proportion declined to 41 per cent. Cancer followed heart-disease as a cause of death in the age-groups 40-79, taking a toll of close to 20 per cent, of the total deaths in each of these groups. Accidents were the third leading cause of death in the 40-49-year group with 15.2 per cent, of the deaths being attributed to this cause. In the 50-79-year groups, intra-cranial lesions of vascular origin took third place, causing about 9 per cent, of the deaths in the first two groups, and 12.6 per cent, in the last group. Intra-cranial lesions were responsible for 12.3 per cent, of the deaths in the 80-89-year group, and thus occupied second place after heart-disease as a death cause. Cancer followed in third place, contributing 9 per cent, of the deaths. Accidental falls, always dangerous as age progresses, came after heart-disease in second place as a killer of people in the 90-99-year group, and this cause was followed by intra-cranial lesions, responsible for 8.7 per cent, of fatalities. KK 26 BRITISH COLUMBIA. REPORT OF THE HEALTH BRANCH OFFICE, VANCOUVER AREA. G. R. F. Elliot, Assistant Provincial Health Officer. INTRODUCTION. In the fall of 1948 Dr. G. R. F. Elliot, formerly Director of Division of Venereal Disease Control, was appointed Assistant Provincial Health Officer in charge of the Vancouver area. He was given dual responsibilities, namely, the direction of the Bureau of Special Preventive and Treatment Service and the administration of the Federal health grants, including conduct of the survey required by the health survey grant. In January, 1949, a separate office was set up, known as the Health Branch Office, Vancouver, located at 2670 Laurel Street. BUREAU OF SPECIAL PREVENTIVE AND TREATMENT SERVICE. The Assistant Provincial Health Officer acts as a liaison officer between the Divisions of Laboratories, Tuberculosis Control, and Venereal Disease Control, all of which are located in Vancouver, in regard to matters of policy or particular problems. In general administration, these three divisions continue to deal directly with the Deputy Minister of Health, Victoria. The Provincial Government is now making substantial grants to certain official non-government health agencies, such as the Western Society for Physical Rehabilitation, the British Columbia Division of the Canadian Arthritis and Rheumatism Society, and the British Columbia Cancer Institute. It was considered advisable, therefore, that the Government should be kept informed on the administration of these organizations and should be assured that these services are integrated with the general public health services in the Province. Responsibility in this regard was delegated to the Assistant Provincial Health Officer. Close co-operation is maintained with the Bureau of Local Health Services in giving advice and assistance to the local public health personnel in the Lower Mainland and Fraser Valley area. Attention has also been given to the formation of health units in this area, in co-operation with the Director of Local Health Services. FEDERAL HEALTH GRANTS. General. Federal health grants to the Provinces were continued in 1949, having been authorized again this year by Order in Council. The total amount available to British Columbia for the year 1949-50 is $2,617,726, an increase of $81,073 over the year 1948-49. This increase was due primarily to an increase in the basis of distribution of the general public health grant from 35 cents -per capita to 40 cents per capita. Other grants increased slightly, as population is one of the factors governing the distribution of the total amount. The Advisory Committee on Research, Ottawa, continued to allocate the public health research grant, the total amount of which increased from $100,000 to $205,148. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 27 The Federal health grants were made available to the Province in 1948 with little warning and well after the fiscal year had begun. As a result, in order to prevent reversion of large unused portions of the grants to the Federal Treasury, attention was given during the remainder of the fiscal year 1948-49 to the preparation and submission of projects based on already known facts concerning public health needs in British Columbia and upon which relatively immediate action could be taken. At the same time, however, the importance of a long-range programme was recognized, and definite steps have been taken this year toward this end. Several surveys concerned with individual phases of health have been completed. In any plans ensuing therefrom, emphasis has been placed on the integration of such services with generalized public health services. In addition, these plans will be integrated with the survey of all Provincial health facilities and needs which is being undertaken by the Assistant Provincial Health Officer under the provisions of the health survey grant. Administration. The organization which was established by the Minister of Health and Welfare when the Federal health grants were inaugurated has remained essentially the same as that outlined in the 1948 Annual Report of the Health Branch. The Health Survey Committee, as the central advisory committee is known, met three times during 1949 to receive progress reports and to advise on particular problems referred to it by the subcommittee chairmen of the individual grants. The attendance of Dr. F. W. Jackson, Director, Health Insurance Studies, Ottawa, at the meeting of July 6th, provided an excellent opportunity for the clarification of various questions. Thus, through this Committee, co-ordination between the various plans for expenditure of the grants is assured and duplication is avoided. Two changes have taken place in the composition of the Health Survey Committee. Miss Alice Wright was appointed as representative of the Registered Nurses' Association of British Columbia, and Dr. Charles Hunt replaced Dr. G. R. F. Elliot as chairman of the Sub-committee on Venereal Disease Control Grant. In addition, Dr. Myron Weaver, Dean, Faculty of Medicine, University of British Columbia, has been asked to attend the meetings. General administration and over-all control of the grants is the responsibility of the Assistant Provincial Health Officer. Where Provincial programmes are established, such as hospital construction, mental hygiene, venereal disease control, tuberculosis control, and general public health services, planning for expenditure of the funds available through the grants is undertaken largely by each of these Government services. The expenditure of the remaining grants, as well as any expenditure of grants by non-government agencies, is under the immediate jurisdiction of the Assistant Provincial Health Officer. Requests for approval by the Federal Government of expenditures under the grants are made in the forjn of projects. The Department of National Health and Welfare, Ottawa, has shown a keen desire to co-operate with this Province. Concrete suggestions have been made in regard to our submissions and administrative problems. At all times there has been a willingness to accede to requests that further consideration be given to rejected projects. KK 28 BRITISH COLUMBIA. All submissions are reviewed by the Assistant Provincial Health Officer to ensure that they conform to the provisions of the grant; that they do not conflict with present or future health programmes in the Province; and that the total amount allocated does not exceed the amount available in each grant. They are then referred for approval to the Deputy Minister of Health as well as to the Minister of Health and Welfare for the Province. The fact that mental health and hospital construction in British Columbia do not come within the jurisdiction of the Deputy Minister of Health has not created any major problems; an excellent working relationship and understanding exists between all members of the Provincial Secretary's Department, the Department of Health and Welfare, and the Hospital Insurance Commission in the management of the Federal health grants. Close co-operation is maintained with the Departmental Comptroller, who is responsible for payment of accounts, submission of all claims to the Federal Government, and maintenance of an inventory of all equipment purchased with the Federal grants. Where such equipment is placed in a non-government institution or agency, it is considered to be the property of the Provincial Government on loan to that agency. The efficient manner in which this work has been handled has contributed greatly to the reasonably easy operation of the programme in British Columbia and to the good relationship with Federal officials. Grants received Year ended March 31st, 1949. Due to the foresight and preparedness of health authorities in this Province, British Columbia was able to take immediate advantage of the health grants. Although the fiscal year 1948-49 was well advanced when these grants were announced, projects approved by the Federal authorities resulted in the allocation of 80 per cent, of the amount of money available. British Columbia ranked second in this regard, being surpassed only by Prince Edward Island. For various reasons it was not possible to implement all approved projects, but health services actually received $1,094,151 up to March 31st, 1949. Of the seven grants where there was no matching principle or the balance could not be carried over to the next fiscal year, expenditures in the amount of $705,768 were completed by March 31st, 1949, that is 63 per cent, of the total amount available was expended. In addition, the hospital construction grant, $1,080,745, and the health survey grant, $52,744, may both be carried over to the next fiscal year so that there is no loss to the Province from these two grants. Expenditures were made from the cancer control grant to the extent that matching Provincial funds were available. The amount available under each grant for the year ended March 31st, 1949, is given in the following table, together with the amount allocated for approved projects and actual expenditures. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 29 Comparison of Amounts approved and Actual Expenditures with Total Grants for the Year ended March 31st, 194-9. Total Grant. Approved. Actual Expenditure. Grant. Amount. Total Grant. Amount. Amount Approved. Total Grant. $42,574 42,574 1,080,745 42,574 338,832 272,740 7,500 52,744 365,400 290,970 $32,635 28,394 1,034,631 39,953 189,011 254,424 7,500 17,667 359,864 48,534 Per Cent. 77 67 96 94 56 93 33 98 17 $29,863 24,600 337,004 37,279 134,785 209,369 4,894 3,024 264,978 48,355 Per Cent. 91 87 33 93 71 82 65 17 74 99 Per Cent. 70 58 31 87 40 77 65 6 General public health Cancer control 72 17 Total $2,536,653 $2,012,613 79 $1,094,151 54 43 * Total grant held by Federal authorities. These figures represent amount allocated to British Columbia. Present Status. Every endeavour has been made this year to utilize to the fullest extent the money available, but there are various factors which influence the allocation of these funds. The amount of possible expenditure may be limited until a Provincial programme is finalized, as in the crippled children's and hospital construction grants. On the other hand, where the Provincial programme is well developed, such as in tuberculosis control and mental health, difficulty may be experienced in meeting the requirement that expenditures must be for new and extended services. Over one-half of the grant for venereal disease control is allocated for projects approved under the Federal grant originally made in 1943 and continued in succeeding years. In addition, as pointed out above, there are reasons why certain grants are lagging in their spending programme. Accomplishments. The Federal health grants have not only made possible new developments in health in British Columbia but have also accelerated expansion of present policies. Although the grants have been in operation for less than two years, that progress has been achieved under each grant is evident from the following record. Crippled Children's Grant. For purposes of this grant, " a crippled child is one under the age of 21 years who, because of disease, accident, or defect, is restricted in his normal muscular movements." This definition restricts planning and makes it necessary to separate this phase of child health from the remaining phases, such as blindness, deafness, rheumatic heart-disease, and mental defectiveness, which must, therefore, be included in the planning under other grants. Representations have been made to the Department of National Health and Welfare, but it has not been possible to broaden the definition due to the limitations of the grant. KK 30 BRITISH COLUMBIA. The most important development under this grant is the survey of crippling diseases in children which is being carried out at present, and which is to include all the phases of child health in accordance with the decision of the Health Survey Committee. A questionnaire was drafted in consultation with representatives from the various medical specialities concerned. Pilot studies completed in a rural and an urban area indicated that 95 per cent, of the questionnaires would be completed from school medical health records through the co-operation of the public health staff. The survey has now been extended to the Province as a whole, and it is expected that a partial analysis of the results will be ready early in 1950. This survey will provide the basic information necessary for the formulation of a Provincial programme for crippled children in this Province. It has already aroused keen interest among the public health staff and brought to light many points on which there was no previous knowledge. Expenditures under this grant have been almost entirely for orthopaedic and other equipment for hospitals and institutions in order not to encumber this grant for future years until the Provincial programme for crippled children is finalized. A new development, which is being financed this year but which will easily become an integral part of any Provincial programme, is the provision of staff and facilities whereby patients under the age of twenty-one will receive the necessary investigation, retraining, and rehabilitation following an attack of poliomyelitis. The management of this project is under the Western Society for Physical Rehabilitation, Vancouver, in co-operation with the Poliomyelitis Advisory Committee of the Vancouver General Hospital and the private physician. The opportunity thus provided for these patients with residual paralysis to have retraining will enable them, as far as possible, to return to normal living. Professional Training Grant. During the year 1948-49, priority was given to applications for training of general public health personnel, although there were also sufficient funds to provide training for some specialized services. In 1949-50 the total amount required for professional training was in excess of the amount of the grant, and projects for training have therefore also been submitted under the crippled children's, venereal disease control, tuberculosis control, mental health, general public health, and cancer control grants. This opportunity for postgraduate study has encouraged personnel presently engaged in health work to improve their qualifications, and it has also made it possible to attract untrained personnel on the understanding that training will be provided. All recipients of benefits under the professional training grant are required to sign an agreement to return to suitable employment in British Columbia for a specified period of time depending on the length of the training provided. As at September 30th, 1949, a total of twenty-five persons had completed their training, including seven physicians and six public health nurses; forty- five persons, including nine physicians and fourteen public health nurses, had commenced training; and approval had been given for an additional six persons whose training had not yet commenced. A total of seventy-six persons to date, DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 31 therefore, has received, or will receive, postgraduate training under one of the Federal health grants. General public health training for additional physicians, nurses, and sanitary inspectors has made it possible to open new health units and fill positions which have been vacant for some time due to lack of personnel. Postgraduate work for those in public health nursing and sanitary inspection supervisory positions, as well as in-service training courses for these two groups, has undoubtedly raised the standard of the service given. Specialized services have also benefited considerably. Physicians on the Provincial Mental Hospitals staff have taken courses in electroencephalography, hospital administration, pathology, and psychiatry; nurses in neuro-surgical technique and nursing supervision; other members of the staff in clinical psychology and psychiatric social work; and, in addition, two school teachers are taking special courses in mental hygiene. Similar training, related specifically to tuberculosis, venereal disease, cancer, and crippled children, has been taken by personnel employed in these services. Hospital Construction Grant. This grant differs from the others in that any amount not expended during the current fiscal year may be carried over to the succeeding year. Administration of this grant is thereby made considerably easier, as it would be very difficult to have plans approved for a hospital of any size and the building completed within the fiscal year. Approval has recently been granted whereby the cost of construction of special services, such as staff quarters, heating plants, etc., may be included in the total cost of construction, even though they are separate from the main hospital buildings, but this still applies only when such facilities are constructed at the same time as additional hospital beds. Representations have been made to the Federal authorities to make it possible for hospitals to receive assistance in constructing these additional facilities required as a result of additional beds constructed prior to April 1st, 1948. The majority of the projects approved to date have been for building under way at the time the Federal health grant programme was announced. The projects which had received Federal approval by December 31st, 1949, made provision for an increase of 1,439 hospital beds in British Columbia (689 in general hospitals, 652 in mental hospitals, and 98 in chronic hospitals). By the end of the year, these projects had been implemented to such an extent by actual construction that 531 additional general hospital beds and 351 additional mental hospital beds were in use or ready for occupancy. It is expected that future construction of general hospitals will be based on the recommendations contained in the report of the hospital survey completed by Messrs. J. A. Hamilton and Associates in October, 1949. Venereal Disease Control Grant. The grant, which became available in 1948, was in effect an addition to existing Federal grants, since the Federal Government has contributed toward the cost of venereal disease control in this Province since 1943. At the beginning of the fiscal year 1949-50, the provisions of both grants were consolidated. KK 32 BRITISH COLUMBIA. A project was approved during the year 1948-49 for a survey of all phases of venereal disease control in British Columbia by Dr. D. H. Williams, of Vancouver. The report of this survey was presented to the Deputy Minister of Health in December, 1949. Other approved projects provided for expansion of clinic services through the provision of additional personnel and equipment, postgraduate studies, and for the visit to British Columbia of an outstanding authority on venereal disease control. More detailed information in regard to this grant is given in the Annual Report of the Division of Venereal Disease Control. Mental Health Grant. As previously stated, most mental health services are under the jurisdiction of the Provincial Secretary, and reference to this grant is made in this report only in order to complete the report regarding Federal health grants. The Crease Clinic of Psychological Medicine was completed in 1948, and as this was a new development it was possible to purchase diagnostic, treatment, occupational therapy, and teaching equipment for this institution worth approximately $150,000. Under this grant, facilities at the Provincial Mental Hospital have also been increased for recreational and occupational therapy and psychiatric nurses' training. A mental hygiene programme has been instituted by the Victoria-Esquimalt Board of Health, and expansion of the programme of the Metropolitan Health Committee of Greater Vancouver has also been approved. The University of British Columbia has been assisted in enlarging their clinical psychology department in order that postgraduate studies may be available. Tuberculosis Control Grant. Expansion of the case-finding programme has taken place through the provision under this grant of X-ray equipment, which was purchased in 1948-49 and has since been placed on loan in nine of the larger hospitals in order to make possible routine X-ray of all admissions. Equipment has also been placed in two strategic health units. Plans are being made for the purchase of additional X-ray units for a number of the smaller hospitals. Approximately $70,000 has been expended in providing equipment for the new Surgical and Educational Unit of the Division of Tuberculosis Control, Vancouver. It has also been possible to institute a rehabilitation service and to provide increased occupational therapy service, a wider use of free streptomycin, and professional staff education. Further information regarding the utilization of this grant will be found in the Annual Report of the Division of Tuberculosis Control. Public Health Research Grant. This grant is allocated by Federal authorities in order to ensure that there is no duplication, to permit of research being directed particularly toward public health problems, and to facilitate reference to the National Research Council and the Defence Research Board of those applications which are not considered to come within the scope of the public health research grant. One application from this Province was approved in 1948-49. This project provided for an evaluation of the Wetzel grid in school health services. The DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 33 study, which has been carried out in the Central Vancouver Island Health Unit area, is a continuation of a preliminary one begun in 1946 by the Department of National Health and Welfare in order to offer guidance in the practical application of the Wetzel grid in public health and welfare services providing it meets Canadian requirements. The project was completed in the fall of 1949 and the report is being prepared. A second research project was approved in 1949-50, namely, evaluation of the antigenicity of cholera vaccine prepared in fluid media. It will enable cholera vaccine prepared in synthetic fluid media, which was suggested during the war period, to be compared antigenically with the commonly used cholera vaccine produced from solid media. This work is being carried out under the direction of Dr. L. E. Ranta, Department of Bacteriology and Preventive Medicine, University of British Columbia, and an application has been made for it to continue in the year 1950-51. Health Survey Grant. The purpose of this grant is to assist the Provinces in setting up machinery to ensure the most effective use of the other health grants and planning a long- range health programme for each Province. Reference has been made in other sections of this Report to individual surveys which have already been completed. Action in regard to the survey of all health facilities in the Province was delayed pending completion of the hospital survey by Messrs. J. A. Hamilton and Associates. This survey will include all phases of hospital administration and personnel. Because of the necessity of considering hospitals in relation to other factors, such as area, population, and existing health services, including physicians and nurses, a large amount of valuable data is being collected through this survey. The Hospital Survey Report was presented in October, 1949, to the Minister of Health and Welfare, and preliminary plans have now been drafted for the Provincial survey of health services and facilities. General Public Health Grant. Expenditures under this grant have been directed primarily toward the expansion and improvement of public health services in local areas through provision of staff and equipment. Since plans have been on hand for some years, comparatively little delay occurred in taking advantage of this grant, 72 per cent, of the total amount available being expended during the year 1948-49. In particular, this grant has made it possible to establish a Division of Preventive Dentistry, to formulate plans for a Provincial dental programme, and to expand and integrate the present dental health services. In addition to the expansion of general public health services, a full description of which is given in the section of this Report entitled Bureau of Local Health Services, expenditures have been made under this grant to other special services directed at improving the public health. A programme for the investigation and treatment of persons suffering from arthritis was inaugurated in 1948, with Federal and Provincial funds, and is being continued. Facilities for the care of premature infants have been improved through the purchase of incubators and resuscitators for the hospitals on the Lower Mainland. Finan- KK 34 BRITISH COLUMBIA. cial help has been given to the University of British Columbia for the provision of equipment to assist in extending training to an increased number of bacteriologists, public health nurses, and other public health personnel. Cancer Control Grant. A cancer control programme had been under discussion and consideration for several years, but no final plans had been drafted at the time the Federal grant was announced. On the recommendation of the Sub-committee on Cancer Control Grant, and with the concurrence of the British Columbia Medical Association, Dr. 0. H. Warwick, Executive Director, National Cancer Institute of Canada, made a survey of the problem in British Columbia in December, 1948. The British Columbia Cancer Foundation drew up a plan, at the request of the Sub-committee on Cancer Control Grant, for the implementation of the recommendations made by Dr. Warwick. This plan provides for the extension of existing diagnostic and treatment services in Vancouver and Victoria, organization of diagnostic centres in other parts of the Province in conjunction with local public health services, organization of a statistical section in co-operation with the Provincial Division of Vital Statistics, provision by the Foundation of a sixteen-bed nursing home in Vancouver, and continuation of lay and professional education by the British Columbia Division of the Canadian Cancer Society and appropriate professional groups. It is gratifying to note that by the end of December, 1949, progress had been made on all phases of this programme with considerable assistance being given through this grant. The question as to whether or not biopsy, radiodiagnostic, consultative, and radiotherapy services should be free was referred to the Health Survey Committee. It was agreed that the biopsy service should be free to the patient and available to everyone in the Province and this has been approved by the Department of National Health and Welfare. With regard to the remaining services, however, no final action has been possible, and patients who are able to pay for treatment are therefore still being asked to do so. Acknowledgments. The progress achieved through the Federal health grants is due to the whole-hearted co-operation of all public health personnel. The staff of the central office of the Health Branch, Victoria, has been ready to assist at all times. The co-operation of officials of the Department of the Provincial Secretary and, in particular, the Civil Service Commission has facilitated the administration of this programme. The members of the Health Survey Committee and the chairmen and members of the sub-committees under the individual grants have given valuable advice and assistance, and their willingness to do this on a voluntary basis is very much appreciated. DEPARTMENT OF HEALTH AND WELFARE, 1949. . KK 35 REPORT OF THE BUREAU OF LOCAL HEALTH SERVICES. J. A. Taylor, Director. INTRODUCTION. Health services on the local or municipal level have long been in the transition stage, emerging from the part-time basis to the full-time service in more and more areas of the Province. Those municipalities and school districts which have united their community and school health services under a Union Board of Health have had a uniform basic community health programme considered to be the most efficient method of public health administration. In recent years, more and more municipalities and school districts have turned to the Health Branch, Department of Health and Welfare, with requests for the introduction of health unit services in their areas. For five years the provision of these services was not possible because of the shortage of qualified personnel. If, for no other reasons, then, the year just passed must be recognized as a notable one from the community health service view-point, because of the establishment of three new health units under Union Boards of Health and satisfactory negotiations toward the opening of a fourth. This constitutes a most significant advance in local health services for any one single year. PREVENTIVE DENTISTRY SERVICES. A major community health problem universal to the entire Province has long been that of the dental health of pre-school and school children. Year after year in annual reports hope has been engendered that a programme of preventive dentistry could be evolved, principally to preserve and, in part, to restore the teeth of these children. It is regrettable that something could not have been done earlier; certainly in no other crippling condition affecting 97 per cent, of the children would such a period of delay have been so long tolerated. The outstanding advance in public health services for this year is, therefore, the establishment of a Division of Preventive Dentistry, for which a report of the first year's activity is included under a separate heading. This represents the culmination of years of planning, and portends a forward advance in local health services as the programme becomes more definitely established on the community level. In no small part, the programme to date has been contingent upon the very definite contribution of the dental profession of the Province through their dental health committee, whose members have given unreservedly of their-time to assist the Department of Health in formulating the four-point programme. CHANGING CONCEPTS IN COMMUNITY HEALTH SERVICES. The scope and pattern of public health services show a progressive change from year to year to fit the altered needs and conditions revealed by mortality, morbidity, and population statistics. Significant decreases in infant and maternal mortality, in communicable-disease incidence, and other changing KK 36 BRITISH COLUMBIA. factors would tend to indicate that the attention devoted to these conditions, concomitant with an improvement in environmental sanitation, is beginning to yield results. These results, however, present new features as the changes in gross mortality rates are examined. The diseases which threatened during infancy, childhood, and the most productive periods of life have, to a considerable extent, been conquered. The leading causes of death to-day are mainly those of the older ages—degenerative diseases. The two leading causes of death for the past several years have been diseases of the heart and arteries and cancer, both considered to be chronic degenerative diseases. The third leading cause of death has repeatedly been accidents, in which slightly more than 20 per cent, were automobile fatalities during 1948, 14.7 per cent were accidental falls or crushing, and 11.6 per cent, were due to drowning. This third cause of death indicates a public health need requiring some concerted action toward development of a programme to curtail its annual toll. Such diseases as typhoid fever and diphtheria have disappeared from the ten leading causes of death. At present, only two of the ten, namely, diseases of early infancy and congenital malformations, in sixth and tenth place in 1948, are associated with early life. In contrast, the chronic illnesses, such as heart-disease, cancer, nephritis, and diabetes, account for an increasing amount of the total mortality each year. In addition to the emphasis placed on control of infectious diseases, it is becoming apparent there is a need for some measure, or measures, designed to control the chronic diseases, to extend the period of active life, and to provide adequate public health protection for the ageing segment of the population. During the year, with the extension of services provided, some attempt was made to deal with two of the chronic diseases, namely, cancer and arthritis. The British Columbia Cancer Foundation has for some time provided service in diagnosis, treatment, and prevention through the Cancer Institute, located in Vancouver and operated by the Foundation. It was considered advisable to inaugurate diagnostic and follow-up services in key centres of the Province to provide the local physicians with auxiliary consultative service, and to save the patient expensive trips to and from the existing single centre. Under the plan, qualified specialists in cancer will visit each centre on a planned schedule, depending upon the volume of the work. The local health unit is charged with the organization and administration of these centres and the subsequent follow-up of patients, ensuring the community facilities for cancer sufferers are provided as efficiently as possible. During 1948 the British Columbia Branch, Canadian Arthritis and Rheumatism Society was organized to carry on an extensive educational campaign on this crippling disease and to provide certain treatment facilities. These are mainly physiotherapy and massage services, designed to be administered in the home by qualified personnel, who could demonstrate and instruct others in the procedures. Extension of these services from the Metropolitan areas to the smaller cities of the Province is under way to provide patients with ready access to these remedial measures. Local health services have a part to play in the referral, supervision, and follow-up of these patients in the intervening periods. DEPARTMENT OF HEALTH AND WELFARE, 1949. . KK 37 Finally, to gauge the magnitude of the public health and medical needs of the Province, contemplation is being given to a morbidity study of a selected sample or samples of the population. It is felt that such a study can best be organized and conducted by the local health services staff, who are already acquainted with the medical histories of the individuals in the survey group. It is likely that this morbidity study will be commenced during the forthcoming year in co-operation with the Division of Vital Statistics. SCHOOL HEALTH SERVICES. School medical services are more directly concerned with the medical and preventive health aspects of the school health programme, including the mental, emotional, physical, nutritional, and immunization status of the school child. In this, the classroom teacher and the public health nurse serve as the spearheads of the service, in which close collaboration is necessary. The effectiveness and success of the programme depends, in no small part, upon co-operation between teachers, parents, children, family physician, public health nurse, and school medical inspector. Each has a responsibility to assume in ensuring the development and maintenance of optimum health by school children, in which health is defined as a " state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Each year, children in Grades I, IV, VII, and X have been examined, constituting in the neighbourhood of 45 per cent, of the pupils enrolled. Figures for 1948-49 are not yet available, but during the academic year 1947-48, 43,662 children were examined, over 90 per cent, of them being found physically fit. The details concerning these school medical services are provided in a separate report entitled " Medical Inspection of Schools Report." A considerable number of examinations could never have been accomplished without the assistance of the seventy physicians in their capacity as part-time School Health Inspectors. Their contribution toward the improvement in health of the school children is doubly appreciated, in view of the fact that the time devoted to this work must be sandwiched into a personal private practice. Investigation of the results obtained through the routine medical examinations has been continued. This has been prompted mainly by a desire for a reorganization of the school medical inspection to provide an opportunity to deal with the nutritional, mental, and emotional, as well as the physical, aspects of the pupil's health. There is continued questioning and searching for the most efficient methods of providing the greatest service to the maximum number of pupils, while giving more individual attention to those needing it most. Early in 1947, consideration was given to a new method of examining the physical status of children on the basis of height and weight measurements, related to chronological age plotted on a special chart known as the Wetzel grid. It would appear from a study of the grid that it would be possible to divide children into two main groups: Satisfactory, those who maintained their individual normal growth and development, and unsatisfactory, those who deviated from their anticipated growth and developmental patterns. In other words, the grid might serve as a screening tool to select the children requiring special attention by the school health personnel. KK 38 BRITISH COLUMBIA. On the basis of the preliminary study conducted in the academic year 1947-48, it was felt advisable to carry on a more intensive study during 1948-49. In this, the Department of National Health and Welfare participated with the Provincial Department and the Central Vancouver Island Health Unit, providing financial assistance, the requisite number of grids, and sending their pediatric specialist from their Division of Child and Maternal Health as director of the study. As the year closed, the study became completed, but the findings must be examined critically prior to public release of the report. Because of the interest in the possibilities of the technique, the methods are being continued as an integral part of the school health service in one local health area in the Central Vancouver Island Health Unit. Frequent assessments of the values to be obtained through its use will be made to ascertain if the school health inspection benefits to the degree expected. Further information on the Wetzel grid study will be found in the Medical Inspection of Schools Report, and in the Report of the Study of the Wetzel Grid in B.C. School Health Services. These reports are published separately. SERVICES OF PART-TIME MEDICAL HEALTH OFFICERS. It is with considerable gratitude that the Department acknowledges the services provided by the sixty-nine medical practitioners throughout the Province who have served as medical health officers for their communities. In large part, the interest and effort of these physicians has prompted an improvement in health measures for their community. No request for their services has gone unheeded, while the degree of assistance and co-operation provided to the local public health nurses and sanitary inspectors has been exemplary. Under their direction and supervision there has been a continued steady growth in public health services throughout the Province, and, in part, the present public demand for development of health units stems from their counsel and advice. HEALTH UNIT DEVELOPMENT. Attention has already been directed to the significant advances in local health services through the establishment of three new health units and satisfactory progress toward the development of a fourth. The development of complete health units has been materially assisted by the introduction of the Federal health grants, which have permitted the organization of planned health units in advance of the time possible under normal circumstances. Progressive planning toward the development of complete health units has been based upon the introduction into the community of an initial public health nursing service. This is considered advisable, since public health nursing is the channel through which1 the majority of the specialized consultative public health services flow to the individual families in the community. During this period of health unit development the public health nurse, in addition to her nursing duties, provides a minimum sanitation service. However, as the public health nursing service develops sanitation becomes increasingly emphasized, so that the next logical step is the introduction of sanitary inspectors to deal more specifically with all the ramifications of that public health field. This was accomplished a year ago through the assistance of Federal health grants, when ten new sanitary inspectors were appointed in local health dis- DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 39 tricts to comply with numerous requests from municipalities for that service. The duties performed by these inspectors, now in the field one year, have again proven the effectiveness of their work in promoting improvements in water- supplies, milk-supplies, sewage-disposal methods, and the many other features of the field of environmental sanitation. During that period, they have served under the direction of the various part-time health officers in their areas, with whom they have manifested the same degree of co-operation that was presented by the public health nurse with those same physicians. The last progressive step in the building up of the health unit is the decision by two or more neighbouring municipalities and school boards to unite their individual health services under a Union Board of Health, and to appoint a health unit director to administer all community and school health services through a health unit. The unit director becomes the medical health officer for all the participating municipalities, and the school medical inspector for all the school districts. This final step in the development of a health unit results from the very efficient groundwork of the public health nurse and sanitary inspector, which has led to a desire on the part of so many municipalities and school boards for a complete full-time service in all respects. In the last Annual Report, the hope for early establishment of health units at Chilliwack, Trail, Courtenay, and Kamloops was presented. Toward midyear it was possible to recommend a qualified public health physician to the local advisory board in Chilliwack, which led to the establishment of the Upper Fraser Valley Health Unit, with headquarters at Chilliwack. This health unit is organized under the Upper Fraser Valley Union Board of Health, made up of representatives from the City of Chilliwack, Municipality of Chilliwhack, Municipality of Kent, and School Districts Nos. 33 and 76. As the unit develops, it is hoped the Municipality of Sumas, Municipality of Matsqui, Village of Abbotsford, Village of Hope, and School Districts Nos. 32 and 34 will enter the Union Board of Health. This unit is at present serving a population of 20,900, but, when fully developed, will meet the public health needs of 35,350 persons. The second health unit to be established was the Upper Island Health Unit in the north portion of Vancouver Island, with headquarters at Courtenay. Negotiations on the formation of a unit in this area have been under way for the past five or six years; only the shortage of qualified personnel prevented earlier progress. The Upper Island Union Board of Health results from the consolidation of the local health services of the Cities of Courtenay, Cumberland, Comox, Village of Campbell River, and School Districts Nos. 71 and 72, providing a total population of 15,550 with the unit services. The complete unit is planned to include School District No. 47 on the Mainland, in which is included the Village of Cranberry Lake, Village of Westview, and the unorganized company town of Powell River. When this population of about 7,550 is added the services will be provided to a total population of 23,100. The third health unit was organized late in the year when the Corporation of Mission City, the Municipality of Mission, and School District No. 75 united their community and school health services into the North Fraser Valley Health Unit. This Union Board of Health is just becoming organized as the year closes and will later recommend that School District No. 76, the Municipality KK 40 BRITISH COLUMBIA. of Kent, and the Village of Harrison Hot Springs secede from the Upper Fraser Valley Health Unit in favour of union with the North Fraser Valley Health Unit. This is considered most practical, as the final unit is expected to include, additionally, the Municipalities of Maple Ridge and Pitt Meadows and School District No. 42, to provide consolidation of local health services on the north side of the Fraser River to 22,950 people. Also, toward the end of the year, two of the three health units without health unit directors obtained their full staff complement again. A well- qualified public health physician is assuming the vacancy in the Prince Rupert Health Unit, serving a population of 16,142, while a young physician has accepted the position of health unit director in the East Kootenay Health Unit, with headquarters at Cranbrook, in which 27,585 persons reside. Both these units have been operating under the supervision of acting directors for a little more than a year. One health unit, the Peace River Health Unit, the most northerly unit in the Province, continues without a full-time director, as has been the case since 1944, but it is anticipated that these circumstances will not exist much longer. In the last Annual Report, it was pointed out that only eight of the planned eighteen health units were in operation, three of them without qualified unit directors. As a direct result of this year's progress, there are now eleven health units in operation, only one without a qualified director. These, in conjunction with the metropolitan services of Vancouver, Victoria and Esquimalt, provide complete health unit service for 83 per cent, of the people in British Columbia. Over a period of ten to twelve years, moves toward the formation of organized public health services in the New Westminster area have been considered periodically. The proposals have never been entirely satisfactory, with the result that the negotiations have never gone beyond the preliminary discussion stage. Proposals advanced during the past year have been much more acceptable to the parties concerned, and it is now hoped that a health unit may come into being early in 1950. The proposed unit will unite the local health services of New Westminster, Port Moody, Port Coquitlam, Fraser Mills, Municipality of Coquitlam, and School Districts Nos. 40 and 43 under one Union Board of Health to provide a planned, uniform type of service in all areas. This unit will be in the nature of a unique experiment in public health services in British Columbia, since it consolidates an urban area with several smaller organized communities, which had built up their public health nursing and sanitary inspection services over the past ten years. It is anticipated this type of health unit will serve as a guide to the formation of others of the same type, where large urban populations are neighbouring on smaller, somewhat rural communities. During the past year, it had been hoped that a complete public health service in the form of a health unit would become operative in Trail and district. Certain moves toward its formation were advanced, but it was found impossible to interest a physician in assuming the directorship. It is the next area to receive consideration and should be under way early in the new year. When completely organized it will serve a population of 32,801. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 41 Following the opening of that unit, the formation of one for the Kamloops area is next on the priority schedule. Local health services in this area were compelled to vacate their office quarters in the school and were accommodated in unsatisfactory premises in a vacant storeroom. Plans for the construction of a health and welfare building were well under way at the close of the year. This building will provide excellently appointed offices and sufficient clinic space for a new unit to fulfil their requirements for many future years. This proposed unit is planned to provide service to 24,100 people. Sanitation difficulties during the year, particularly with regard to water- supplies, required that the staff personnel from the South Okanagan Health Unit provide consultative services to the health officer at Princeton. To fulfil completely the needs there, it is proposed that School Districts Nos. 16 and 17 be added to the South Okanagan Health Unit; representations suggesting such a move have been placed before the South Okanagan Union Board of Health for their consideration and opinion. If that board approves, it is likely these districts will be invited to join their services with that organization. Progress has continued within the metropolitan health services, in which some reorganization has been gradually undertaken to establish each unit as a more or less self-contained entity, responsible for the health services of its own area. The North Shore Health Unit, reorganized within the metropolitan service a year ago, has become satisfactorily consolidated to provide more efficient administration of services in that area. Unfortunately, staff problems have created some difficulties, but it is hoped these will be rectified within the near future to provide stabilization in the service. Expansion in public health dentistry, mental hygiene, child welfare, public health education, public health nursing, sanitation, and nutrition services were all possible under the Federal health grants, as a result of recommendations submitted by the Senior Medical Health Officer. Details of these services will be found in the Annual Report of the Metropolitan Health Committee. Similar expansion was possible in Victoria-Esquimalt Health Unit, in which plans for advancement of public health education and mental hygiene were forwarded as a direct result of the Federal health grants. In this case, these two special services are to be provided conjointly to the neighbouring Saanich and South Vancouver Island Health Unit. In this regard, a study of the health services in these two health units was conducted during the year by the Public Health Educator, utilizing the evaluation schedule of the American Public Health Association, which revealed that the several services were being conducted on a high level as compared with the public health indices in other areas in United States and Canada. Quarterly meetings of the health unit directors, including the senior officers of the metropolitan areas, were held in February, April, and September to discuss changes in policies and services and to review present programmes. Such meetings permit an expression of the practicability of the programmes in the field and result in a uniformity of service throughout the Province, while permitting single units to test new services prior to their adoption as a definite programme. KK 42 BRITISH COLUMBIA. INTERDEPARTMENTAL RELATIONSHIPS. Certain other fields of Government, concerned with service to the public, are engaged in tasks which often require co-operative action with local health services. The fields of welfare and health are closely related in their types of services and are becoming more closely united on the local level. This is very evident in the Vernon and Kamloops areas, where the administration is becoming housed in the same building, developing a co-operative relationship of public service. A most harmonious agreement was developed during the year between the Department of Agriculture and this Department to provide a co-operative supervision of milk production. In the past, each Department maintained an inspection service on the farm and in the plant, almost entirely unrelated in effort. Several meetings between representatives of the two Departments during the year resulted in the development of a joint programme which provides for co-ordination of inspections to avoid duplication. Reports on all tests and inspections are provided to both Departments so that the interested individual inspectors are furnished with complete information on each milk- producer and each plant from both the agricultural and the health view-points. This collaboration was evolved to incorporate more effectively the intent of the " Milk Act " and the " Health Act," requiring the officers of the Department of Agriculture to deal with the production of the milk and the sanitary inspectors to concern themselves with the quality of the milk supplied to the consumer. The joint programme has been in effect for several months, with apparent success, and should become more efficient and effective as further experience leads to minor improvement in the plan. It has proven the justification of interdepartmental collaboration in the promotion of improved public service. MORBIDITY STATISTICS. The need for a morbidity study to supply information on the total amount of sickness in various age-groups, the time lost to the individual and to industry, the amount and types of treatment involved, the costs of such sickness, and many other factors has been mentioned. The study of the methods of conducting such a survey in all the Provinces of Canada is now being made. In the meantime, records of the morbidity due to specified notifiable disease is maintained from year to year. In the past, these reports have made comparisons between the total numbers reported from year to year without any attempt to allow for the effect that population changes might have on them. This year, the statistics are being shown on the basis of rates per 100,000 population, and future comparisons can be made on a sound statistical basis from year to year. It is anticipated this will more correctly assess any upward or downward trend in the individual disease ratios to indicate more clearly the trends of certain diseases in the Province. The comparison of the rates for 1948 and 1949 are shown in Table I, page 45. From this table it will be noted there was an upward trend in the Provincial morbidity picture, the rate increasing from 2,184.1 per 100,000 population for 1948 to 3,147.8 per 100,000 for 1949. The major responsibility for this would seem to lie in the increase in the childhood communicable infections of chicken- DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 43 pox, measles, and mumps, which was predicted in the last Annual Report. There was, however, a significant increase in cancer reporting, which requires some consideration. The incidence of syphilis showed a downward trend, but all other notifiable diseases showed a fairly stationary trend. During the year, plans for improvement in reporting of the notifiable diseases were devised, based upon follow-up reporting to the various medical health officers of the positive laboratory reports for their areas. It was pointed out that recent specimens submitted to the laboratory had been reported positive, indicating possible clinical disease and requesting the medical health officer to investigate. It is self-evident that an intensification of effort by each health officer is needed when a study of the reported incidence of certain diseases is compared with the number of positive laboratory reports. For example, only 16 cases of undulant fever were reported, yet 194 positive laboratory reports were recorded; only 1 case of paratyphoid fever was reported, yet 10 paratyphi B patients were investigated bacteriologically, while 163 other cases of salmonellosis were reported by the laboratory, compared to the 95 reported clinically. There were as many cases of typhoid fever (17) reported clinically by the physicians as by the laboratory bacteriologically—the only instance in which there was exact coincidence. Even in diphtheria there was some variation, 12 cases reported as compared with the 20 positives found by the laboratory; an explanation of this latter difference lies in the fact that some of the patients who were positive carriers were not reported as cases. There is, however, sufficient variation to indicate that reporting of notifiable diseases in certain instances presents only a fraction of the actual number of cases. This is probably also true in influenza, in which there would seem to be some unreliability of reporting, as evidenced by the very few reported this year (4.2 per 100,000) as related to the number of a year ago (114.4 per 100,000). In last year's report, attention was directed to the very low incidence of measles (382.3 per 100,000) during 1948, with the prediction that a peak might be expected in 1949. A very definite increase was recorded (966.3 per 100,000), but this is somewhat less than in other epidemic peak years. Mumps also exhibited an appreciable increase, from a rate of 93.2 per 100,000 for 1948 to a rate of 387.3 per 100,000 for 1949, four times as many cases. The trend occasioned a year ago toward a decrease in the incidence of whooping-cough has been continued during 1949, the rate for 1948 of 26.3 dropping to 19.2 this past year. It is felt that the immunization measures carried on in recent years are beginning to have their effect in lessening the disease which formerly had such severity among infants. Poliomyelitis exhibited an upward trend during 1949, the majority of the cases being centred in Vancouver and the Lower Mainland, where it reached epidemic proportions. Although the epidemic taxed the facilities of the communicable disease hospital in Vancouver, the lessons gained through experience with previous recent epidemics were again brought into play to deal with the situation, with the result that every suspected and actual case received immediate and thorough attention. There was a significant increase in the number of cases of cancer reported, 315.0 per 100,000 in 1949 as compared with a rate of 230.3 in 1948. This may KK 44 BRITISH COLUMBIA. be the result of improved reporting, as more patients seek early medical attention on the basis of the educational programme of the Cancer Society coupled with the more effective diagnostic measures continually being improved and brought into practice. Whatever the cause, it merits consideration, since the efforts of recent years have continually urged recognition of early symptoms, and early treatment for these measures present the immediate major hope for control of this disease. The continued encouraging trend in diphtheria shown last year was continued through 1949, there being only one-third as many cases this past year, a rate of 3.2 in 1948 as compared to 1.1 in 1949. Carrier conditions in certain individuals create the greatest hazard, their presence indicating the need for continued vigilance toward maintenance of a high community immunization status throughout the Province. The follow-up of these carriers, in endeavours to overcome the harbouring of virulent positive organisms, places demands upon clinical and laboratory facilities, possibly more so upon the laboratory than any other. Tick paralysis occurred again during the year in two instances, emphasizing the fact that this diagnosis must be kept in mind during the spring season when wood-ticks are common throughout the Province. A case of anthrax occurred in the Fraser Valley, where one human contracted the condition from a cow. This was an unusual and serious occurrence which precipitated an immediate investigation by Department of Agriculture officials to prevent further spread to other herds. It is felt the situation is presently under control. The complete list of the diseases reported from the various areas of British Columbia by the medical health officers is recorded in Table II, page 46. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 45 Table I.—Incidence of Notifiable Diseases in British Columbia (including Indians). 1948. 1949. Notifiable Disease. Number of Cases. Rate per 100,000 Population. Number of Cases. Rate per 100,000 Population. 1 1 3,509 18 7,370 287 12 23 10 1 32 3,833 12 47 1 1 10,765 4,314 225 1 19 567 1 95 491 102 859 3 2 9 4 2,202 17 16 3 214 0.1 2 2,492 24 6,087 164 35 31 36 0.2 230.3 2.2 562.6 15.2 3.2 2.9 3.3 0.1 315.0 1.6 661.6 25.8 Diphtheria 1.1 2.1 1.0 0.1 41 3,615 3.8 334.1 2.9 344.1 1.1 1,238 114.4 4.2 0.1 0.1 Measles 4,137 1,008 118 2 12 405 7 41 383 382.3 93.2 10.9 0.2 1.1 37.4 0.7 3.8 35.4 966.3 387.3 20.2 0.1 1.7 Rubella Salmonellosis— 50.9 0.1 Other 8.5 44.1 157 14.5 9.2 1,018 3 4 6 94.1 0.3 0.4 0.6 77.1 0.3 0.2 0.8 0.4 2,178 22 66 15 285 201.3 2.0 6.1 1.4 26.3 197.7 1.5 1.4 0.3 19.2 23 632 1 2.184.1 35,066 3,147.8 C- OS P3 H s Eh 0. 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I i M ! . i i ! Iiil 1-1 •si^Bdajj oiuiapidg © T-H ■X-ia_^uasAQ[ MMMH 1 s |rt j Mji CO CM •Bjjaqq.qdi(]; :;:;:::; »h ^j. j j : ; ; : CM •ST-^lApDUnCuOQ i i i : i h ! h : *>tf m : : ; : i : : : : : : : M : : I : : tree tt •xod-uaispiqQ h o t- co : ! io t- ©eD"rj<; :::! in cc ::ooo to in th : :::: : ; l—i co in : : : : : co" : i : i : CO tr- CO tr? •si-^iSuma]^; puidsojqaja^ : i ! ; : : : >-h © : : ; : : CO •uisi[n;og •jaouBQ 3,509 3,509 *XB_IHrUy ! i ! ! ! i ! ! |j | | | j I j 1 rt Squamish Tofino Trail 1 tH tH c CQ Tulsequah Upper Fraser Health Unit Upper Island Health Unit Greater Vancouver Metropolitan Health Committee Victoria Woodfibre Zeballos Whole Province— Cancer Gonorrhoea Syphilis Tuberculosis , a 0 H-> o EH DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 49 REPORT OF THE DIVISION OF PUBLIC HEALTH NURSING. Monica M. Frith, Director. INTRODUCTION. Nursing service is a vital component of any health programme—hospital, medical care, and public health, whether these! be individualized or organized on a group basis. The importance of nursing as a community service has been brought more and more to the attention of the public with the unprecedented demand for nursing care, which has yet to be met. Contributing to this increasing need have been the expansion of hospital facilities available to individuals requiring hospital care through the institution of the Hospital Insurance Plan, increased emphasis on early diagnosis and treatment, and the greater awareness of the preventive aspects of disease. Public health authorities have to some extent been responsible for stimulating this demand for nursing care and therefore are prepared to assist in planning to meet this need for nursing service. Although more nurses are engaged in nursing in British Columbia than ever before, there still exists a shortage of qualified personnel. Public health nursing, as a specialized branch of nursing, has felt the effects of the general shortage. By making the best possible use of the available nurse-power, a satisfactory ratio of public health nursing staff to general population has been maintained, in spite of the greater demand arising from the opening of new nursing districts and from a rapid population increase. It is recommended by Haven Emerson in his " Local Health Units for the Nation," and also by the National Organization for Public Health Nurses, that one public health nurse serve not more than a population of 5,000 where a generalized public health programme is carried, that is, when school nursing is included but not bed-side care of the sick. If the public health nurse is to give health guidance and bed-side care to the entire family, it is recommended that one public health nurse should be provided for every 2,000 people. In British Columbia the ratio of public health nurses to population is 1 to 4,000. This figure represents an adequate coverage when two important factors are considered. First, travel conditions, particularly in the more rural areas, make it more difficult and time consuming to provide public health service than in more urban areas. Second, public health nurses, although not attempting to carry a complete bed-side nursing care programme in every district, have been increasing gradually the amount of nursing care given in the home on a demonstration and treatment basis. PERSONNEL. Staff Changes. During the past year there have been a great many changes in the public health nursing staff. Forty-one nurses were newly appointed. Twenty-eight nurses left the staff: eight to be married or return to their home duties, twelve to attend KK 50 BRITISH COLUMBIA. university, eight for basic public health nursing training, four for more advanced public health studies, and seven for other reasons, for example, retirement, return to institutional work, missionary work, etc. In all, there has been an over-all increase of four staff public health nurses during the year. One nurse transferred to the Division of Venereal Disease Control, while another took advantage of the opportunity of one year of planned experience with the Child Guidance Clinic in Vancouver. The field staff at the end of December totalled 111 members. From Table III it may be seen that 28 per cent, of the staff are in the first year of service, while over 63 per cent, have served for less than three years. Table III.—Length of Service of Public Health Nurses with Provincial Health Department as shown in 1949. Years of Service. 1 Public Health Nurses. 31 20 16 21 6 Years of Service. 7 Public Health Nurses. . 4 2 8 1 3 9 2 4 5 _ 10-15 Total 8 6 2 ______ 111 Internship Plan. Once again it has been necessary to take on staff a limited number of registered nurses. They have been placed in carefully selected districts under the close supervision of a senior or supervising nurse, who carries through with a planned orientation course, which permits the nurse to gradually assume responsibility for a public health nursing district. Registered nurses taken on staff on this basis must have signified their intention of completing a course in public health nursing at a recognized university, following a period of experience with the Department. During the past year, the division was fortunate in being able to recommend eight registered nurses, who had demonstrated their ability as potential public health nurses, for bursaries under the Federal Government professional training grants. Only one registered nurse decided not to continue in public health. These nurses have accepted the bursaries on the understanding that they will return to the Provincial field staff for a minimum period of two years following the completion of their course. With the withdrawal of eight registered nurses from field positions, it has been necessary to find replacements. Since a sufficient number of qualified public health nurses were not available this fall, it was necessary to employ an additional group of registered nurses. It is hoped that this group will qualify for bursaries, and, with the return of the first group of public health nurses trained under this plan, that there will be greater stability within the service. New Districts. The division was fortunate to have experienced public health nurses available to open the three new public health nursing districts which were organized during the year, with funds provided through Federal health grants. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 51 In March, in response to local request, the Gibsons Landing service, formerly partially subsidized through grants from the public health service, was reorganized, and a public health nurse was placed in the area covered by School District No. 46. This extended the public health nursing area beyond the territory covered by the Victorian Order of Nurses, giving service to Bowen Island, Egmont, Pender Harbour, and Halfmoon Bay. A Victorian Order nurse was retained in the district. In the fall, the Howe Sound and Kettle Valley public health nursing services were also organized. The Howe Sound service has its headquarters at Squamish and includes Britannia Beach, Woodfibre, and the Pemberton Meadows area. The Kettle Valley service has its headquarters at Greenwood and serves the surrounding area, extending to Beaverdell, Bridesville, Rock Creek, and Westbridge. Notwithstanding the fact that service was extended to new districts, the percentage of the total population covered by public health nursing service remains at 94.9 per cent, a very slight increase over last year, due largely to the general population increase in British Columbia and the fact that the new services were organized in areas with small scattered populations. SERVICE ANALYSIS. Each year it is necessary to assess the public health nursing programme by statistical methods in order to obtain a critical analysis of the various activities being carried out to determine whether an efficient service is being rendered to the community in as economical a manner as possible. This year a time-study covering a three-week test period in October and November was completed by ninety-two nurses. It is hoped that broad analysis of the results of the study will indicate the need for either increasing or decreasing various services and activities, while the study of each report by each individual public health nurse will point out areas where services should be altered in a specific manner in order to meet local needs more efficiently. Table IV.—Comparison of Total Time in per Cent, spent on Specified Activities by Public Health Nurses in Period 1946-1949, as indicated by Time Studies. Year. 1946. 1947. 1948. 1949. 17.7 3.6 18.6 10.8 16.9 18.1 11.9 5.9 16.0 4.6 18.7 11.6 13.1 18.8 17.2 7.0 19.1 6.3 20.3 11.1 20.9 16.3 6.0 5.8 17 4 18 1 Professional clerical 16.8 9.4 Travel 18.3 Other 14.2 4.2 Totals 100.0 100.0 100.0 100.0 Table IV gives a breakdown of various activities by broad groupings by per cent, of total time, with a comparison of the same types of activities for each year since 1946. Table V gives a detailed breakdown of some of these larger activity groups for 1949. KK 52 BRITISH COLUMBIA. Table V.—Per Cent, of Total Time spent by Public Health Nurses in Selected Activities as indicated by Time Study in 1949. Activity. Per Cent. Per Cent. Visits to schools 17.4 17.4 Child Health Conference (total) 7.3 Professional time 5.8 Non-professional clerical 1.5 Home visits 17.1 Prenatal 0.5 Infant 3.2 Postnatal 1.0 Pre-school 3.0 School 3.1 Nursing care 1.9 Tuberculosis 1.7 Venereal disease 0.3 Other 2.4 Other activities 58.2 58.2 Totals 100.0 100.0 It is interesting to note that in order to give the services shown in Table IV, overtime has been necessary. The upward trend of overtime, from 5.9 per cent, in 1946 to 7 per cent, in 1947, has been lowered to some extent by the addition of clerical assistants in 1948 and 1949. This overtime should be considered in relation to a total day's activity rather than in relation to a specific activity. In other words, nurses tend to render specific services and to account for the overtime as clerical or travelling time, while in reality the work they have planned for a specific day may necessitate the expenditure of time in addition to their prescribed daily working time. The public health nurses are to be commended for their unselfish desire to render the service to the best of their ability at the expense of their own time. However, it is hoped that by more careful planning of time all but the emergency service overtime may be eliminated. In addition, public health nurses, as residents of local communities, take an active part in many of the local organizations related directly or indirectly to health, for example, Parent-Teacher Association, Women's Institute, Cancer Association, Tuberculosis Association, Registered Nurses' Association, etc. Participation in these organizations is essential to the success of the general health programme but automatically increases the amount of time which the public health nurse must spend on her total programme. Training Programme. As public health activities have become more comprehensive, it has been necessary to continue in-service educational programmes to keep the staff up to date on current practices and new developments in the public health field. Staff and regional study group meetings, as well as the annual institute, have offered stimulation and guidance in the development of new programmes. For example, during the past year an audiometer hearing-test programme was instituted, and DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 53 a cancer programme was started in a number of selected areas. Use of the Woods quartz lamp was outlined. Arrangements were made through the Division of Health Education to provide the staff with the latest technical knowledge on the use of visual-education equipment. Through meetings on a local level, opportunities have been available to promote better understanding of the work being carried out by other specialized workers, for example, social welfare, etc. Public health nurses have continued to provide field training for undergraduate nursing students as well as for graduate nurses taking the university postgraduate course in public health nursing. Undergraduate nursing students from the Royal Columbian Hospital in New Westminster, St. Paul's Hospital and Vancouver General Hospital in Vancouver, St. Joseph's Hospital in Victoria, and the Royal Inland Hospital in Kamloops have had short, planned orientation programmes. Public health nurses have assisted with the public health lectures at St. Joseph's and the Royal Jubilee Hospitals in Victoria, as well as at the Royal Columbian and the Royal Inland Hospitals, and the Provincial Normal School in Victoria. This programme has given students some appreciation of the opportunities for nursing in the public health field and already has proved to be an effective method of recruiting nurses. Public health field experience for postgraduate nursing students from the University of British Columbia was provided for eighteen nursing students for a one-month period, while fourteen were with the field staff for two weeks. Through the co-operation of public health nursing field agencies with the Committee on Co-ordination of Theory and Field Practice, increased opportunities have resulted in providing the public health nursing students with well-rounded programmes of experience planned in relation to the previous experience record of the student. In addition to the British Columbia nursing students, one student from the University of Manitoba received field work for one month. Senior public health nurses have accepted responsibility for planning orientation programmes for the registered nurses who have been appointed to the staff on a temporary basis. Although this programme is time-consuming, especially since the senior nurses carry large districts, it has proved to be the only method available for providing nursing service during the critical nursing shortage. A plan of orientation for trained public health nursing staff has also been carried out. This has consisted of overlapping of experience with the public health nurse leaving the area and a plan for public health nurses trained outside British Columbia to have special experience as required with the various divisions of the Provincial Health Department and other health agencies. PUBLIC HEALTH NURSING SUPERVISION. Through the local public health nurse in the district and her public health nursing activities in the home, school, and the community, all the available resources of the Provincial Health Department are channelled to the people of British Columbia. Supervision is necessary to ensure a quality of service which will meet acceptable standards. The National Organization for Public Health Nursing recommends a ratio of one full-time supervisor to ten staff public health nurses. KK 54 BRITISH COLUMBIA. This goal is being approached gradually through a plan of experience and training on the staff for potential candidates. As public health nurses demonstrate administrative ability in the field, additional responsibilities for supervising student nurses, registered nurses, and new staff public health nurses are gradually added. During the year a supervisor was appointed to the West Kootenays, supervising in the Trail, Nelson, New Denver, Arrow Lakes, and Kaslo districts. A supervisor was also appointed to the Saanich and South Vancouver Island Health Unit, her territory extending beyond the health unit to include Howe Sound, Powell River, and Gibsons Landing. In addition, following a course in supervision at the University of Toronto, one supervisor was placed in the Fraser Valley at Abbotsford, and she will be available to the New Westminster Health Unit when it is organized. One full-time supervisor continues on the staff of the Central Vancouver Island Health Unit, while the supervisor for the Northern Interior continues to cover the Peace River, Prince Rupert, and Cariboo areas. Miss Margaret Campbell returned after completing the Master of Public Health course at the University of Michigan, and was appointed Assistant Director, Public Health Nursing. During the past year, the senior group of nurses carrying supervisory responsibilities met twice in Victoria for special conferences to discuss practical methods of improving service through supervision. The group also assisted with the revision of various records and manuals and completely revised the daily report form. A progress evaluation scale for public health nurses was also completed and is being tried in the districts this year. For the second time, the staff were fortunate in having Miss Marion Murphy, assistant professor, public health nursing, from the University of Michigan, to conduct an advanced course in public health nursing supervision for a period of two weeks. It was attended by nineteen senior public health nurses from the field staff, and representatives from the Metropolitan Health Committee in Vancouver and the Victoria City Health Department. The course was made possible by Federal health grants and provided an excellent opportunity for supervisors to discuss and work out in a democratic way the problems being faced in their districts. SPECIAL SERVICES. The Division of Public Health Nursing has continued to work closely with the Divisions of Venereal Disease Control and Tuberculosis Control, particularly in relation to nursing affairs. The additional nurse who had been centred with the Division of Tuberculosis Control to do special work in connection with the Mobile Survey Units was released to open a new public health nursing district, following completion of her project. The public health nurse representative with the Division of Tuberculosis Control, Miss Doris Bullock, continues to co-ordinate activities within the tuberculosis institutions and clinics with those of the public health nursing field staff. The Tuberculosis Manual for Public Health Nurses is in the process of revision. One rural epidemiology worker from the Division of Venereal Disease Control has continued to give specialized assistance to the public health staff in DEPARTMENT OF HEALTH AND WELFARE, 1949.- KK 55 their districts in relation to the venereal disease programme. Public health nursing staff have assumed greater responsibility for venereal disease epidemiology on the local level. Following a trial survey of the crippling diseases of children in the Matsqui-Abbotsford-Sumas public health nursing service, plans were drawn up for a survey to be completed throughout the Province over a one-year period. Dr. Donald Paterson, as chairman of the Sub-committee on Crippling Diseases of Children, is working closely with the Bureau of Local Health Services, the field staff, and the Division of Vital Statistics. The survey is being carried out in conjunction with the general programme. It is expected that the results of the survey will indicate where the emphasis should be placed in providing the best preventive and treatment services for children suffering from crippling diseases. Members of the central office staff of the Division of Public Health Nursing have represented public health nursing on various committees—the Educational Policy Committee, the Labour Relations Committee, and the Public Health Nursing Committee of the Registered Nurses' Association of British Columbia. The Director of Public Health Nursing is a member of the Provincial Red Cross Committee, the Provincial Junior Red Cross Committee, the Committee on the Co-ordination of Theory and Practice at the University of British Columbia, as well as the Senate Sub-committee of the University of British Columbia which is studying nursing education in British Columbia. Excellent contributions to the general health programme have been made by related services, that is, the Victorian Order of Nurses, the Red Cross, and the Indian Health Services, as well as lay groups, including the Women's Institute, Parent-Teacher Association, the I.O.D.E., and service clubs. Their generous assistance and splendid co-operation are greatly appreciated. Through the Public Health Nursing Council, the public health nurses have had the opportunity of clarifying their problems with one another at their annual meeting in Victoria. The Council has brought forward suggestions for improving the service and has also directed the interests of the public health nurses toward the broad field of nursing. This was evidenced by the appointment of an official representative to attend the International Nursing Conference at Stockholm, Sweden. During the year, the Division of Public Health Nursing was happy to provide two distinguished nurse visitors with information relative to Provincial and National nursing surveys. Miss Dorothy Percy, of the Federal Department of Health and Welfare, visited the Province with a view to determining how the nursing need for Canada might be met on a broad basis. Miss Lucile Petry, Assistant Surgeon-General, United States Public Health Service, studied the adequacy of the public health service in relation to the broad picture of nursing in British Columbia as part of the James A. Hamilton and Associates Report on Hospital Services in British Columbia. Miss Petry in her report states: " The Health Branch of the Department of Health and Welfare has an exceedingly well-conceived plan for public health nursing services in the Province and has succeeded in implementing the plan extensively. The combination of local and Provincial financing and design of programme KK 56 BRITISH COLUMBIA. bring sound planning and operation. The fact that the Provincial Health Department nursing service is often first on the scene and aims at a comprehensive service should avoid the complications found elsewhere, where two or more services with slightly different functions must later go through the difficult stages of co-ordination and final integration. . . . The desirable trend toward generalization of public health nursing services is well advanced here. . . . The nurses in this service are generally well prepared and receive expert and dynamic leadership. A stimulating permissive atmosphere pervades the service, and co-operative planning is evident both among nurses themselves and between nursing service and the administration." This report by Miss Petry has been most encouraging to public health nurses who have seen the need for more extensive health service and have felt that the service should expand more rapidly than has been possible. The fact that the public health nursing service has been able to maintain its strength in spite of great difficulties is a great tribute to the high calibre of the public health nurse, who joins the public health nursing staff willing to give unselfishly of her time and personal comfort in order to bring public health nursing service to British Columbia residents. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 57 REPORT OF THE NUTRITION SERVICE. E. M. Yvonne Love and Doris L. Noble, Consultants. INTRODUCTION. During 1949 the programme of the Nutrition Service continued to be directed toward meeting the needs of public health staff for consultant service on all matters related to nutrition. The staff of the Nutrition Service has not increased, although the continuing development of local health services has brought additional demands on the nutrition consultant programme. The further extension of the consultant programme to local public health personnel has been an important achievement of the Nutrition Service during the past year. CONSULTANT SERVICE TO LOCAL PUBLIC HEALTH PERSONNEL. During home and school visits, clinics, and conferences, the field staff give advice concerning the wise selection and use of foods for the promotion of health. Problems such as those related to low-cost meal planning, school lunch programmes, and prenatal and infant diets are encountered, and food habits must be considered in dealing with other health problems in the community. The purpose of the consultant programme to local health services is to provide technical data and direct assistance to the field staff in order that they may deal most effectively with these problems. An important part of this programme is that of visits to each health unit. During 1948 the nutrition consultant was able to spend some time in seven health units in the Province. The visit was arranged to coincide with a monthly staff meeting of the unit. At this time the nutritionist has dealt with problems and questions from the field staff and has reported on new developments in the field of nutrition and discussed the application of this information in the local health programme. The remainder of the time in the health unit has been spent in visiting the public health nurse in her own district in order to give direct assistance. Many of the public health nurses have requested direction with school lunch problems. Frequently the visit has included the observation of school lunch programmes, analysis of problems, and recommendations. In most areas public health nurses have asked for direction in advising families on low-cost meal planning. It is planned to continue visits to health units during the coming year, since this is proving to be an effective method of meeting the needs of the field staff. The nutrition consultant has worked with the local public health personnel in two areas where special studies of food habits have been possible. In an Okanagan district, public health nurses and teachers co-operated on a project of improving the school lunches. A study was made of the food eaten by the children at lunch-time. From the information gained, it was possible to make specific suggestions for better lunches to the parents and pupils. After several months, a second study showed a marked improvement in the content of lunches brought to school. Such a method of demonstrating the actual need promotes results of an education programme. KK 58 BRITISH COLUMBIA. In another area of the Province public health nurses, teachers, and local doctors are working together on a comprehensive study of food-habits of the school children and a long-term education programme. A week's record of foods eaten by the school children was obtained early in the school term. This information has been correlated with that of school medical examinations and soil conditions in the area in order to assess the extent of the nutrition problem. A programme to improve food-habits is now under way, in which the school lunch committee and Women's Institute are co-operating with school and health personnel. This project is the first of such an extensive nature to be carried out in the Province. The Nutrition Service is providing technical direction throughout this study and has analysed over 1,000 diet records of the school children. The nutrition consultant held two conferences with the senior public health nurses during their refresher course last summer. It was possible, with this group, to review the entire consultant programme to field staff and to plan the further development of the programme in line with needs and problems which were brought to the fore. In addition to field trips and conferences, a number of requests and specific problems from public health personnel have been dealt with through correspondence and articles in the staff bulletin. To illustrate the variety of problems that has been met, the following will serve as examples:— (1) Analysis of individual diet records where studies have been conducted to assess food-habits. (2) Preparation of study outlines on various topics of food and nutrition for the guidance of local study groups. (3) Specific recommendations where problems of food selection were influenced by such conditions as reduced income, long-term illness, and other disabilities. (4) Preparation of menu guides and quantity recipes where a school lunch programme was planned or in operation. The programme for consultant service to field staff is planned under the supervision of the Director of Local Health Services and in close co-operation with the Director of Public Health Nursing and other divisions. CONSULTANT SERVICE TO INSTITUTIONS. Consultant service to institutions has been continued under the administration of the Director of Local Health Services. The objective is improved food-habits of the people who are served in such establishments. This service has been developed in line with requests for information on the various phases of food service, including food selection, preparation, effective equipment, and organization of staff. In each case, an analysis is made of existing conditions with an outline of suggested recommendations. These are discussed with the personnel concerned and assistance is given to implement changes and improvements. In the past year, continued service to Provincial gaols has included Oakalla Prison Farm, Women's Gaol at Prince George, and Nelson Gaol. At Oakalla Prison Farm and Prince George, an analysis of the average food consumption is completed annually, as recommended in the revised rules and regulations. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 59 Related factors affecting food service, including food cost accounting, food selection, storage, preparation, equipment, and staff supervision, are also given consideration in these reports, and many improvements have been made toward increased efficiency of operation. Continued assistance has been given to Fairbridge Farm School until recently, when circumstances have necessitated that it be closed. With the opening of accommodation for patients under treatment at the British Columbia Cancer Institute, consultant services have been provided in organizing and supervising meal service. Consultant service to hospital administrators, in relation to food service, has been discontinued from this Department during this past year due to the reorganization in Hospital Insurance Service. CONSULTANT SERVICE TO OTHER DEPARTMENTS AND ORGANIZATIONS. Throughout the year the Nutrition Service has received the closest cooperation from other departments concerned in any way with problems or activities of the consultant programme. Conferences with the nutritionists of the Greater Vancouver Metropolitan Health Committee, University Extension Service, and Home Economics Department have been held during the year. These meetings have provided an opportunity for a review of activities and have facilitated joint planning toward meeting mutual problems. This group has completed a booklet dealing with the economical selection and preparation of foods in the home for the reference use of health and welfare personnel. Consultant service on matters of nutrition education in schools and the evaluation and revision of pamphlets has been provided for the Department of Education. At the request of the teaching staff, the nutrition consultant has assisted with the planning and development of the nutrition course for public health nursing students at the University of British Columbia. Throughout the year, the Nutrition Service has had the closest co-operation from the staff of the Bureau of Economics and Statistics on problems of food budgets and costs. Conferences have been held with the Department of Agriculture on matters relating to soil content in various localities, food production and processing. COMMENTS. Staff shortages were experienced in the Nutrition Service during the year. Miss Doris Noble returned to the staff in May, on completion of a certificate course in public health at the University of Toronto. Shortly thereafter, Miss Yvonne Love spent a period of four months on loan to the British Columbia Hospital Insurance Service in connection with hospital food studies. With the service of two nutritionists again available in the fall, it was possible to divide the responsibility for consultant programme to field staff by assigning each nutritionist to one section of the Province. This arrangement will facilitate closer working relationship with local public health personnel during 1950. KK 60 BRITISH COLUMBIA. REPORT OF THE DIVISION OF PREVENTIVE DENTISTRY. F. McCombie, Acting Director. INTRODUCTION. The Division of Preventive Dentistry has been established during the past year with the object of improving the dental health of the people of British Columbia. The most common disease of civilized man is dental caries. Untreated caries or other dental diseases will cause dental ill-health. Diseased teeth and surrounding tissues produce a lowered resistance to general infection and disease, and may be the original cause of a systemic condition causing chronic suffering and even death. Dental diseases are, in the vast majority of cases, preventable, or most certainly the incidence may very significantly be reduced. That dental disease should be vigorously attacked is recognized now as being a public health measure long overdue. Furthermore, it is recognized that the improvement of dental health cannot fail to help to improve the general health of the people, and lower the incidence of, and deaths attributed to, many general infections and diseases. Due to the shortage of dental personnel throughout the Dominion, if for no other reasons, it is obviously impossible at the present time to remedy immediately all dental defects within the Province. However, it is the hope of the division to concentrate immediate attention on the possibilities of preventing dental disease, with particular emphasis on care of the younger children. Furthermore, it is hoped that in successive years it may be possible to continue to safeguard these children from the ravaging destruction of dental disease, and have a generation grow up that is dentally fit and unmarred by the dental cripples so evident to-day. It is appreciated that, at the present time, there exist within the Province many areas where there are insufficient dentists to meet the requirements of the communities. In co-operation with the College of Dental Surgeons of British Columbia and the British Columbia Dental Association endeavour is being made to improve this situation. ESTABLISHMENT OF THE DIVISION. Dr. F. McCombie was appointed as Acting Director of the division early in 1949. He has since visited many communities of the Province to assess the available dental facilities and to suggest possible means for improving the dental health of the people of this Province. From the information gained from these tours and from the latest published research on dental health, the policy of the division was formulated. This policy is prevention. To implement this policy the objectives of the division are summarized as follows:— (1) To provide consultation and assistance to local health units in the formation and development of a preventive dental programme, and to supervise operation of these programmes. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 61 (2) To advise the Department of Health on all problems including or affecting dentistry or dental health. (3) To promote a dental health educational programme. (4) To encourage the location of dentists in rural districts and assist in their location. (5) To serve as a link between the Provincial Department of Health and the dental profession. (6) To organize and assist the existing resources of the dental profession in this Province so as to endeavour to solve the problems resulting from dental decay. (7) To organize and encourage research projects aimed at controlling dental caries and other dental diseases. PERSONNEL. The Acting Director left in September to attend the School of Hygiene, University of Toronto, for a year's postgraduate study leading to a diploma in dental public health. Dr. W. G. Hall joined the division in August from the staff of the Faculty of Dentistry, University of Alberta. He has been deputizing for the Acting Director, and will be appointed as the dental director in the first health unit of the Province to establish a comprehensive dental programme. DENTAL HEALTH EDUCATION. Education in dental health is of primary importance in assisting the people of British Columbia to arrest the appalling annual increase in dental disease. To this purpose all available dental health educational materials are reviewed by the division, and, wherever suitable, supplies are stocked for distribution through local public health personnel. A library of audio-visual aids pertaining to dental health has been built up and is maintained by the Division of Health Education for loan to local health units and other interested groups. A limited number of text-books relating to dental health have been issued to each local health unit to facilitate instruction in this subject to lay groups by local public health personnel. Further books of reference and periodicals are now held by the central library of the Department. Short articles pertaining to dental health are regularly prepared by the division for inclusion in the two monthly publications of the Department. The Acting Director sincerely appreciates the opportunities made available to him to address the Annual Institute of the Department and the senior public health nurses at their biannual conference. It is hoped that by these means it was possible to help make known to the field staff the latest possibilities in the prevention of dental disease. Through the Division of Public Health Education and in co-operation with the Department of Education it has been possible to suggest revisions in the school curriculum for junior and senior high school grades to include specifically, and by detail, dental health education. It is believed that no programme of preventive dentistry can attain its maximum potentialities without the co-operation and assistance of the Department of Education in this respect. KK 62 BRITISH COLUMBIA. However, it is advised that a child free of dental disease is a child more receptive to education and less likely to be guilty of absenteeism. ADVISORY SERVICE TO LOCAL PUBLIC HEALTH PERSONNEL. The division, throughout the year, has answered numerous inquiries from the field staff regarding dental problems, local dental programmes, and dental health educational material. Information is forwarded monthly to the field staff regarding all new supplies of local pamphlets, posters, and audio-visual aids. By personal visits of the Acting Director and by correspondence, the division, in co-operation with local public health personnel, has helped many communities study the possibilities of establishing local dental programmes. It is hoped that several such programmes will be commenced during the coming year with the co-operation and assistance of local dental practitioners. Requests for greater dental facilities are frequently received by the division from many parts of the Province. These requests are referred to the Council of College of Dental Surgeons of British Columbia, who, with the British Columbia Dental Association, are endeavouring to persuade recently graduated dentists, and others, to locate in communities outside the metropolitan areas of Greater Vancouver and Victoria. DENTAL PROGRAMMES. Various types of dental programmes have been evolved by the division and finalized in consultation with representatives of the British Columbia Dental Association. These programmes are based on the preventive aspects of dentistry, and wherever possible will incorporate dental treatment services to preschool and Grade I school-children. This age-group has been selected so as to make available to the youngest children a comprehensive dental service before mass destruction of their teeth makes the problem expensive and difficult, if not impossible, to control. In subsequent years, it is hoped that it may be possible to provide similar care for the older children and, in addition, to maintain in good dental health the children treated in previous years. It is at present planned that during the coming years full-time dental directors shall be appointed to local health units. The duties of such directors will include the encouragement and supervision of local dental programmes within the health unit area, the direction of educational programmes to assist in the improvement of dental health, the study of the effectiveness in the field of proven research methods for decreasing the incidence of dental disease, and the provision of preventive dental treatment for pre-school children and those in the lower grades. In an endeavour to increase forthwith the dental services available to young children, other programmes have been designed whereby the services of private dental practitioners, working in their own offices, may be utilized for preventive dental programmes by communities requesting them. In this programme a local committee is formed to organize their local dental programme for young children in conjunction with a private dental practitioner; his services are paid for monthly on a schedule agreed to by the British Columbia Dental Association. The Department will reimburse the committee to the extent of 50 per cent, of DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 63 the payments made to the dental practitioner on the presentation of prescribed forms notating the treatment rendered to, and the time spent with, each child. To endeavour to make such programmes possible in areas where, at present, there is no resident dentist, two further programmes have been established. First, a system of grants-in-aid has been made available to encourage dentists to locate in rural communities at present without a resident dental practitioner. Second, basically equipped dental offices may be established by the Department in the smaller rural communities with travel allowance available to a near-by dentist for him to visit such offices in his capacity as a private practitioner. To qualify for either of the above grants, such dentists will be required to co-operate with the local community in a preventive dental programme such as outlined in the preceding paragraph. For larger communities desirous of establishing and operating their own dental clinic, and employing therein full-time or part-time dentists, annual grants are available, which include refund by this Department of 60 per cent, of the initial cost of the equipment in such a clinic. DENTAL HEALTH COMMITTEE OF THE BRITISH COLUMBIA DENTAL ASSOCIATION. In conclusion, it is to be recorded that the above programmes are endorsed and supported by the Dental Health Committee of the British Columbia Dental Association. In this respect, this report would be incomplete without recording, with deep appreciation, the diplomacy and untiring efforts of the chairman of this committee, Dr. J. Ewart Gee, D.D.S., also the help of Dr. A. Poyntz, D.M.D., member of the College of Dental Surgeons of British Columbia, and Dr. D. J. Sutherland, D.M.D., of the British Columbia Dental Association. The Dental Health Committee, representative of the dental profession of the entire Province, met on numerous occasions, some members travelling especially from the Interior to attend the meetings, and gave much thought and consideration to the problems affecting the dental health of the people of the Province. Drs. Gee, Poyntz, and Sutherland, in addition to attending these meetings of the committee, met with the Department on numerous occasions to discuss these problems. As a result of their efforts, these programmes were evolved and have been circularized to the dental profession in the belief that, with their sincere co-operation, a beginning will be made to help improve the dental health of the people of British Columbia. KK 64 BRITISH COLUMBIA. REPORT OF THE DIVISION OF PUBLIC HEALTH ENGINEERING. R. Bowering, Director. INTRODUCTION. The Division of Public Health Engineering is concerned with factors in the environment that affect the health of the public. The technical staff of the division includes properly qualified professional engineers and sanitary inspectors. Included within the scope of the Division of Public Health Engineering are water-supply sanitation, sewage-disposal, milk-plant sanitation, industrial-plant sanitation, shell-fish sanitation, sanitation of eating and drinking places, sanitation of housing and tourist resorts, sanitation of frozen-food locker plants, and the miscellaneous items which are included in the term " Environmental Sanitation." This report will deal with the various features under specific headings. WATER-SUPPLY. There are approximately 150 separate water-supply systems in British Columbia. There is a public water-supply system in each of the thirty-five cities in British Columbia. Most of these water-supplies are municipally owned although some are privately owned. There are public water-supplies in twenty- three of the twenty-seven district municipalities in the Province. In some of the district municipalities, there are several separate water-supply systems to serve separate townsites. In some of the district municipalities, a considerable number of the people use private water-supplies. Thirty-three of the thirty- eight villages in the Province have public water-supply systems. These again are mainly municipally owned. In addition to the water-supply systems in the organized municipalities, there are a number of water-supply systems in the unorganized territory. It is estimated that, based on the 1948 population estimate, 835,690 people use water from public water-supply systems. This amounts to 80 per cent, of the population of the Province. One of the most important responsibilities of the division is to be sure that these public water- supply systems provide safe water. The " Health Act " requires that all plans of new waterworks construction be approved by the Deputy Minister of Health. In studying the plans for approval, the source of supply and the distribution system are gone over very carefully in order to see that no public health hazards exist. In many instances, the division is able to suggest alterations to the plans that are of benefit to the local water authorities. Chlorination equipment has been installed and is in use in about thirty water-supply systems. There are two water-filtration plants in the Province. Most of the water-supplies in British Columbia are drawn from surface sources by gravity into the distribution areas. In addition to approval of plans, sanitary surveys of a number of the existing water-supplies were carried out. An increased interest on the part of local water authorities in water safety is apparent. With the increased staff of sanitary inspectors, mentioned in the 1948 Report, it has been possible to do sampling of public water-supply systems on a much greater scale. In addition to this, the results of the samples that are taken may be judged more intelligently. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 65 About 20 per cent, of the population of the Province use private water- supplies. The sanitary inspectors do a considerable amount of work in taking samples from and making sanitary surveys of private water-supplies. Literature is distributed showing how to make wells safe from contamination. There have been a number of requests in the past year for information on how to improve water which has chemical defects. With the assistance of the laboratory provided by the Division of Public Health Engineering of the Department of National Health and Welfare, a considerable amount of service to the public has been rendered in advising on how to treat water to make it more potable. It is hoped that in 1950, with the appointment of the additional public health engineering personnel which were covered in the Federal health grants, a more intensive programme on water safety will be carried out. SEWERAGE AND SEWAGE-DISPOSAL. Sewerage and sewage-disposal is an important feature of the work of the division. Sewerage and sewage-disposal falls naturally into two classes—the private sewage-disposal system and the public sewerage system. The " Health Act " requires that plans of all new sewerage-works construction be approved by the Deputy Minister of Health. In studying the plans submitted for approval, the sizes and grades of the sewers in the collection system are carefully checked. The method of sewage treatment and disposal is also carefully considered, taking cognizance of the body of water into which the sewage is to be discharged. Most of the sewerage systems in British Columbia are built in line with good standards. The pollution of streams and tidal bodies of water by domestic sewage has not yet become a serious problem in British Columbia. However, it is recommended that studies be made during the coming year to appraise the total effect of discharge of domestic sewage into the waters of the Province. The year 1949 saw the commencement of the construction of the new sewerage system and sewage-disposal plant at White Rock. Also, during the year, the ratepayers of Saanich again rejected the sewerage-construction bylaw, although the proportion of persons in favour greatly increased. There are now forty sewerage systems in the Province. There are twelve sewage-treatment plants. It is estimated that 583,500 people are served by public sewerage systems. This amounts to 54.2 per cent, of the population. Almost 500,000 people in the Province have their sewage disposed of by private sewage-disposal systems. This means that the septic-tank problem in British Columbia is a major one. Standard plans have been prepared showing the proper method of constructing septic tanks and private sewage-disposal systems. These have been very widely distributed and very widely used. Standard plans for sanitary privies have also been produced. The problem of sewage-disposal in urbanized unorganized territory is still a serious one. In certain types of soil the septic-tank method of sewage-disposal does not work well unless each house is located on a sufficient area of ground. The result is that the need for sewerage systems is urgent in some of our unorganized territories and also in some of our municipalities. A committee was appointed by the Honourable the Minister to look into this problem late in 1949. It is hoped that this will result in some improvement. KK 66 BRITISH COLUMBIA. The Province does not have a set of standards regarding sewage-collection and sewage-treatment. Studies have been made during 1949 toward the adoption of such standards. It is quite probable that in 1950 a set of recommended standards will be published for the guidance of engineers preparing plans and specifications for sewerage systems. STREAM-POLLUTION CONTROL. The problem of the pollution of streams by wastes other than that produced by domestic sewage is coming to the forefront generally in North America. In British Columbia, the " Health Act" and regulations give the Minister fairly wide authority to prevent pollution of streams from any cause. It is proposed that, should engineering personnel be available, a survey of the pollution status of the Fraser Basin and probably of the Columbia Basin in British Columbia be commenced in 1950 to assess the total effect of pollution produced by domestic sewage and by industrial wastes. The prevention of pollution is not only a public health problem. Pollution creates a problem for any industry which uses water, including agriculture, fisheries, tourist trade, and many other industries. It is felt that an appraisal of the present pollution of all types, together with an appraisal of the capacity of the streams to receive pollution, will be of great value at a time when the Province is on the threshold of major industrial development. It is proposed therefore that, with the greater availability of engineering personnel, work be started on this important matter early in 1950. MILK SANITATION. There were no major epidemics that were proved to be milk-borne in British Columbia during the year. With the increased use of pasteurized milk, milk-borne epidemics should become quite rare. While there is still a considerable amount of raw milk sold in the Province, it is now possible to buy pasteurized milk in all of the major cities and towns in British Columbia. Milk sanitation in British Columbia is under the jurisdiction of the Department of Agriculture as far as the grading of dairy farms is concerned and as far as the licensing of pasteurizing plants is concerned. Quality of the milk itself is a responsibility of local health authorities. The work of the Division of Public Health Engineering in regard to milk is mainly that of a consultative service to local health services. The day-to-day sampling and supervision of the milk-supplies is a responsibility of the local sanitary inspectors. In addition to the taking of samples to be sent to the laboratories operated by the Division of Laboratories, a considerable amount of field testing of milk is now being done by the sanitarians. Kits have been provided to each of the sanitary inspectors for the carrying out of resazurin tests and for the carrying out of phosphatase tests. The continuous co-operation between the Health Branch and the Department of Agriculture in the matter of milk sanitation is definitely improving the quality of the milk sold to the people of British Columbia. SHELL-FISH SANITATION. A considerable amount of effort was directed toward shell-fish sanitation. A new set of regulations governing the sanitary control of the shell-fish industry DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 67 was written and passed during the year. The regulations became effective on October 1st. The shell-fish regulations were prepared to fit in with regulations recommended by the Department of National Health and Welfare and by the United States Public Health Service, so that free shipment of shell-fish from British Columbia to other parts of North America could be carried out. One of the main features of the regulations was to provide for the certification of shucking plants and the certification of shell-stock shippers. Another important feature of the regulations was a requirement that shucked shell-fish could not be repacked in the Province. This has meant a considerable amount of alteration and rebuilding of shucking plants and to a certain extent altering the methods of shell-fish marketing in the Province. By the end of the year, eighteen shucking plants had been granted certificates of compliance with the regulations and twenty-two shell-stock shippers had been granted certificates of compliance. A considerable amount of sanitary survey work was done on the oyster- beds. Boundary Bay and Esquimalt Harbour were given very thorough sanitary surveys. It is quite probable that by the end of 1950 the quality of the shell-fish produced, both from the nutritional and sanitary point of view, in British Columbia will be second to none elsewhere in North America. The division would like to record its appreciation to the Provincial Department of Fisheries for its assistance in writing the shell-fish regulations. Regarding toxicity in clams and mussels, sampling was continued by the Federal Department of Fisheries during the year. Unfortunately, the amount of sampling is not sufficient to determine adequately the extent of shell-fish toxicity in British Columbia waters. The west coast of Vancouver Island is still closed for the taking of clams and mussels for commercial purposes. It is felt that this cannot be opened until much more intensive work is done on the problem. INDUSTRIAL-CAMP SANITATION. With the increased staff of sanitary inspectors that were in the field during 1949, a considerable amount of attention was paid to the problem of making inspections of industrial camps. The division has a record of 1,028 industrial camps. It is estimated that if these camps were inspected by one man, on a full- time basis, it would require approximately twenty-nine months to cover the camps once. If all the sanitary inspectors had an equal number of camps in his district, each man would take 1.33 months to inspect his camps. Thus, an average of 11 per cent, of the sanitary inspector's time would be spent on inspection of camps. This is not possible, however, in practice. In some districts there are only a few industrial camps and the work entailed in inspecting them is not great. However, there are certain districts in the Province where some modification in the programme of inspection of industrial camps may have to be made. In one district served by two sanitarians there are 341 camps. It is estimated that it would take one man a full year to visit these camps. Many of these camps are in almost inaccessible places. Many of the camps are very small and are portable. In this area, during the past year, it has been found possible to inspect only the more permanent type of camp in the routine measure and inspect the smaller camps upon complaint. KK 68 BRITISH COLUMBIA. The sanitation and living conditions in industrial camps to-day are much better than they were several years ago. The new regulations governing industrial camps that came into effect on January 1st, 1947, have now been in operation for three years. The results have been very gratifying. Owing to the time required for inspection of camps in some health unit districts, it is quite possible that the inspection of all the very small camps may have to be dropped as a routine measure. It is the intention of the division during the year 1950 to make a very close estimate of the number of camps which could be called permanent in nature, and attempt to have all these inspected. All camps will be inspected where specific complaints are received. SANITATION OF TOURIST RESORTS. Detailed inspection of tourist camps have now been carried on for a period of about four years. During 1946 and 1947 a special inspector was appointed for tourist-camp work. In 1948 it was felt that the work had been reasonably well started and the responsibility of tourist-camp inspection was placed on the local sanitary inspector. This policy has been continued through 1949. There are a total of 1,112 registered tourist camps in British Columbia. This means that there is an average of almost fifty tourist camps per sanitary inspector. However, there was a very good coverage of the tourist-camp facilities in 1949. Tourist camps are inspected by the local sanitarians prior to granting of a licence. This has been very effective in bringing some of the lower-grade tourist resorts up to standard. In addition to the inspections made by the sanitary inspectors, the Department of Trade and Industry grades tourist camps from the point of view of comfort and luxury. As mentioned in the 1948 Report, the application of the regulations has shown several weaknesses in the presently established regulations. It is hoped that these regulations will be strengthened and improved in the year 1950. SUMMER CAMPS. Summer camps for children are exempted from the regulations governing tourist camps. They do, however, come under the " Welfare Institutions Licensing Act." This Act is administered by the Inspector of Hospitals and Institutions. A large number of these camps were inspected during the year 1949. The operators of these camps are very anxious to have camps of a good standard. There have been considerable improvements in many of the summer camps during the past two years. Summer camps that are operated by non-profit organizations have certain problems which other types of camps do not have. There is usually a shortage of funds, and recommendations by sanitary inspectors are made with the knowledge that economy is essential. It is felt that with the continuation of this policy, summer camps will be greatly improved in the next few years. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 69 ENVIRONMENTAL SANITATION OF SCHOOLS. Detailed inspections of the environmental conditions in and around schools are made by the local sanitary inspectors. The inspections are reported on forms provided for this purpose. Detailed reports are prepared in the health units and copies are prepared for the school boards. These reports are used in programmes of improvement. With the tremendous expansion in the number of sanitary inspectors in the field in 1949, most of the schools in the Province were inspected. SANITATION OF EATING AND DRINKING PLACES. The inspection of eating and drinking places is a very important feature of the work of the local sanitary inspector. It is the desire of the division to have food places inspected at least four times annually. The year 1949 was the third year of the enforcement of the regulations governing eating and drinking places which were passed late in 1946. The good effects of these regulations are still being felt. The eating and drinking places in the Province are gradually coming into line, and the local sanitary inspector encourages a greater sanitation consciousness on the part of local food-handlers. In some parts of the Province food-handling courses have been established. The purpose of the food-handling course is to teach the personnel handling food in public eating and drinking places the fundamentals in the safe handling of food. A uniform report form has been in use during the past year for the use of inspectors reporting on examinations of eating and drinking places. The forms are designed to show whether or not a restaurant is improving. Many restaurants were inspected for the first time in 1949, because complete sanitary inspection service was not available to many areas until this year. Accurate figures on the number of restaurants in the Province and estimates of the number of persons eating meals in restaurants are very difficult to obtain. However, one sanitary inspector reports that in his area, which contains a small city and a fairly large rural area, the number of persons served per day in restaurants is equivalent to 18 per cent, of the population of the area served. He also reports that over 80 per cent, of the items listed on the restaurant sanitation form are satisfactory. In areas where health units have been established for some time, the general sanitation in restaurants and beer- parlours is much better than that found in the areas which have not had this service. Sanitary inspection service will be slightly expanded in 1950 and the result will be a more complete programme of restaurant and beer-parlour sanitation. FROZEN-FOOD LOCKER PLANTS. The year 1949 was the second complete year in which the regulations governing the construction and operation of frozen-food locker plants were in operation. While these regulations require that plans and specifications governing the construction of all new frozen-food locker plants be approved by the Deputy Minister of Health, they do not require the licensing of the existing plants on an annual basis. There were twenty-two approvals of plans for new KK 70 BRITISH COLUMBIA. frozen-food locker plants during 1949. At the end of the year, the division had knowledge of ninety-eight plants, either in operation or under construction. It is estimated that there are approximately 48,500 lockers in the Province. Estimating that each locker serves four people, it means that the locker plants of the Province are serving almost 200,000 people. Routine inspections of the frozen-food locker plants are made by the local sanitary inspector. The experience gained with the operation of the regulations indicates that certain amendments are necessary. These amendments will probably be made in 1950. TRAINING PROGRAMME FOR PERSONNEL. As a result of the Federal health grants, it has been possible to provide considerable training for sanitation personnel. In July and August, a short course was arranged for sanitary inspectors. The attendance at the short course was between forty and fifty. Professors W. S. Mangold and A. H. Bliss, from the University of California, School of Public Health, conducted the course. It is felt that this course provided a real impetus to the sanitary inspectors employed in the Province. It is recommended that courses of this nature be repeated in the future. Through the Federal health grants, N. J. Goode, Assistant Public Health Engineer, has been provided a postgraduate course in public health engineering. Also, the Chief Sanitary Inspectors of the Cities of Victoria and Vancouver and of the Province were provided with a five-month refresher course in sanitary inspection at a university. The constant improving of the qualifications of personnel required for sanitation work will have a permanent effect on the quality of work done by the division. GENERAL OBSERVATIONS. In 1949 the biggest single piece of work of the Division of Public Health Engineering was in connection with shell-fish sanitation. This work occupied almost the whole of the time of the Assistant Public Health Engineer, who had been appointed in January, 1949, together with the work of two students during the summer months. The work of approval of plans continued to be fairly heavy in 1949. The increase in staff of sanitary inspectors, which was recorded in the 1948 Report, threw a tremendous amount of administrative work on the Chief Sanitary Inspector. It is quite probable that the headquarters staff will have to be augmented in order to properly administer sanitation work throughout the Province. The adoption of better and more efficient types of record systems in the local areas will make it easier for the division to evaluate the work of the sanitary inspectors in the field. With the increased interest in prevention of pollution of streams, it is quite probable that the engineering side of the work will be brought more into focus during the year 1950. The division wishes to express thanks to the Division of Laboratories for its co-operation in the examination of samples of water, sewage, and milk. The division would also like to record its thanks to the officials of the Division of Public Health Engineering, Department of National Health and Welfare, for their co-operation on many public health engineering problems. Other members of the staff of the Provincial Department of Health and Welfare have given invaluable assistance to the Division of Public Health Engineering. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 71 REPORT OF THE DIVISION OF VITAL STATISTICS. J. D. B. Scott, Director. INTRODUCTION. The division has two main functions. The first function is statutory, namely, the administration of the " Vital Statistics Act," the " Marriage Act," and the " Change of Name Act" and certain provisions of the " Wills Act." The second function is statistical. The division is expected to give factual information in a precise form, to check and assess results, and to make suggestions regarding further improvements to all services of the Health Branch. Due to virtually complete registration of vital statistics amongst all of the population, except Indians and Doukhobors, the emphasis has, in 1949, been placed upon improving the quality of all registrations accepted. Progress has also been made in the collection of vital statistics records of both Indians and Doukhobors. The Vital Statistics Council for Canada, of which the director is a member, was again active, and further details relating to the Council are reported hereunder. Constant attention has been given to the revision of forms and procedures, to the end that the maximum efficiency will be obtained with a minimum of effort. As a result, many forms were revised and reprinted during the year. Lack of adequate space has continued to add to the difficulties of the staff and general public alike. Such lack of proper facilities has a limiting effect on productivity as well as morale. The transfer of the office of District Registrar in Vancouver from the Government Agency to the Health Branch enabled the division to give better services in the largest centre of the Province. COMPLETENESS OF REGISTRATION. Indians. Current Registrations. Prior to the year 1917 there was no provision for registration of vital statistics of Indians, but in that year arrangements were made whereby this became possible on a voluntary basis and continued in that manner until 1943 when registration became mandatory, as for whites, by an amendment to the " Vital Statistics Act." It naturally follows that such a system leads to inaccuracies and incompleteness in recording. The payment of family allowance, which commenced in July, 1945, brought particular attention to the inadequacies of Indian registrations by necessitating the verification of many hundreds of records of births and deaths which could not be located in the indexes. Experience soon proved that this would be a most difficult task and that an effort would have to be made to review many registrations so as to ensure sufficient identification and verification. An educational programme was carried out amongst the Indian Superintendents in 1946, with definite instructions being laid down, to take effect on January 1st, 1947, aimed at ensuring more complete records in Indian Agency KK 72 BRITISH COLUMBIA. offices, as well as establishing uniformity in the method of handling registrations by the superintendents. This was supplemented in January, 1947, by a comprehensive project of documentary revision, described under a separate heading hereunder. The division is continuing to follow up the progress made in this phase of registration by maintaining frequent contacts with the Indian Superintendents and the Indian Commissioner for British Columbia. A considerable improvement was noted in the completeness and quality of registration of Indian births, still-births, marriages, and deaths. Payment of family allowance to Indians constitutes a great incentive toward completeness of birth registration, while other factors, such as a growing need for accurate vital statistics records by the Indian Superintendents and a greater appreciation of the importance of this service by the Indians themselves, have all advantageously influenced the progress of registration generally. The Indian Commissioner for British Columbia, as in previous years, has taken a keen interest in the work conducted by the division and has wholeheartedly supported the various measures which have been implemented to eventually attain the same standard of registration as for whites. Discussions were held during the year between officials of the Indian Commissioner's office and the division, resulting in a further co-ordination of policy aimed at securing a continued improvement in the recording of vital statistics. The matters discussed dealt with:— (a) A continuation of the report of enrolment of new pupils in schools in September, 1949. (b) The submission to the Director of a copy of the nominal roll of all agencies in the Province, with amendments from time to time. (c) The methods to be used to maintain continuation of given names and surnames. (d) The collection of church records of births and marriages by Indian Superintendents so that such records may be microfilmed by the Director and thus serve the division as a source of reference, particularly when handling delayed registrations. (e) The appointment within each agency staff of a Deputy District Registrar of Births, Deaths, and Marriages and Issuer of Marriage Licences for Indians only, so as to facilitate the administration of the " Vital Statistics Act " and the " Marriage Act," particularly during the absence of the Superintendent from his office. During the year no inspections of agency offices were made by the inspector but instead, in six agencies, valuable assistance in documentary revision was given for brief periods by a senior clerk. It is planned to continue this practice in other agencies and to supplement it with routine visits by the Inspector of Vital Statistics. Documentary Revision. The project of checking, typing, reindexing, and correcting registrations filed during the period 1917 to 1946, inclusive, was continued throughout the year. The indexing of all the births and deaths which occurred within the period from January, 1917, to December, 1946, of the West Coast Indian Agency and the births of the Queen Charlotte Indian Agency was completed. Work is pro- DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 73 ceeding on the deaths of the Queen Charlotte Agency, the births and deaths of the Williams Lake Agency, and the births of the Babine Agency. Priority was given to the searching of 2,305 unverified Indian births forwarded by the Family Allowance Branch, Department of National Health and Welfare. The value of the project was proved when intensive searching revealed that 1,069 of the unverified births were registered, of which number 4.11 were registered under different names. This discovery enabled steps to be taken to correct registrations which had been originally made under nicknames, phonetic spellings, given names, etc. The errors had been caused by the completion of registrations by well-intentioned but poorly informed persons without sufficient reference being made to the agency census in order to ascertain correct spellings of names and other details. The agencies were requested to forward delayed registrations for the 1,236 unverified births which were not registered. By the end of November, 5,704 registrations were reviewed, 123 were found to be duplications, 3,529 corrections were effected, and 607 names were cross- referenced for the indexes. Delayed Registrations. The difficulty of obtaining correct and sufficient verification to meet standards for accepting delayed registrations of births increases the work in this phase of record-collection. However, the division is constantly adding to its library of verifications and is encouraging the Superintendents of Indian Agencies to prepare and submit documentation for all those persons whose names appear on the Indian census and whose births are known to be unregistered. During the year, 264 applications for delayed registration of birth were approved and many more were reviewed but held in abeyance pending submission of more adequate verification of date and place of birth. Appointments of Deputy District Registrars. For a considerable time it had been felt that it would be advantageous to have an appointment of a Deputy District Registrar of Births, Deaths, and Marriages made in each Indian Agency office so as to facilitate the handling of both current and delayed registration work, particularly during the absence of the Superintendent from his office. Arrangements were made with the kind consent of the Indian Commissioner for British Columbia to have such appointments made in thirteen of the agencies in British Columbia. The persons concerned were also appointed as Issuers of Marriage Licences in order to effectively deal with the administration of the " Marriage Act " during the absence of the Superintendent. It is hoped that this will improve the handling of vital statistics work amongst the Indians and will result in more complete registration amongst this minority group. Doukhobors. Current Registrations. The improvement in birth registration amongst Doukhobors, which was noted in 1948, continued during 1949. This was due, in large part, to the efforts of the special field representative and to careful planning of policy concerning the collection of vital statistics. A study of overdue registrations for KK 74 BRITISH COLUMBIA. the year clearly shows that the faction known as Sons of Freedom is the only group which still opposes registration of births. Adequate follow-up work should overcome this situation eventually. The opposition to registration experienced so frequently in the past has largely given way to mere disinterest, which is being overcome by contacts with the field representative and by the natural tendencies of many Doukhobors to abandon the communal form of existence in favour of the standard of living enjoyed by those who have become independent of the communities. Births which occurred in 1949 are virtually all registered, with the exception of events occurring to some members of the Sons of Freedom. With the prospect of a stronger policy in dealing with Doukhobors, this omission will be given close attention in the coming year. During the year, the division was successful in securing registrations of birth of all children of the Hilliers group of Doukhobors, who had previously opposed registration most strenuously. In the past, there has been bitter opposition to accepting any form of marriage except the family-type Doukhobor ceremony, which is not recognized by British Columbia law. However, during 1949 an increasing number of Doukhobor couples have been married by civil contract in order to ensure the validity of their union. This is a step in the right direction and will be encouraged. Registration of deaths still presents problems, for, in many instances, a neighbour of the deceased prepares a crude coffin and the burial takes place as a family affair, without the services of a minister or an undertaker. In these instances, knowledge of the death is often not received until some time after the burial, and it is then very difficult to obtain a medical certification of cause of death. A close check on the completeness of the information shown on death registrations will have to be maintained for a considerable time to come. Delayed Registration. It has been found that Doukhobors seldom seek to have delayed registrations of birth filed for the sake of later benefits to the children. There must be some immediate benefit, such as family allowance, to act as an incentive. At its inception, family allowance was regarded by these people with suspicion, but the number of Doukhobor applicants for the allowance is increasing and thus previously unregistered births become known and are recorded. Employment of Doukhobors by some of the larger companies is also assisting indirectly, as these companies demand proof of age of employees for pension purposes. Registration of Births, other than Indians and Doukhobors. Current Registrations. Except in a small number of isolated areas of the Province, there is no lack of proper birth registration. As almost all births now occur in hospitals, a means is thus provided to ensure the prompt collection of records, since all District Registrars currently receive notices of births by the attending medical practitioner, usually completed at the hospital. Having been thus notified, each District Registrar is responsible for contacting the parents concerned and for any follow-up work necessary to obtain a registration. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 75 The payment of family allowance has assisted greatly in securing birth registrations promptly, but it cannot be assumed that this alone is sufficient to guarantee the recording of all events. The mothers of illegitimate children must be contacted shortly after confinement, otherwise it is often found that they have moved from the locality and quite frequently are not interested in family allowance, especially if the child is to be placed for adoption. Conversely, attempts have been made, due to ignorance or otherwise, to duplicate registrations previously filed, and the greatest diligence must, therefore, be used to ensure the accuracy of the facts as stated by parents. Investigations carried out during the year have indicated that improper records were made in ignorance rather than with obvious intent to defraud. The information has, in most cases, been supplied in such a manner as to supposedly protect the immediate interests of the child. Gratitude is expressed to the medical profession and to hospital staffs for their excellent co-operation in reporting births to the district offices. This feature of the registration system has unquestionably contributed to the high standard of registration presently existing. A new foolscap-size birth registration form was put into use on January 1st, 1949. The content of this form was changed little, but the questions themselves were rearranged and an effort made to simplify the questions so they would be more easily understood by the general public. Delayed Registration of Birth. Delayed registrations accepted during the year continued to indicate that the majority of unregistered births pertain to the period immediately prior to the turn of the century, up to approximately 1920. Many of the remainder were births of illegitimates or reregistrations following cancellations. The reason for non-registration of the former group in many cases was due to the fact that the mother moved away from the district before registering the birth of her child. Steps are being taken to ensure that there is a minimum of loss of registrations of current events through the same cause. Many church records of baptisms and marriages were placed on microfilm, thus adding valuable information to the reference material used for assisting the general public with the completion of documentation for delayed registrations. Effect of Family Allowance. As has been noted each year since the inception of family allowances, many inaccuracies in registrations have been brought to the attention of the division, and, in most instances, records have been amended. While the payment of the allowances has meant a considerable increase in the volume of work, it has contributed to a higher standard of registration than existed heretofore. Many records which were incorrect could previously have been unnoticed for many years, but with the continuing verification of registration of births by the Family Allowance Branch errors now seldom escape discovery beyond a comparatively short time. Gratitude is hereby expressed to the Regional Director of the Family Allowance Branch and his staff for assistance rendered to the division at all times. KK 76 BRITISH COLUMBIA. Registration of Deaths. No difficulty is encountered in obtaining completeness of death registration except in the most remote areas of the Province and among Doukhobors and Indians. There has been an improvement in both these groups during the year, and efforts are being made through the District Registrars to secure still better returns in the future. A slightly revised registration form was put into use in January, 1949. This embodied clarification of certain questions and appears to have largely achieved the desired results. A further revision has been necessary in order that the portion of the form dealing with certification of cause of death will conform to the Sixth Revision of the International Lists of Diseases and Causes of Death. The newly amended form will be placed in the field as from January 1st, 1950. Registration of Marriages. The checking of completed marriage registers issued to the clergy is the chief means of controlling the completeness of marriage registrations and has revealed that proper recording of these events is virtually complete. However, there is need for improvement among the Doukhobors and Indians. In both cases the lack of registration is due to continuation of " family custom " marriages, but these are becoming fewer in number. Education of these groups will eventually correct this situation, though a long-term programme is necessary as these forms of " custom" marriages are long established in both minority groups. Documentary Revision. Owing to the varied purposes for which certificates of births, deaths, and marriages are required, there are indeed few records which can be considered as " dead." While the greatest volume of work is entailed in handling and amending birth registrations, the series of marriages and deaths are also in constant use in order that they may be kept up to date. In the birth series the original registrations must be withdrawn from volumes in order to add notations of alteration of given names, corrections, adoption, change of surname, and legitimation. Marriage registrations must be referred to in order to make notations of divorce or nullity, change of name, and corrections. Revision of death registrations consists largely in entering notations of corrections to the information originally supplied. Since the originals must be kept completely up to date in order that accurate certification may be issued, it follows that prompt revision is a very important part of processing records. . DISTRICT REGISTRARS' OFFICES, INSPECTION, ETC. Changes in Registration Districts. Vancouver District. Space was obtained in the Provincial Government building at 636 Burrard Street in Vancouver for the establishment of a district office so that the overcrowded space in the Government Agency could be utilized for other purposes. The change in location was made on March 15th, 1949. Seven members of the DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 77 agency, who were employed solely on work for the division, were transferred directly to the staff of the Division of Vital Statistics, in addition to which the District Registrar, Assistant District Registrar, and a junior clerk were drawn from other sources. From the outset, it was apparent that the staff was inadequate to handle the large volume of work and it became necessary to add two more members. This situation had been impossible to foresee, as several others of the agency personnel performed part-time vital statistics duties which varied greatly in extent from day to day. The change in organization was accomplished with a minimum of confusion to the division and general public alike, owing to the fact that such a large percentage of the personnel were thoroughly experienced in their respective duties. In addition, the District Registrar had served previously in the Vancouver Government Agency for many years prior to his appointment as Deputy Government Agent at Penticton. The Assistant District Registrar had wide experience, which has contributed greatly to the smooth running of that office. As the Vancouver office is now staffed by Health Branch personnel, it means it is able to undertake certain additional responsibilities which are not generally carried out by district offices. Netv Westminster District. In the New Westminster district office the issuing of marriage licences and solemnization of civil marriages was consolidated in the Government Agency early in the year. This resulted in a considerable increase in the volume of counter work for the agency, so that three persons now perform full-time duty for the division. Changes in other Districts. Four offices of Deputy District Registrars were closed in 1949, after inquiries revealed that their continuation was no longer necessary on account of the small volume of registrations handled. These offices were at Agassiz, Beaton, Telkwa, and Tofino. The work formerly done by these officials has been consolidated within the offices at Chilliwack, Revelstoke, Smithers, and Ucluelet respectively. The former vital statistics district of Fort Fraser was consolidated with Vanderhoof registration district in Februrary, 1949, at which time the Government Agency office at Fort Fraser was transferred to Burns Lake. The change in registration district boundaries was so made because both the Fort Fraser and Vanderhoof registration districts were within the police district of Vanderhoof and the District Registrar of Births, Deaths, and Marriages for Vanderhoof is a member of the British Columbia Police. Two new offices of Deputy District Registrars were opened in order to give better service to the public, the need for these being established by investigation in each case. The additions were made at Armstrong as a deputy of Enderby registration district and at Gibsons Landing as a deputy of Vancouver registration district. Inspections. Fourteen district offices and sub-offices in the Province were inspected routinely, in addition to the instructional visits made to six Indian Agencies. KK 78 BRITISH COLUMBIA. Frequent visits were made to the Vancouver office and several, during the course of the year, to North Vancouver and New Westminster. One visit was made to the Kootenay area to check on the progress of registration of vital statistics of Doukhobors. As noted in former reports, instruction regarding procedure was given to District Registrars at the time of inspections and it has been possible to check the approximate growth and shift of population, which information is valuable for the statistical section as well as for general administrative purposes. At the close of the year there were 72 registration districts under the supervision of a District Registrar and, in addition, there were 22 sub-offices, a special representative for Doukhobors, a Marine Registrar, and 18 Indian Superintendents acting ex officio as District Registrars of Vital Statistics for Indians. Thirty-nine of the District Registrars were Government Agents and Sub-Agents, 39 District Registrars and Deputy District Registrars were members of the British Columbia Police, 8 District Registrars and Deputy District Registrars were other Government employees, while the remaining 9 were nongovernment employees. The Marine Registrar and the 18 Indian Superintendents are Dominion Government employees. VITAL STATISTICS INFORMATION FOR HEALTH UNITS. The system of notification of births, deaths, and still-births to public health personnel was extended so that the Metropolitan Health Committee in Vancouver is now advised of events which occur to residents of the Metropolitan Health District who are temporarily in other parts of the Province. In order to do this, the District Registrars of Births, Deaths, and Marriages at North Vancouver, Vancouver, and New Westminster supply details of their respective districts to the Committee, while the central office of the division segregates events for the remainder of the Province and notifies the Committee directly. This is in addition to duplicate statistical punch-cards for births and deaths and duplicate death index cards. Consideration is being given to a revised method of supplying to the health unit directors information regarding births. The object of this is to assist the public health service in carrying out its various functions, particularly regarding postnatal programmes. Commencing in January, 1950, the Sixth Revision of the International Lists of Diseases and Causes of Death will be taken into use and, as this will entail slight changes in the certification of causes of death on death registrations, a closer liaison between the Director of Vital Statistics and the health unit directors will be formed. A copy of each death registration filed on and after January 1st, 1950, will be forwarded by the District Registrars of Births, Deaths, and Marriages to the health unit director of the area in which the District Registrar is located. Queries resulting from ill-defined causes of death, etc., shown on death registrations will be channelled from the division through the health unit directors to the private practitioners or coroners. Vital statistics are compiled by school district and organized municipalities and this data is forwarded to the health units for their use. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 79 STATISTICAL SERVICES. The statistical sections of the division are responsible for the development of statistical programmes and reporting techniques in all bureaux and divisions of the Health Department, including health units from the planning stage to the collection and processing of data and to the final analysis and presentation of results. It also prepares and analyses demographic data stemming from the registration functions of the division and from population studies. It coordinates such data with the statistics derived from the public health programme. Furthermore, it correlates wherever necessary the statistical work of the division with that of the Federal Departments, notably the Dominion Bureau of Statistics and the Department of National Health and Welfare. In effect, this means that the division acts as a " Division of Health Statistics " rather than performing duties in a limited field. Vital statistics as such are very important because they are basic items in the book-keeping of health. However, with the increased demand for statistical services on the part of the Health Branch arising from the rapidly developing programme for public health, it has become necessary to develop a centralized statistical office for the whole Health Branch. The division continued to assist the Health Branch in the drafting of new forms and in the revision of existing forms to minimize duplication and to establish uniform methods of recording wherever possible. Demography. Monthly summaries of vital statistics registrations are routinely completed by the division, presenting data by age, sex, racial groups, place of residence, place of occurrence, etc. The section continued its study on infant mortality and has accumulated five years of a special punch-card series correlating birth and death registrations. The incidence of maternal mortality and statistics on the causes of death were emphasized as of particular value since they are an important measure of the state of health in the Province. Many detailed annual tables are prepared. Many data are available from the punch-card files and many special tabulations were made from this source during the year. Various population estimates were compiled during the year. Information is given to individuals, business firms, and both official and unofficial agencies. No charge is made for such service. Service to Bureau of Local Health Services. Consultative statistical service was given to health units, covering such varied items as annual-report data for the metropolitan areas of Vancouver and Victoria respectively; assistance in completing the evaluation schedules of " Health Practices," recommended by the American Public Health Association, in Saanich and South Vancouver Island Health Units and also in Greater Victoria; assistance to the Central Vancouver Island Health Unit in connection with an epidemic of gastro-intestinal infection at Port Alberni and Alberni, etc. In addition, special tabulations were prepared for most health units. A great deal of work was done by the division in the compilation and analysis of the data collected in the Wetzel grid study. This was a special study made in the Central Vancouver Island Health Unit area and jointly KK 80 BRITISH COLUMBIA. carried on by the Federal Department of National Health and Welfare and the Division of Health Units of the Health Branch of the Province. The division helped the Nutrition Services in connection with diets in Provincial institutions, including Oakalla. It also assisted in the statistical analysis of the data collected for a Province-wide study of school-lunch programmes sponsored by the Parent-Teacher Association. The information given on public health nurses' records was transferred to punch-cards and tabulated. A change was made during the year in the report form, which meant a redrafting of the punch-card. Each month a summary was completed showing the amount and type of work done by the nurses. During the year, the division made special tabulations for the Director of Public Health Nursing. The division discontinued the work of acting as a clearinghouse for public health family records. It was felt that this function could better be done under the direct control of the Director of Public Health Nursing. Among other services performed for the Bureau of Local Health Services were the preparation of the data for the annual reports of School Environmental Sanitation and Medical Inspection of Schools. Service to Bureau of Special Preventive and Treatment Services. The division continued to render very tangible assistance to the Divisions of Tuberculosis Control and Venereal Disease Control respectively in the preparation, tabulation, compilation, and presentation of their monthly, quarterly, and annual reports. Special tabulations are prepared from time to time for each division. Special assistance was given to the Division of Venereal Disease Control in collecting data required for the surveys made by Dr. Stokes and Dr. Williams respectively on the venereal disease programme of the Province. Service to Public Health and Associated and Voluntary Agencies. As in previous years, the division collected notifications of cancer cases and compiled statistics therefrom. Detailed figures on causes of cancer deaths were assembled. The division is endeavouring to assist the British Columbia Cancer Institute in reorganization of its cancer record system. A Province-wide survey of crippling diseases of children was commenced during the year. The Division of Vital Statistics assisted in the preliminary phases of the study, including the drafting of the questionnaire and a corresponding punch-card. At the close of the year it had coded several thousand records. At the present time, there is no accurate information available to indicate the extent of the problem of the handicapped child in this Province. Therefore, this information should be very valuable to the Health Branch for planning the best utilization of the Federal grant for crippling diseases of children. Also, assistance was given to the British Columbia Division of the Canadian Arthritis, and Rheumatism Society in preparing a monthly record of its activities. In addition, certain discussions have been held with the organizing secretary preliminary to the planning of a record system for the Society. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 81 Mechanical Tabulation. Continuous use was made of the mechanical tabulation of the division during the year, both for routine monthly tabulations and listings of various indexes as well as for special assignments. The marriage index was completed covering all marriages filed in the division since 1872. Searching is now much more accurate and faster than with the old hand-typed or handwritten indexes. Also during the year death-cards were punched for the period 1872 to 1916. Throughout the year the division prepared extensive tabulations for the Bureau of Local Health Services, including the Divisions of Environmental Sanitation, Public Health Nursing, and also for the Bureau of Special Preventive and Treatment Services including the Divisions of Tuberculosis and Venereal Disease Control. A monthly list of all social assistance cases is prepared for the Departmental Comptroller showing names, types of cases, and amount to be paid. This listing is not static from one month to another. Many amendments have to be made. During the year the mechanical equipment was surveyed by the International Business Machines Company, with the result that all the printing, duplicating printing punches were replaced with combined alphabetic, numeric punches, also an interpreter was added to the equipment of the section. This change provides greater flexibility in production so that the division will be better able to undertake more varied tasks in the future. Special applications requiring other types of equipment are sent either to the Bureau of Economics and Statistics or to the office of the International Business Machines Company in Vancouver, depending upon wherever the work can be done first. VITAL STATISTICS COUNCIL FOR CANADA. In May, 1949, the Vital Statistics Council for Canada met in Ottawa for the sixth meeting. Twenty items were placed on the agenda, the most important being in connection with the International List of Causes of Death, a report on the adoption of Minimum Standards of Evidence for Delayed Registration of Birth by the Provinces, also a progress report on the Model Vital Statistics Act. International Statistical Classification of Diseases, Injuries, and Causes of Death. It was reported to the Council that the regulation No. 1 adopted by the World Health Organization was to come into force in Canada on January 1st, 1950. The Dominion Bureau of Statistics, however, will commence coding causes of death according to both the old list and the new list for 1949. Publication of mortality data in the official vital statistics reports will be according to the new international classification from January 1st, 1950. The Council agreed that the material for the Provincial annual reports would be prepared according to the three-digit breakdown in the detailed list. It was reported to the Council that a new Medical Advisory Committee to the Dominion Statistician was established by order in council. The functions KK 82 BRITISH COLUMBIA. of the new Committee cover studies in the field of international health statistics, the relation to economic factors, and, in general, " matters of medical significance as may be required to co-operate effectively with respective agencies of the World Health Organization in the field of vital and health statistics." Both the United Kingdom and the United States have already established their national committees. The Council passed a resolution recommending that the general rules in the manual be adhered to as far as possible in connection with the principle of coding to the underlying cause of death. Further, it recommended that medical certificates of cause of death showing ambiguous or doubtful information should be returned to the physician concerned for clarification. In other words, the main responsibility for selecting the underlying cause rests with the physician, and therefore all efforts should be directed to educating the medical profession in the use of the certification form. It was the opinion of the Council that exceptions and detailed instructions should be kept to an absolute minimum because they would only tend to confuse the issue. In order to improve the accuracy of death statistics, the Council resolved that the coding of the causes of death done in the Dominion Bureau of Statistics be compared with the coding in the respective Provincial offices. Report on Minimum Standards for Delayed Registration of Birth. A committee of the Council reaffirmed that the Minimum Standards for Delayed Registration of Birth, as adopted at the 1944 Vital Statistics Conference, should remain unchanged. This was agreed to by the Council. The Provinces went on record as being willing to give full information regarding the proof accepted for the registration of any particular case. It was reported that the delayed registration problem is now being handled by all the Provinces under a uniform system. ADMINISTRATION OF THE " MARRIAGE ACT." The administration of the " Marriage Act " is a direct responsibility of the division. This includes checking the qualifications of persons about to marry, particularly regarding proof of divorce, proof of age of minors, and proof of presumption of death. Consents of parents for marriage of minors must be reviewed and applications for orders of remarriage dealt with. Owing to the small number of caveats lodged each year it had not hitherto been considered necessary to print a special form for the purpose. However, as the handling of caveats required to be made more uniform, a form was devised and placed in use. In addition, a review of the caveats outstanding for several years was made and many names were cleared from the list. A revised list of those cases still outstanding was sent to the district offices throughout the Province. Before being authorized to solemnize marriages in British Columbia, it is necessary for ministers and clergymen to be registered with the division. When an application for such recognition refers to a denomination which is not yet registered, an investigation is made in order to determine whether the group is a bona-fide religious body, as required by the " Marriage Act." The DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 83 points which are given particular attention include the method of ordination of ministers, the growth and extent of the denomination, its rites pertaining to the solemnization of marriage, and its possibilities of continuity of existence. A personal visit to the locality in which the group functions is made by the Inspector of Vital Statistics in those areas which are reasonably accessible, and in other localities by the District Registrar. These full inquiries provide a protection to properly constituted denominations and the general public alike. During the year one new denomination was recognized and seven applications were under consideration as at December 31st, 1949. All current marriage registrations are checked to ensure that every marriage has been performed by a duly registered clergyman or Marriage Commissioner. A further revision was made in the consolidated Form M. 2, Statutory Declaration; Form M. 3, Notice of Marriage; and Form M. 4, Marriage Commissioners Certificate of Compliance. This reprint shows more clearly the requirements to be fulfilled in order for a marriage licence to be issued or a civil marriage to be performed. It is of considerable assistance to district officials and the general public, both in providing concise instructions and in avoiding misunderstandings between officials and the public. ADMINISTRATION OF THE " CHANGE OF NAME ACT." A further reprint of Forms CN. 2 and 3, covering an application for change of name, was made. Instructions on these forms and on Form CN. 1 have been clarified. A form-letter containing concise instructions to the general public regarding procedure, fees, etc., was revised. Also, a similar form-letter was furnished to the District Registrars for distribution to the general public. The number of applications for change of name which were approved during the year remained almost the same as in 1948. ADMINISTRATION OF SECTIONS 34-40, INCLUSIVE, OF THE "WILLS ACT." In 1945 an amendment, was made to the " Wills Act," providing that any person could file with the director a notice regarding the execution of a will, date of the will, and its location. It was also made possible for subsequent changes to be made on account of new wills, codicils, etc. Upon receipt of proof of death of the testator, a search of such notices may be made so that settlement of the estate may be completed. In order that the records may be readily available, it is necessary that wills-notices be numbered and indexed at frequent intervals. Indexes themselves must be periodically rerun in order to avoid lengthy searches. Hollerith punch-cards are prepared from the original notices and it is, therefore, possible to prepare or rerun the indexes with a minimum of effort. It is interesting to note that the first notices filed in accordance with the above amendment were received in April, 1945, and that only forty-seven notices were filed by December 31st, 1945. In 1946, the first complete year in which the notices were filed, a total of 394 reports were received, but for 1949 the number had grown to 1,562, almost all of which were notices of wills currently KK 84 BRITISH COLUMBIA. executed. In 1947 there were 2,254 notices filed, but many of these referred to wills made during a period of many previous years and hence the number was extraordinarily large. The number had dropped to 1,363 in 1948, as almost all of these then represented notices of wills currently executed. No figures are available for 1945 to show how many revenue searches for wills-notices were made, but by the end of 1949 these had reached almost 400 per month. GENERAL OFFICE PROCEDURES. Processing of Mail. The new combined cash-register receipt, application form, suspense sheet, and reply form (V.S. 30), which was put into use in the central office on January 1st, 1949, has proven a great success and has greatly simplified handling of correspondence. With the introduction of this form, the direction of correspondence was centralized in one clerk, who controls the disposition of incoming mail and who also ensures that, in the outward mail, delivery instructions of the applicants have been observed, that the appropriate type of certification has been issued, and that any other special instructions have been followed. This rearrangement of routine has virtually eliminated complaints as to incorrect mailing of documents. Free Verification and Certification. The Application for Interdepartmental Free Searches and Certificates was again revised and, due to its changed uses, it was renamed Interdepartmental Verification (Free). It was printed as a three-part form with interleafed one-time carbon so that the office making the request for verification prepares the details and sends the form to the division, where the information is checked and (or) amended according to the original record. The form is then date- stamped, initialled by a senior member of the staff, and returned to the originator. A copy is provided for the originating office when the form is first prepared and also for the division, in addition to the copy or copies which are returned to the originator. Separate single sheets are added, as necessary, in order to do this. The procedure eliminates the preparation of Forms V.S. 23, 24, and 25 which were, respectively, Certificate of Birth, Certificate of Death, and Certificate of Marriage—for pensions purposes only. Where the above verifications are not suitable for the department concerned, a positive photographic print (described in more detail hereunder) is provided. As the average number of free searches approximates 500 per month, the use of the new form has saved a considerable amount of clerical time in the central office. Special means were found necessary in order to fulfil the needs of certain departments and yet keep to a minimum the number of verifications made per Form V.S. 8a, Interdepartmental Verification (Free). The Old-age Pension Board has been supplied with a numbered weekly list of deaths of persons 70 years of age and over. This list has been typed weekly from the death registration files and has met the requirements of the Old-age Pension Board auditors, who must verify dates of death of pensioners in order to properly adjust pension accounts. A further refinement of this list, in the form of a combined mechanical tabulation and typewritten list, will be issued as from January 1st, 1950. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 85 The British Columbia Government Hospital Insurance Service must adjust premium rates due to change in status of insured persons and (or) their dependents. The onus for reporting births and marriages was left with such persons, but the division undertook to supply the Hospital Insurance Service with a monthly death-index in duplicate as from January 1st, 1949, and, in addition, a weekly death-index in duplicate as from May 1st, 1949. Section 3 of the " Children of Unmarried Parents Act" requires that each District Registrar shall notify the Superintendent of Child Welfare of the birth of every illegitimate child registered in his office. However, it has been found more satisfactory that such notifications should be sent direct from the division and, accordingly, during the year, an arrangement was worked out whereby the Director furnishes the Superintendent with a positive photographic print of the original registration of birth of every illegitimate child registered throughout the entire Province. This action ensures completeness and uniformity of the data supplied. Revision of Forms and Certificates. Form V.S. 8, Application for Certification, was radically changed so as to provide the division with information as to the reason for which certification is being requested so that the appropriate certification can be issued, as well as furnishing a form which is relatively simple for the public to complete. Supplies were distributed amongst all the District Registrars and to many law firms in order that applications received at the division will contain a maximum of the required details for searching and for mailing replies. Form V.S. 11, Alteration of a Christian or Given Name; Form V.S. 12, Statutory Declaration (for correction of an error) ; Form V.S. 15, District Registrar's Letterhead; and Form V.S. 17, Statutory Declaration (for legitimation) were all revised and reprinted with concise explanations for the use of each being shown thereon. This has resulted in a saving of time both in the district offices and the central office, since the forms are more self-explicit than heretofore and hence fewer need be returned for corrections or additions. Since the Vancouver district office is now part of the division, special forms and form-letters, where necessary, were printed for that office so as to handle, as much as possible, all the routine work with a minimum of effort. In addition, time-saving form-letters were supplied to other district offices in accordance with local needs. The F.L. 36, Instruction for Correction of a Birth Registration, proved particularly helpful in handling birth registrations which had to be returned to parents for correction. A new stock of birth certificates for use as laminated copies was printed and embodies the use of a counterfoil. This has reduced duplication of effort in the accounts section and at the same time has produced information on the duplicate which is more complete than existed previously, thus assisting greatly in tracing misplaced certificates, as well as in tracing original files when requests for duplicates of certificates are received. The new stock of paper birth certificates for District Registrars has likewise been printed with counterfoils. Change in Delayed Registration Procedures. Delayed registrations of births, deaths, and marriages, after acceptance at the central office, are no longer forwarded to District Registrars to be included KK; gg BRITISH COLUMBIA. with returns. This change in procedure minimizes the possibility of documents being lost in the mail and also results in more rapid delivery of certificates to applicants for delayed registration. As soon as a delayed registration is accepted at the division it is placed on file and the District Registrar is merely requested to inform the director as to the district registration number allotted to the record. Methods to Improve Registrations. A good deal of study was given to methods of improving the over-all quality of registrations. This was considered necessary both from the legal aspect of such records and for obtaining better microfilm impressions of registrations. Under the system which was devised to solve the problem, all letters of advice regarding additions or corrections requested by the District Registrars or the central office are preserved for future reference. In the central office, the processing of current records has also been changed in that the checking of all registrations is now carried out prior to numbering, so that only complete records are placed on permanent files. This has eliminated a great deal of refilming which had formerly been necessary and has decreased the number of cards which have to be repunched by the mechanical tabulation staff. Microfilm Procedures. Filming of Documents. The microfilm operators filmed 15,680 files relating to delayed registration of birth in order that much-needed space could be made available by the destruction of the original files themselves. In addition, a start was made on filming files pertaining to alteration of Christian names. When this project is completed, further space for volumes of registrations can be gained by the destruction of the original correspondence files. Sixty-six volumes of transcripts, containing over 30,000 individual records of baptism, were placed on microfilm, as well as numerous volumes of baptismal records loaned by various churches throughout the Province for this specific purpose. Positive Prints. On April 1st, 1949, a new type of certification was introduced in the form of " positive photographic prints." These documents embody a projected enlargement from a 35-mm. microfilm image combined with a contact print certification, on a sheet of paper 7% inches by 8% inches. The prints can be produced in reasonably large quantities and with fair rapidity. They are neat in appearance, durable, free from possible errors in transcription, and have been well received both by the official agencies and the general public. They are used in place of the certified copies hitherto issued and for each series, that is, births, deaths, and marriages where more complete details are required than are shown on the typewritten transcripts. Standardization in Size of Registrations. Since the introduction of the new birth registration form in January, 1949, it has been possible to standardize the binders used for filing registrations in all series except still-birth and Indian. The former will be on a standard-sized DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 87 sheet to fit the new binders as from January 1st, 1950. Stocks of blank Indian registration forms will be punched to fit both the present type of binders used for filing Indian records and the new binders. Such standardization assists materially with the planning of space requirements for the permanent storage of registrations. A further minor change in binders has proved helpful when attempting to locate volumes rapidly. This consists of a different colored backing for each series of registrations, that is, brown for births, green for deaths, and red for marriages. Many hundreds of old files dealing with the non-registration of births of school children were again reviewed and searched in the birth indexes. As a result, it was found that many events have been properly recorded since the correspondence originated (that is, 1933 onwards), and it was thus possible to destroy many of these letters. The correspondence relating to events which are still apparently unregistered was retained so that it will be on hand when applications to register are eventually received. PROBLEMS OUTSTANDING AT THE END OF THE YEAR. Goal in Registration. The ideal situation under this heading would be prompt, complete, and accurate registration of every birth, still-birth, death, and marriage occurring in the Province. It can be truly stated that as far as quantitative registration is concerned there is little more which can be desired, except amongst Doukhobors and Indians, though definite progress is being made with both these minorities. A special field representative is continuing to work among the Doukhobors and frequent contact is maintained between the division, the Indian superintendents, and the Indian Commissioner. Improvement in transportation and educational facilities is bound to have an advantageous effect in this work. Some delays in registration of births have occurred during the latter part of the year and steps are being taken to ensure that there will not be any consequent loss of current registrations. Many delays regarding birth registration are caused by ignorance or disinterest of parents, but even more are the results of efforts to conceal illegitimacy, sometimes complicated by false identification of a mother at the time of admission to hospital. Much improvement has been made in the over-all quality of registrations during 1949, but this feature will continue to be a real challenge for some years to come, especially in the death series. In the more remote regions of the Province it is often very difficult to obtain full personal details of deceased persons, particularly if no relatives can be contacted to supply such information. Also, people frequently die in inaccessible areas without medical attention, and adequate certification of cause of death is thus exceedingly difficult to procure. Owing to the large number of positive photographic prints issued, a great deal of attention must continue to be directed toward better quality in birth and marriage registrations. The term " quality " must be interpreted as including legibility, the use of non-fading ink, the elimination of abbreviations in names, dates, etc., full and sufficient answers to questions on registration forms, correct signatures, properly initialled corrections to original statements, and the like. The fact cannot be overemphasized that all registrations are important KK 88 BRITISH COLUMBIA. legal documents and as such may be demanded in court at any time. Hence all possible measures must be taken to ensure the highest standard of original records. District Registrars have rendered excellent co-operation in improving both quantity and quality of registrations in the past and will be encouraged to continue their good efforts. There has not been any indication of overregistration of births, although this possibility is not being overlooked. Each fraudulent or improper record is carefully investigated before any decisive action is taken. The Inspector of Vital Statistics must continue to be ever watchful for any suspicion of duplication in birth registration, as numerous types of fraud could be perpetrated through the use of false certificates. Since virtually all births now occur in hospital, there is a certain amount of duplication between the Form 3, Physician's Notice of Birth, and Form V.S. 26, Monthly Return of Births (submitted from all hospitals in the Province). A careful study is being made with a view to a consolidation of the two reports, with possibly a more widespread distribution so as to include the directors of established health units. It is hoped that a revised procedure, more suitable to all concerned, may be adopted in the forthcoming year. Legislation. No changes were made in the " Vital Statistics Act," " Marriage Act," or " Change of Name Act," all of which are administered by the director. There is, however, an indication that certain provisions of all these Acts need strengthening and (or) amending to bring them into line with changing conditions. The amendments under consideration do not involve major changes in policy or procedure but must be carefully investigated before being recommended to the Legislature. The matter will be reviewed in the forthcoming year so that, if possible, the suggested revisions could be considered at the 1951 Session of the Legislature. General Office Manual. Owing to pressure of other office business, including a thorough study of several procedures in processing registration, the material which had been gathered for the above publication was held in abeyance. An effort will be made to complete the project in the forthcoming year so that all routines in the division will be committed to writing and thus be easier to study when consideration is being given to making any subsequent revisions. Such clarification of instructions also helps to standardize the treatment of all work carried on within the division and to avoid any misunderstanding of interpretation of accepted procedure. National Register of Vital Statistics. Experience gained in the use of the National Register since July, 1945, has brought out the need for keeping the National Index Section of the Dominion Bureau of Statistics aware of differences between the National Register and the Provincial Vital Statistics Index and has pointed the way toward maintaining agreement between them. Many discrepancies were discovered by the Family Allowance office and a system was devised and placed in operation so as to DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 89 utilize such information by originating a form in the Family Allowance office, to be checked in the Vital Statistics office, and, where necessary, the details relayed to the Dominion Bureau of Statistics in order that amendments could be made to the National Register. The Dominion Bureau of Statistics must prepare its punch-cards from microfilm, whereas the Family Allowance office can check the original and any supplementary application for Family Allowance when in doubt about spelling of a name and also can contact the division in order to verify spellings from an original registration. In this way, punching- errors at the Dominion Bureau of Statistics, caused by errors in names, can be corrected through advice supplied by the Family Allowance office and the Division of Vital Statistics. Information concerning the correction of other errors or the addition of supplementary details is passed, routinely, by the division to the Dominion Bureau of Statistics. However, queries are sometimes raised by the Dominion Bureau of Statistics regarding the answers to various questions on registration forms, and consideration is being given to an improved method of transmitting supplementary information to the Dominion Bureau of Statistics to provide for earlier use of amended film than previously. A reasonably good system of this inter-office advice has been instituted, but it appears that there is room for improvement and an effort will be made to accomplish this in the next year. Certification of Documents. The production of positive photographic prints appears to have solved any problems which could have arisen over the issuance of long-form certificates, as no adverse comments have been received regarding this form of certification. Consideration has been given to replacing the long-form parchment death certificates with an abbreviated document of the same style. However, the stock on hand indicates that a reprint will not be necessary before the fall of 1950. Certification of Causes of Death. With the adoption of regulation No. 1 of the World Health Organization by Canada, it becomes imperative that the certification of causes of death by physicians be improved. This is largely a matter of education. Health unit directors are the most effective persons to introduce the subject to their confreres. The division will have to refer all doubtful cases to the health unit directors for querying by the attending physician or coroner. Results cannot be obtained overnight. A continuing programme of education in the principles of certification will have to be maintained both by the division and the health unit directors. Public Health Statistics. In the last quarter of the year, a great deal of thought was given to the reorganization of the statistical sections of the Division. The addition of new public health programmes and the extension of existing ones in the Health Branch have been largely implemented with the aid of Federal health grants. Consequently, the responsibilities of the statistical sections of the division have increased considerably. Without the authorization of a continuing Federal health grant project for health statistics, involving the employment of three additional statisticians, it would have been impossible for the division to fulfil its proper functions. KK 90 BRITISH COLUMBIA. The statistical sections have been patterned to tie in closely with the general organization of the Health Branch. For instance, one statistician is to head up the work connected with the Bureau of Local Health Services, another is to give service to the Bureau of Special Preventive and Treatment Services, a third has been assigned to related health services not coming directly under these two bureaux. Another statistician has been assigned to deal with the customary demographic functions peculiar to a vital statistics office. A fifth statistician was appointed as a consultant and to act in a liaison capacity between the central office of the division and the services of the branch located in Vancouver. Within the framework of this organizational pattern, it should be possible to meet not only the present demands of the Health Branch but also the urgent requirements for additional service in the immediate future. The major problem facing the division for the forthcoming year is to put the reorganization into full and effective operation. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 91 REPORT OF THE DIVISION OF PUBLIC HEALTH EDUCATION. Kay Beard, Consultant. INTRODUCTION. " Education does nothing for people. Education helps people to do things for themselves, and if health is a state of complete physical, mental, and social well-being, then health education is helping people to live in such ways that their ways of living will contribute to their physical, mental, and social well- being." The above statement by Dr. Thomas Parran outlines briefly the purpose of health education. As a part of a Provincial service, this division cannot work directly with individuals throughout the Province toward the accomplishment of this aim. The health education programme of the community is the responsibility of the local public health staff. This educational programme represents an increasingly large proportion of the work of local public health personnel. In each local public health unit or district, public health education must be planned and conducted by the health unit director, public health nurses, and sanitary inspectors as a part of their already onerous and varied programme. Each meeting attended, each clinic held, and each individual interview presents important educational opportunities. The full utilization of these opportunities requires specialized study and detailed preparation which cannot possibly be included in the already heavy schedule of the present staff without seriously curtailing the service programme. The importance of a well-planned and widespread programme of community health education to the success of local public health services is well recognized by local public health personnel, and increasingly urgent demands have been made for full-time assistance from persons trained in methods of public health education. Since it has not been possible as yet to provide full-time public health education personnel in local health units, the efforts of this division have been devoted to providing consultative service and materials to meet the most urgent educational needs of local public health personnel. LOCAL HEALTH SERVICES. During 1949, assistance to local public health services has been provided in the following ways: Visits to local health units, consultative service by correspondence, supplying of reference materials on loan and general materials for distribution, loan of visual aids, and preparation of special materials on request. The most tangible form of assistance has been through visits to local health units. Four units and three nursing districts were visited during 1949, and discussions were held on the particular health education problems of each area as well as those problems common to all areas, such as utilization of visual aids, methods of filing reference materials, and motivation of health education in schools. KK 92 BRITISH COLUMBIA. In addition to visits, an increasing number of requests for assistance were met through correspondence and by loaning reference materials. This service provides to the public, through their local public health service, reliable information on unusual phases of public health not readily available through local channels. Through funds available from Federal health grants, a basic library of seven public health reference books was supplied to each public health office, and an additional eight books to each proposed or established health unit centre. These books form the nucleus of a local public health library which provides a readily accessible source of technical information for public health staff. In addition, they may be made available to any interested individual or group seeking technical public health information. VISUAL AIDS. Through the assistance of Federal health grants, audio-visual equipment, including a film projector, film-strip projector and record player, has been supplied to each of the eighteen health unit centres. The provision of audio-visual equipment has resulted in a greatly increased demand from local public health staff for visual-education materials. As a result, the film library has been increased to include eighty-five films and forty-nine film-strips. A further expansion will be necessary early in the new year. To prepare local public health personnel for the increased use of visual aids, a series of short demonstrations was presented at the Annual Public Health Institute in April. Since time did not permit the presentation of a complete course on this occasion, a series of one-day courses in health unit centres has been planned to teach the local staff the use and care of the equipment and to discuss the utilization of audio-visual materials. To date three of these classes have been presented. The remainder of the series is scheduled for completion during the new year. This course has not only provided valuable information for the public health field staff but has served as a stimulus to improve their techniques in visual education. The discussions on utilization of visual aids have stimulated interest in the preparation of study guides for films. A number of these have been prepared by the staff of this division, and several public health nursing study groups are engaged in the preparation of others. It is hoped that through these combined efforts it may be possible to provide study guides for all films in the library. As in other years, a large number of films have been previewed with a view to purchase, and those of value in the public health programme have been added to the film library. Films of particular interest to other departments have been referred to the appropriate department, and, on several occasions, film previews have been conducted for members of other departments. A revised film catalogue has been prepared, which, at the request of the field staff, contains more complete film descriptions than are usually included in catalogues of this type. This necessitated viewing all films in the library in order to rewrite the descriptions. The revised catalogue is scheduled for distribution early in the new year. A descriptive catalogue of film-strips has also been prepared and distributed. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 93 Experiments have been carried out in the production of slides, utilizing the microfilm equipment of the Division of Vital Statistics. Through their co-operation, the present possibilities and limitations of this method have been determined and several sets of slides of charts and graphs have been produced. With some additional equipment, it may be possible to include the production of a greater variety of slides. In co-operation with the National Film Board, a series of film showings was planned and conducted for the Western Conference of Social Work held in Victoria in May. MATERIALS, A large volume of reference materials has been requested by field staff during the year. As a result, more books and other reference materials have been ordered than in previous years, particularly in the fields of mental hygiene and child development. It is encouraging to note the increasing interest of public health personnel and of community groups in developing a greater understanding of the effects of the mental environment of the young child. The importance of an active mental-hygiene programme in public health has long been recognized, and the role of the public health nurse in assisting parents to understand their children, and to provide for them a happy, healthy environment, is an important part of this programme. The present staff of this division can assist through the provision of reference materials and suggestions, but the responsibility for arousing interest in, and providing guidance for, local groups remains with the local public health personnel. A classified list of books included in the reference library has been completed and is ready for distribution early in the new year. At the same time the card-index systems for books and pamphlet material were completely revised and brought up to date. This is a task which required the efforts of two persons over a period of several months, but the resulting system should greatly improve the functioning of the library and reference section. Improvements have been made in the system of ordering materials for distribution and reference. This work has been centralized and a method of recording orders has been developed which will prove valuable in ordering materials in the future. As in the past, the staff of the Provincial Library has provided invaluable assistance in obtaining information and providing technical advice. The Health Bulletin completed its nineteenth year of publication. During this year, considerable research into the functions of this type of publication was conducted, and plans for improvement in the format and content were made. Unfortunately, the resignation of the editor in August has again delayed any major revision of this publication. In its present form, however, it continues to serve as a useful source of information to interested groups and individuals who receive it. SCHOOL HEALTH. During 1949, it has been possible to devote a larger proportion of time to school health. At the request of the Department of Education, the senior health educator spent the month of July in planning the health phases of the revised curriculum in " Effective Living," which will include health, guidance, KK 94 BRITISH COLUMBIA. and family relations in one course. The planning of such a course is a most progressive step. The implementation of this course by interested and well- qualified teachers should do much to improve the health of the coming generation, both from a personal and a community standpoint. The curriculum is being planned to help students to help themselves by providing them with a necessary background of scientific knowledge on which to build, by developing an inquiring attitude, and by linking health improvement with basic interests of adolescents. Other projects in school health include the preparation of articles for the " British Columbia Schools," and the assembling of kits of reference materials for public health nurses to supply to school health teachers. This material, requested by senior public health nurses, has proved a valuable stimulus to better health teaching in some districts. A plan for the production of materials on school environment has been discussed with other Provinces and information services of the Department of National Health and Welfare. Suggestions concerning subject-matter and treatment have been forwarded from this office, and it is hoped that these materials will be produced by the National Department during the coming year. Other school health reference materials which have been in a partly completed stage are still delayed until additional staff with teaching experience can be obtained. These reference materials for teachers, when completed, would provide a most useful guide in the implementation of the new curriculum. PRE-SERVICE TRAINING. The orientation programme, planned to acquaint new staff members with the programmes and policies of the department, has been continued during this year. Courses were planned and conducted for six newly appointed health unit directors, two health educators, one senior clerk, and one Junior Red Cross worker. Although this programme has made large demands on the time of the health education staff and senior members of all divisions, it serves a valuable purpose in familiarizing new appointees of the department with policies and programmes. It is difficult to estimate the value of this programme since the results of such training manifest themselves at intervals over a long period of time. The importance of job training is widely recognized in industry, and although the results may not be as tangible it is considered to be a most worthwhile procedure in public health. IN-SERVICE TRAINING. In-service training programmes held during 1949 included the Annual Institute, attended by public health workers throughout the Province, two health unit directors' meetings, a two-week conference for senior public health nurses, and a ten-day conference for sanitary inspectors. The Health Education Division assisted in the provision of visual aids and reference materials for these conferences. Lectures were given to students in the public health nursing class at the university, third-year nursing students at Royal Jubilee and St. Joseph's Hospitals, and teachers in the Junior Red Cross class at the Summer School. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 95 In addition to these special programmes, educational material is provided to public health personnel through the monthly news-letter. This medium is also a means of circulating information regarding new projects in health education undertaken by local personnel throughout the Province. STAFF CHANGES. Three health educators joined the staff during 1949. Miss Joan List, who had formerly been employed on a temporary basis, joined the staff in January, and proceeded in September to the University of North Carolina for a full year's postgraduate work, on a fellowship provided through Federal health grants. Miss List is a science graduate trained in physical education and has considerable teaching experience, a most useful background for her work in health education. Miss Hilary Castle joined the staff in January and Paul Nerland in September. Miss Castle and Mr. Nerland are science graduates, a necessary prerequisite for acceptance to a postgraduate school of public health. Miss Hope Spencer resigned in July of this year to accept the position of executive secretary with the Greater Vancouver Health League. A noteworthy advance in health education in British Columbia was made this year when the Victoria-Esquimalt Health Department added a local health educator, Keith MacDonald, to its staff. This is the first appointment of a health educator in a local health department in British Columbia. Mr. MacDonald, a graduate in science, who has completed one year of postgraduate study in agriculture, is now on leave of absence for postgraduate study in public health education, and will resume his duties in the fall of 1950. Applicants for additional positions in public health education are still being sought. The difficulty of obtaining suitable candidates at the present salary has hampered recruiting efforts during the year. It is hoped, however, that at least one or two positions may be filled early in the new year in order to train public health educators to meet the insistent demand from health units for local health education services. An increase in the central office staff is also necessary if the division is to keep pace with the increasing volume of work which is resulting from a more widespread understanding of the functions and services of this division. KK 96 BRITISH COLUMBIA. REPORT OF THE DIVISION OF LABORATORIES. C. E. Dolman, Director. INTRODUCTION. During 1949, the Division of Laboratories carried out nearly 380,000 examinations, of which about 315,000, or roughly 80 per cent, were done in the central laboratories in Vancouver. These totals represent an increase of approximately 7 per cent, over those for the previous year. Almost all this increase occurred in the main laboratories, although there is good reason to believe that many branch laboratory activities would have shown at least similar degrees of expansion if trained technical staff had been available to them. In Table VI are classified the comparative totals for 1948 and 1949. The tendency alluded to in last year's report, for an increasing percentage of specimens to be sent to the Vancouver Laboratories from sources outside the Greater Vancouver area, has persisted. Over one-quarter of all reports from these laboratories go to physicians and public health officials stationed in other areas of the Province, whereas until recent years the corresponding ratio was only one-tenth. This trend is gratifying in so far as it reflects growing recognition, by the physician and health official in rural areas and small towns, of the importance of public health laboratory work, and also to the extent that it is a consequence of the division's policy to centralize responsibility for the more complex types of tests. However, there is a disturbing possibility, which must be faced, that many specimens now reaching Vancouver from the Province at large might better have been examined closer to their places of origin; and, further, that for every specimen shipped a long distance several might have been sent to a near-by laboratory. The circumstances which have hitherto prevented any expansion in branch laboratory facilities will be discussed in a later section of this report. TESTS FOR DIAGNOSIS AND CONTROL OF VENEREAL DISEASES. As in previous years, tests relating to venereal diseases accounted for about 75 per cent, of the total tests done. However, it should be stressed again that other types of procedures are apt to be far more intricate and costly. Specimens examined for the Division of Venereal Disease Control on the whole proved the most time-consuming, since they more frequently entailed supplementary and quantitative tests, owing to the high incidence of syphilis among the patients from which they came. The great majority of blood specimens reached us, however, from practising physicians, most of whom now appear very conscious of the importance of these sero-diagnostic checks. In co-operation with the Division of Venereal Disease Control and the Indian Health Services, Department of National Health and Welfare, this division was glad to take part in several blood-test surveys of Indian groups living in the Interior and northern parts of the Province. These surveys indicated rather unexpectedly wide fluctuations in the probable incidence of syphilis among these groups. The division continued to examine blood specimens, without charge, for the Canadian Navy, Army, and Air Force. The findings pointed DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 97 to a gratifyingly low incidence of syphilis in the armed forces. This observation apparently applies in general to the population at large, and is borne out by another marked drop in the numbers of dark-field examinations requested. But it should be emphasized that these trends chiefly reflect benefits accruing from introduction of newer methods of treatment and prophylaxis, especially penicillin therapy. There is no evidence whatever suggesting any diminished frequency of exposure to the risk of infection. During 1949, the results were received of the fourth sero-diagnostic survey, launched in November, 1948, under the auspices of the Laboratory of Hygiene, Department of National Health and Welfare, Ottawa. The tabulated summaries of performance indicated a very high standard of specificity and sensitivity in the tests carried out on 100 selected blood specimens shipped from Ottawa to the main laboratories in Vancouver. The Laboratory of Hygiene also arranged, in November, a second refresher course in syphilis sero-diagnostic methods. This was again attended by Miss Mabel Malcolm, senior bacteriologist, who remained throughout the year in charge of this important activity. The course was of roughly three weeks' duration, and included two weeks spent at the Laboratory of Hygiene in Ottawa, with another week given to observation of arrangements at the Ministry of Health Laboratories for the Province of Quebec, in Montreal, and at the Department of Health Laboratories for Ontario, in Toronto. Miss Malcolm also took the opportunity of stopping off a day in Regina, for observation and discussion of procedures at the Provincial Laboratories for Saskatchewan. Microscopic examinations of smears for gonococci and gonococcus cultures conducted for the Division of Venereal Disease Control remained practically unchanged in numbers. But the laboratories gained the impression that there has been a reduction in both the percentage and the actual numbers of positive specimens, particularly among cultures received from the clinic. It was felt that some part of this apparent reduction may have been due to faulty methods of handling culture plates at the clinic. With this in mind, and at the invitation of the director of the division concerned, one of our senior bacteriologists, A. R. Shearer, visited the Vancouver Clinic on several occasions and demonstrated the correct methods of inoculating and treating gonococcus culture plates prior to their being shipped to the Division of Laboratories for incubation and subsequent examination. TESTS RELATING TO TUBERCULOSIS CONTROL. There was a very substantial increase in the numbers of cultures for M. tuberculosis, owing to growing tendencies to request repeat examinations at short intervals from the same patient, and to submit stomach washings for culture from suspected cases of pulmonary tuberculosis. This trend represents a heavy burden to the division, in terms of work-hours and of risk to personnel. On its own initiative, the division undertook in the main laboratories a comparative study of the incidence of positive sputum specimens, as detected by the cultural and direct microscopic methods. Similar inquiries have been made into the question whether inoculation of suspected tuberculous material into guinea-pigs yields results significantly superior to direct cultural methods. While the former procedure, in skilled hands, appears to give a slightly higher percentage of positive results, it is questionable whether this advantage is KK 98 BRITISH COLUMBIA. commensurate with the difficulties inherent locally in the procurement and maintenance of a guinea-pig colony. During the greater part of the year under review, it was necessary for the central laboratories to abandon or curtail animal inoculations, owing to retirement of our guinea-pig supplier and our inability to secure a dependable alternative source. Arrangements were finally made, through the Division of Tuberculosis Control, whereby the guinea-pig colony at Tranquille Sanitorium would be enlarged, as soon as possible, to permit an assured supply sufficient for the needs of the Division of Laboratories. FOOD-POISONING AND GASTRO-INTESTINAL INFECTIONS The customarily large number of outbreaks of staphylococcal food-poisoning were identified during the year, particularly in the summer months. There was also another botulism episode—the third such occurrence in British Columbia within the past five years. It is a striking fact that these three outbreaks are the only recorded examples of bacteriologically proven botulism in Canada to date. In the 1944 Nanaimo outbreak, due to canned salmon improperly processed at home, there were three fatal cases. The 1948 Grand Forks episode, comprising two fatal cases, was due to asparagus bottled on a farm under very unhygienic conditions. The most recent episode, which occurred early in October, 1949, involved two persons in Vancouver, one of whom died while the other recovered after consuming home-pickled herring. Thus, in all, there have been, in recent years, seven known cases of botulism, six of them fatal, in British Columbia. On such a record, the disease can hardly be regarded as a great rarity in this Province, and its high mortality rate alone should warrant redoubled efforts by all those concerned with public health education to emphasize and help avert the dangers of botulism. The Nanaimo outbreak was proved due to the rare and little-known Type E Clostridium botulinum, while the Grand Forks cases were due to the more common Type A organism. In both instances, corresponding strains were isolated from near-by garden soil, and this would seem to point to the probable source of the contaminations. By co-operative effort between this division, the Western Division of Connaught Medical Research Laboratories, and the Department of Bacteriology and Preventive Medicine at the University of British Columbia it was established that the recent cases of botulism from pickled herring were again due to Type E organisms. The evidence so far available points to these organisms having probably gained access to the herring from the intestinal contents of the fish rather than from an exogenous source. To the relatively well-known hazards incidental to consumption of any uncooked food-stuff which has been subject to pollution by human hands must therefore now perhaps be added the special risk, however remote, that pickled herring may convey a fatal dose of preformed botulinus toxin, elaborated from organisms derived from within the fish itself. It should be added that, in this particular instance, the toxin was presumably manufactured during the interval between catching the fish and their subsequent storage in a deep-freeze locker, and possibly also during the twenty-four-hour period elapsing while they thawed out prior to being pickled. Such an event could befall the most fastidious housewife, and the only certain preventive measure would be to cook the herring either immediately before addition of the vinegar and spices or just prior to eating the fish. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 99 Acute gastro-enteritis due to micro-organisms of the Salmonella-Shigella groups (that is, typhoid-paratyphoid-dysentery infections) occurred more frequently than in 1948. Over 150 separate cases of salmonellosis were identified, and more than 20 cases of shigellosis, or bacillary dysentery. These figures represent the highest annual total so far noted for British Columbia, except for the year 1946, when there were several extensive epidemics traced to public eating-places. In 1949, the total mostly represented isolated individuals or small familial group infections. There was no evidence that any of these infections were conveyed from animals to man, although several of the Salmonella types identified locally are known to be transmissible to man from either sick or healthy animals. It should be emphasized that if animal reservoirs of Salmonella infection be not already present in British Columbia they are almost bound to develop sooner or later. In any event, utmost care should always be exercised to prevent pollution of human food-stuffs with animal excreta, particularly from rodents, while animals whose flesh, milk, or eggs are sold for human consumption should be subject to rigorous inspection. Moreover, the definite possibility that water-borne Salmonella outbreaks could originate from infected animals in, for example, the Greater Vancouver watershed has been overlooked by those who contended an unchlorinated surface water-supply will be safe provided the watershed be guarded against human intrusion. These comments seem especially pertinent in view of the fact that throughout the past six years in British Columbia first or second place in frequency of isolation has been held by <S. typhi murium, a Salmonella type notorious for the wide range of wild, domestic, or laboratory animal species which it appears capable of infecting. Apart from S. typhi murium, which was isolated from over sixty different patients during the year, S. typhi itself, and also S. paratyphi B. and S: newport were each obtained from roughly twenty individuals. These four types, and to a lesser degree S. oranienburg and S. bareilly, should be regarded as relatively widespread and endemic in British Columbia. After being unrepresented in 1948, S. thompson and S. bredeney reappeared, while no less than five Salmonella types were identified which had not previously been isolated in this Province. Of these, the following types are well known in other parts of North America: S. anatum, S. kentucky, S. manhattan, and S. potsdam. The remaining organism represents a new Salmonella type. Its antigenic composition was determined by a co-operative effort, in which this division was joined by the Western Division of Connaught Medical Research Laboratories and by the Salmonella Typing Centre of the Laboratory of Hygiene, Department of National Health and Welfare. The formula under the Kauffmann-White schema is XVI:C-1,5, and the designation Salmonella Vancouver is proposed for it. There are no clues to the route followed by these strains in effecting their entry into British Columbia. Some of them may be expected to become established among human and possibly animal carriers. The increasing variety and incidence of Salmonella infections in the Province alone provide a cogent argument for a more complete epidemiological service. Incidentally, a tendency for the daily press to use the term " salmonellosis " rather loosely led, in the autumn, to complaints from representatives of the fishing and canning industries that the public might presume some connection between these infections and salmon. There is, of course, no such relationship. KK 100 BRITISH COLUMBIA. The derivation of the generic term Salmonella is from Dr. Salmon, discoverer of the prototype strain (now known as S. cholerae suis), and the term has come to stay among bacteriologists. Any system of nomenclature which helps to enlighten the public with respect to the causation and prevention of the different forms of bacterial food-poisoning is welcomed by this division. References to " ptomaine poisoning " still regrettably appear, tending to perpetuate the mistaken notion that only decomposing food can be toxic or infective for man. On the other hand, the division certainly recognizes the unfortunate consequences of any reduction in consumer demand for fresh or canned salmon, and deplores the term " salmonellosis " being bandied about by those who do not appreciate its significance. A reasonable compromise for the present would seem to be that the term be used where necessary on laboratory reports sent out to practising physicians and health officers, but that when public health officials have occasion to make statements to the press bearing on a proven food- borne outbreak of salmonellosis the phrase " bacterial food infection" be employed. This is sufficiently definitive for most occasions. However, if the public interest requires that more specific information be divulged, this might best be done by stating that the infection was " due to a micro-organism of the Salmonella group, so-called after its discoverer, Dr. Salmon." In those instances where a definite food-stuff has been incriminated, it would appear desirable, from the standpoint of public health education, to specify it, briefly indicating the factors which apparently led to the outbreak. The incidence of shigellosis (bacterial dysentery) has slowly declined in this Province during the past five years. Throughout this period the numbers of Salmonella organisms isolated in any given year have always greatly exceeded the corresponding numbers of Shigella organisms. In 1949, over 150 Salmonella strains were isolated from separate individuals, whereas only around thirty Shigella strains were identified. Apart from the fact that alternative animal hosts are an almost unknown feature of Shigella infections, there are no significant differences between the modes of transmission in shigellosis and salmonellosis. These apparent disparities in incidence are not easily accounted for, but a lower liability for cases of shigellosis to develop the carrier state and the reputed tendency for Shigella organisms to die out in faeces specimens in transit to the laboratory may be contributory factors. Shigella ambigua (one case) and Sh. newcastle (four cases) made their first known appearance in British Columbia during 1949. The emergence of these new types serves as a reminder that shigellosis may at some future date present problems as formidable as those involved already in salmonellosis. BACTERIOLOGICAL ANALYSES OF MILK AND WATER SUPPLIES. The upward trend in bacteriological tests of milk- and water-supplies, especially the former, was maintained during the year. Milk samples underwent a greater than 50 per cent, increase, while phosphatase tests for efficient pasteurization doubled in number. About three-quarters of these types of tests were done on samples collected from the Greater Vancouver licensing area. Lamentably few municipalities outside Vancouver enjoy the security afforded by compulsory pasteurization ordinances, duly checked by phosphatase tests. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 101 The demands are heavy upon the division for establishment of additional milk- and water-testing facilities in several centres of the Province remote from existing branch laboratories. The division recognizes the advantages of decentralizing the performance of many of these tests, and is doing all within its present limited powers to further this objective. But it seems relevant to urge here that the main issues be not obscured. The only adequate safeguard for supplies of milk and milk-products is efficient pasteurization. Over the years, the division has more than played its part in spreading this gospel. Meanwhile, the central laboratories have kept in continual circulation several boxes for shipping iced specimens into Vancouver, and close co-operation has, on the whole, been achieved between the division and the sanitary inspectors who collect and express the specimens. Brucellosis, as in previous years, presented difficult laboratory problems. There were several instances noted of really high serum agglutinin titres against Brucella abortus, but this micro-organism was not isolated by blood culture on any occasion. This situation contrasts with that obtaining a few years ago, when it was customary for at least two or three cases of acute human brucellosis to be detected primarily on the basis of laboratory evidence. However, questions bearing on the laboratory's role in suspected cases of sub-acute or chronic brucellosis remained troublesome. The significance of circulating Brucella agglutinins in low or medium titre, of brucellergen skin reactions, and of the results of opsono-cytophagic tests, cannot be interpreted categorically by the laboratory worker, who is usually supplied with little or no clinical data. When, as fairly often occurs, the results of the foregoing tests conflict, the total findings must be assessed in the light of the clinical and epidemiological evidence. This is the responsibility of the clinician and medical health officer and not of the laboratory worker. The latter's main task is to secure accurate performance of the most specific tests available. The difficulties which have always beset the diagnosis of brucellosis have become aggravated recently by the enthusiasm of a small group of physicians for specific therapy (using antibiotics such as streptomycin and aureomycin, with or without sulpha-drugs) in cases of vague, chronic illness having mild fever but no localizing signs. In view of this situation and of the growing conviction among most public health laboratory directors that the opsono-cytophagic test was particularly prone to fluctuations depending upon personal technique, the decision was made during 1949 to cease carrying out this test, unless the circumstances were quite exceptional. Tests of water samples for the presence of the Coli-aerogenes group of micro-organisms increased in the central laboratories from 6,930 in 1948 to 7,942 in 1949, or by 15 per cent. Nearly three-quarters of these samples came from sources outside the Greater Vancouver Metropolitan Health Area. The laboratories are now in a position to handle more frequent specimens from the intakes and from various points along the distributing system of the Greater Vancouver Water District. In view of the extraordinary situation which obtains from the public health standpoint, in respect of the water supplied by this authority, the carrying out of such examinations at shorter intervals should be welcomed by every one of the nearly 500,000 consumers concerned. Attention was drawn to this situation in our annual report for 1948, but not until the North Shore floods in late November and early December did it become generally KK 102 ' BRITISH COLUMBIA. known, through the press, that for over two years water from the Capilano intake had been chlorinated at its source. Citizens living in the area, roughly bounded on the east by Main Street, have thus been supplied—for the most part entirely unknown to themselves—with safe drinking water. Other citizens, receiving supplies from the Seymour intake, have been served with potentially hazardous untreated water. The floods, of course, resulted in a turbid water-supply and raised bacterial counts. Yet, despite the conviction expressed by public health and medical association officials, and also by the Board of Trade, that all drinking water distributed in the Greater Vancouver area should be chlorinated, the decision was reaffirmed that the water-supply of about half the citizens of Canada's third largest city should remain unprotected by chlorination. In this report this division must be content to reiterate the following points in connection with water safety:— (1) The internationally accepted standards of the United States Public Health Service for the bacteriological analysis of drinking-water supplies rest upon interpreting the presence of organisms of the Coli-serogenes group as presumptive evidence of pollution with human or animal excreta. (2) The consensus is that these standards need to be more, rather than less, stringent, particularly when applied to large municipal water-supplies. (3) The allegation that no human beings can enter the watershed is irrelevant, even if it could be substantiated. The earlier references in this report to salmonellosis clearly show that excessive numbers of Coli-ae-rogenes organisms of animal origin in a water-supply may indicate a hazard to human health, because of the possible coincident presence of lesser numbers of disease-producing bacteria. (4) To suggest that chlorination need not be instituted until disease- producing bacteria have actually been detected in the water under test is analogous to bolting the stable-door after the horse is stolen. By the time such bacteria were isolated, thousands of citizens might be incubating, or already suffering from, a water-borne enteric infection. The division is not yet able to provide an adequate Province-wide water- testing service for small municipalities and the owners of private wells. As branch laboratory resources improve, this situation may be remedied. But it must be emphasized that bacteriological examinations of single specimens, or even of a small series of specimens from a given source, is of very limited usefulness. A sanitary survey of the site, with special regard to possible sources of pollution, and to faulty construction of the installation, should in any event always precede the submission of samples for laboratory tests. With this principle in mind, we have referred many requests for well-water examination to the Division of Environmental Sanitation. OTHER TYPES OF TESTS. Among miscellaneous tests, those relating to diphtheria loomed by far the largest. Cultures for C. diphtheria? totalled nearly 20,000, an increase of DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 103 roughly 30 per cent, over the 1948 figure. The division may here fittingly repeat the comment made in last year's report, that " diphtheria remains far more prevalent in this Province than it should be." The section responsible for examining suspected diphtheria swabs, under the able supervision of Miss C. Reid, appeared to be continually faced either with a suspected new outbreak of the disease or with problems relating to the release of convalescent carriers and contacts. Here, again, the final responsibility for making these decisions must rest with the physician and the health officer, but it is inevitable that these persons should seek guidance from the laboratory in the interpretation of phenomena which have at times been very puzzling. For example, the type of bacillus implicated in one outbreak apparently changed its characteristics, presumably as a result of bacterial variation. Another outbreak (and occasionally even the same patient) yielded more than one type of C. diphtherias,. Again, patients and carriers sometimes appeared to interchange different strains of diphtheria bacilli. Fluctuating reactions to virulence tests were also noted among successive cultures isolated from the same patient or group of patients. Such findings have been experienced in many laboratories, particularly in recent years, and perhaps represent, in part, an effort of adaptation by diphtheria bacilli to widespread immunization programmes. At any rate, these hitherto rare occurrences may eventually come to be regarded as almost commonplace responses on the part of the parasite to a changing host-environment. They certainly should not be deemed evidence of poor laboratory technique. The division is glad to acknowledge here the typing service for strains of C. diphtherias which was again offered by the Laboratory of Hygiene, Ottawa. Very close concordance has been obtained between our reports and those returned in due course by Dr. Bynoe. Finally, with regard to the vexing question of what criteria should be followed in determining the release from quarantine of convalescent or chronic carriers, the underlying principle here would seem to be that the carrier, no matter how intractable, ceases to be a menace if all the potential contacts be effectively immunized. The number of Paul-Bunnell tests for infectious mononucleosis increased from 739 in 1948 to over 1,000, or by roughly 40 per cent. Requisitions for these tests have practically doubled in the last two years, although there is no convincing evidence that the disease is locally prevalent. Incidentally, this is the only test relating to presumed virus infections now carried out as a routine by this division, although the division is still prepared, should the occasion warrant, to perform the complement-fixation test for smallpox. The central laboratories have agreed to act as intermediary in the shipment of specimens relating to certain suspected virus infections to the Laboratory of Hygiene at Ottawa.' Strict conditions have been imposed by that laboratory respecting the clinical data which must accompany such specimens, and also as regards the times and modes of collecting and shipping the samples. This commitment is liable to prove onerous, without being as satisfactory as the operation of a virus section under this division's own auspices. Cultures of throat swabs for hasmolytic staphylococci and streptococci continued to mount, nearly 4,000 of these being reported on during 1949. Several outbreaks of rather severe scarlet fever and of streptococcal pharyngitis were thus identified. Microscopical examinations for intestinal parasites also KK 104 BRITISH COLUMBIA. increased, to the extent of over 25 per cent. However, there was no evidence of any greater incidence or variety of such parasites. BRANCH LABORATORIES. In June, a Federal public health grant made possible the appointment of A. R. Shearer as a senior bacteriologist and also as supervisor of branch laboratories. The main purposes of this appointment were to facilitate closer integration between branch and central laboratory activities, and to provide information bearing on the location and organization of any new centres it might seem desirable to establish for the performance of certain public health laboratory procedures. With these aims in view, Mr. Shearer made various trips during the last four months of the year which enabled him to visit all the then existing branch laboratories, at Prince Rupert, Kamloops, Nelson, Nanaimo, and Victoria. He also surveyed the situation at Prince George, Vernon, Kelowna, Penticton, Cranbrook, and Courtenay. All of these cities, except Penticton, had become headquarters of full-time health units, and all of them had certain claims to consideration as possible centres for small laboratories, where at least bacteriological analyses of milk and water might be conducted. Very helpful co-operation was received from directors of branch laboratories and health units, from sanitary inspectors, and from many others, including local practitioners consulted during this extensive survey. A series of reports prepared by Mr. Shearer for the director of this division and many discussions about future branch laboratory policy will provide the basis for recommendations to be submitted in due course to the Deputy Minister of Health. Meanwhile, it may be stated that there appears no possibility of establishing new branch laboratories in the immediate future because of the lack of adequately trained persons available. An ill-trained or careless technician, left to his or her own devices in a small town, may actually prove more of a menace than a help to the community. This division is regrettably unable to assist in the training of the needed personnel, owing to its extremely overcrowded and unsatisfactory quarters. Until these major difficulties are alleviated, our soundest policy is to seek to improve the facilities of the present branch laboratories. A threefold approach is proposed, and some measures have already been introduced along each of the following lines:— (1) Improved Equipment.—Two laboratories have been supplied with a high quality electric incubator. Considerable quantities of glassware have also been distributed. These items were purchased under a Federal public health grant made to the division expressly for extension of branch laboratory services. They will permit an enlarged programme of milk- and water-sample testing. (2) Enlargement of Geographic Areas covered.—There is a natural tendency for a branch laboratory centred in a small city to restrict its fields of interest to the demands of its own citizens and to be slow in offering its resources to " outsiders." This kind of parochialism can be broken down by tactful leadership from headquarters, with emphasis upon the democratic significance of a broad concern for our neighbours' health. At least two DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 105 laboratories, when requested to extend their coverage of milk and water analyses to territory under the jurisdiction of another health unit, readily agreed to do so, up to the limit of their resources. Indeed, in one instance, the board of directors of a certain hospital offered to assign more rent-free space for laboratory work which might reach it from centres up to 200 miles away. (3) Provision of Short Refresher Courses.—For the past several years, the central laboratories have gladly provided, on occasion, a refresher course of one or two weeks' duration to a visiting technician from some branch laboratory. From our standpoint, the chief obstacles to widening the scope of this mutually beneficial arrangement have been shortages of staff and accommodation. On the other hand, the branch laboratories have been chiefly handicapped by the unavailability of substitute personnel and by lack of funds to cover the travelling expenses and board incurred by their representatives in visiting Vancouver. During the spring, the senior technician and two other technicians from the Royal Jubilee Hospital laboratory at Victoria each spent one week at the central laboratories. The value of this experience to themselves and, therefore, to their public health laboratory responsibilities is best summed up in these words written by their own laboratory director: " Our three technicians have returned to this hospital extremely enthusiastic over the time spent in your laboratory. They have introduced many changes in the short time they have been back and have given us many altogether new and different ideas. No expenditure the hospital has ever made, I am sure, has increased the efficiency and accuracy of our procedures as has this one. ..." Such gratifying testimonials encourage the division to spare no effort to further these opportunities as circumstances permit. In fact, it is hoped to secure a Federal public health grant in the coming year, which will permit reimbursement of the larger branch laboratories for the costs entailed in sending one or more of their technicians to Vancouver for brief refresher courses in the central laboratories. The division records with regret the resignation of Dr. R. E. Coleman, effective August 31st, 1949, from his position as pathologist at the Prince Rupert General Hospital and as director of the branch laboratory at Prince Rupert. The technician hired by the hospital to replace Dr. Coleman was found to have no time available for public health laboratory work, and so far it has not proved possible to find a suitably qualified person to take over this work. The Prince Rupert branch laboratory is therefore not operating for the present. This is especially regrettable because of the extensive area which Prince Rupert could logically serve as a centre for the referral of specimens. Until the situation can be rectified, specimens are being sent to the central laboratories, where necessary by air mail. Miss Jessie Craig, R.N., senior technician at the Royal Inland Hospital, Kamloops, also resigned at the end of the summer. Her departure made it necessary to have the sero-diagnostic tests for syphilis transferred to the cen- KK 106 BRITISH COLUMBIA. tral laboratories. The Kamloops branch laboratory, which is under the direction of Dr. F. P. Sparkes, thus operated at a reduced turnover for the last four months of the year. The remaining branch laboratories, located at the Royal Jubilee Hospital, Victoria; the Kootenay Lake General Hospital, Nelson; and the Nanaimo General Hospital, experienced increases in specimens examined ranging up to 10 per cent. We are glad to record our appreciation of the good work done at these three branches, under the direction of Dr. R. G. D. McNeely, Miss Betty Johnson, and George Darling respectively. The activities of the branch laboratories for 1948 and 1949 are set forth in Table VII. GENERAL COMMENTS. As in past years, the central laboratories have continued to discharge many responsibilities beyond those indicated in Table VI. These obligations tend to become increasingly onerous. For instance, the demand for biological products relating to the control of communicable diseases continued to mount. That the very substantial sum appropriated for these products was so economically spent was largely due to the efficiency with which Mrs. M. B. Allen, who is in charge of the office, checks all requisitions and redistributes surplus products sent back to the laboratories. Again, especially large shipments had to be made throughout the year—glassware and specimen outfits to branch laboratories, milk- and water-sample containers to sanitary inspectors, and innumerable packages for practitioners. The clerk in charge of supplies, Miss B. Thomson, has handled these miscellaneous tasks most effectively. Reference should also be made here to the increasingly troublesome burden entailed for the office staff in the multiplying demands from various quarters for copies of laboratory reports. This burden is now excessive, and a new system will have to be devised in the near future. The director was consulted, chiefly by mail or telephone, by all sorts of people and about an extraordinary variety of questions. Fortunately, the assistant director, Miss D. E. Kerr, was able to cope satisfactorily with many of the telephoned inquiries. A high percentage of these inquiries bear on the interpretation of our laboratory reports, particularly those relating to serological tests for syphilis. Co-operation with the Division of Venereal Disease Control has indeed been manifested in numerous ways. The division was glad to arrange, for instance, that for a fortnight during the summer Mr. Shearer should take charge of the laboratory work of the Division of Venereal Disease Control. This afforded him an opportunity for noting the techniques currently in use there, and he has since made several practical suggestions regarding possible improvements. Research Activities. Apart from the so-called " routine " tests and this consultative work, there were frequent requests, from many quarters (ranging from the lay public to the coroner), for special investigations. The division has adhered firmly to the principle of launching such researches only at the request of registered physicians or their authorized representatives, and then only when, in the opinion of the staff, the time and trouble entailed were commensurate with the importance of the problem. Under these provisoes, three particularly inter- DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 107 . esting projects were initiated during the year. Two of these, namely the isolation of Salmonella Vancouver and the Type E. botulism episode due to home-pickled herring, have already been mentioned. The other concerned two cases of rat-bite fever, involving Indian infants living in North Vancouver, from both of whom Streptobacillus moniliformis was isolated by blood culture. These inquiries, which will eventually be the subject of technical reports, were all pursued as co-operative ventures jointly with the Department of Bacteriology and Preventive Medicine and the Western Division of Connaught Medical Research Laboratories. Conferences and Publications. The Director attended the annual meeting of the Technical Advisory Committee on Public Health Laboratory Services to the Dominion Council of Health, held in Ottawa early in December under the auspices of the Laboratory of Hygiene, Department of National Health and Welfare. These meetings furnish most valuable opportunities for the exchange of views on numerous technical topics as well as for discussion of present and possible future Government policy in relation to matters affecting the Provincial laboratories throughout Canada. After this conference, the Director attended the annual meeting of the Laboratory Section, Canadian Public Health Association, held in Toronto, where he presented a paper on the two cases of Type E botulism due to home-pickled herring. A paper on S. Vancouver, under the joint authorship of Dr. C. E. Dolman, Dr. L. E. Ranta, and Miss V. G. Hudson, all of Vancouver, and also of Dr. E. T. Bynoe and two of his associates in Ottawa, has been accepted for publication by the Canadian Public Health Journal. A paper by Dr. Dolman, entitled " The Aetiology, Epidemiology, and Control of Influenza," was published in the April and June, 1949, numbers of the Canadian Journal of Comparative Medicine. Accommodation. Attention has been drawn for more than a decade, in successive Annual Reports, to the serious handicaps under which the headquarters of the division labours. The unsuitability and inadequecy of the quarters cannot be overemphasized. They are fire-traps of the worst order, are intermittently and unavoidably infected with rodents, and the heating and ventilation arrangements are deplorable. At the year-end, during a severe cold spell, almost all the sinks became plugged from freezing of the drains, one furnace and one gas hot-water heater disintegrated, while two of the houses were rendered uninhabitable through freezing of taps and hot-water pipes. Only extraordinary good humour and forbearance on the part of the whole staff made it possible for the laboratories to remain operating in this crippled condition. A similar situation obtained last year, and the division surely cannot be expected to endure these working conditions any longer without some definite assurance that satisfactory alternative accommodation is shortly forthcoming. Meanwhile, the division must perforce continue to improvise. It has managed to scrape by each year by exercise of good-will and by constant concern for effecting improvements in our internal methods and policies. The possibilities here are, of course, seriously limited by physical circumstances. As an KK 108 BRITISH COLUMBIA. example, one may cite the installation of two mechanical washing-machines. Their introduction released a small room previously used for hand-washing of Kahn-test tubes. This room was converted into a laboratory and attached to the tuberculosis and miscellaneous section, under the capable supervision of Miss J. McDiarmid. The additional space thus made available permitted a consolidation in the one section of all laboratory work relating to tuberculosis control. Unhappily, there is no room for further washing-machines of this kind in the glassware-cleaning and outfits-making section. During the year, it was decided to hold monthly evening meetings of the senior technical staff. The problems facing the division are becoming so complex that it seemed sound policy to encourage those in charge of the various sections to share in a wide appreciation of the nature of these problems. The meetings have been very helpful, and the policy will be continued. The relations of this division with the medical profession and with other divisions of the Department of Health have remained cordial and co-operative. It remains only to record the director's appreciation of the fine example set by all senior staff members, which has contributed so much, under trying circumstances, toward maintaining a high morale throughout the division. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 109 Table VI.—Statistical Report of Examinations done during the Year 1949. Out of Town. Metropolitan Health Area. Total in 1949. Total in 1948. Animal inoculation _ Blood agglutination— Typhoid-paratyphoid group Brucellosis — Infectious mononucleosis Miscellaneous Cultures—■ M. tuberculosis — Typhoid-Salmonella-dysentery group.. ._ C. diphtherias Hemolytic staphylococci and streptococci... Gonococcus Miscellaneous __ _._ Direct microscopic examination for— Gonococcus M. tuberculosis (sputum) M. tuberculosis (miscellaneous).— Treponema pallidum Vincent's spirillum Ringworm _ Intestinal parasites _._ Serological tests for syphilis— Blood- Presumptive Kahn _ Standard Kahn . Quantitative Kahn.______ Complement fixation Cerebrospinal fluid— Complement fixation Quantitative fixation Cerebrospinal fluid— Cell count Protein Colloidal reaction Milk- Bacterial count Coli-eerogenes Phosphatase Water— Total bacterial count __ Coli-serogenes Unclassified _ Sputum cultures (special study). Totals 148 3,710 1,684 197 869 744 3,337 1,067 505 3,800 5,592 869 46 71 * 160 23,190 4,910 1,024 4,867 584 51 312 550 624 843 843 457 100 5,484 159 3,019 69,824 438 7,700 4,937 831 15 2,858 3,414 16,451 2,752 10,508 821 30,051 3,347 2,858 408 302 * 401 96,715 17,431 4,586 16,863 2,600 271 1,211 2,029 2,519 1,392 1,391 1,255 810 2,458 377 1,591 241,591 586 11,410 6,621 1,028 23 3,727 4,158 19,788 3,819 10,508 1,326 33,851 8,939 3,727 454 373 561 119,905 22,341 5,610 21,730 3,184 322 1,523 2,579 3,143 2,235 2,234 1,712 910 7,942 536 4,610 869 13,036 6,184 739 26 2,608 5,058 14,689 3,092 10,322 1,264 33,990 9,015 2,608 605 439 1 460 111,739 23,939 5,838 22,864 3,141 295 1,588 2,579 3,141 1,421 1,421 877 851 6,930 424 311,415 292,053 * Under " Unclassified.' KK 110 BRITISH COLUMBIA. Table VII.—Number of Tests performed by Branch Laboratories in 1949. Examination. Kamloops. Nanaimo. Nelson. Prince Rupert. Victoria. Total, 1949. Total, 1948. 65 49 129 36 65 1,428 705 40 194 Blood agglutination— 286 295 596 164 445 105 52 12 4 860 609 8 Cultures—■ 15 461 266 2,638 2,638 597 461 282 2,745 2,792 597 76 1,934 6,306 439 37 116 15 313 20,113 16,416 729 2,623 154 464 698 665 526 2,130 1,968 948 1,028 2,586 185 214 Typhoid-paratyphoid-dysentery group 36 30 16 6 62 261 50 62 64 • 336 377 23 2,868 Haemolytie staphylococci and strepto- 2,498 744 12 258 1,016 11 65 Direct microscopic examination for— 193 934 3 99 164 1,048 3,815 402 22 89 12 207 20,113 1,718 385 2,623 2,628 6,687 246 Treponema pallidum.. 15 65 8 9 10 3 75 126 Ringworm ,„. 14 31 2,346 6 56 280 Serological tests for syphilis— Blood— 3,915 205 16,944 7,029 133 1,408 17,860 215 2,770 Cerebrospinal fluid— Kahn ... 89 9 177 464 417 322 428 953 953 893 930 1,033 9 448 Cerebrospinal fluid— 99 88 41 76 14 49 123 65 63 114 49 104 97 135 22 6 8 310 310 727 Protein ... 536 559 Milk- Bacterial count __ 688 691 2,309 2,202 Miscellaneous (phosphatase and reduc- 6 348 1,024 Water—■ 98 755 111 582 327 2,647 367 Totals, 1949 Totals, 1948 4,495 5,822 6,858 6,257 11,756 11,659 2,761 3,338 43,715 40,658 69,585 67,734 Note.—Prince Rupert operations discontinued after August 31st, 1949. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 111 REPORT OF THE DIVISION OF VENEREAL DISEASE CONTROL. C. L. Hunt, Director. INTRODUCTION. The trend in venereal diseases in general shows a slight but definite decline throughout the Province. The greatest and most gratifying improvement has been shown in relation to syphilis, early infections having shown a decline of over 50 per cent, in 1949 over 1948. The figures for gonorrhoea have remained fairly steady. In Vancouver, it has been felt that there remains a pool of infection which is difficult to eradicate, and special efforts have been made by the epidemiological section of the division, with the co-operation of the Vancouver City Police, to bring in all suspects for examination. Many persons who are examined in this way show doubtful symptoms but lack confirmation of gonorrhoea infection. In view of the recognized difficulty in isolating the organism in many cases of chronic infection, it has been decided to treat these patients on clinical and epidemiological evidence. It was realized that this would have an adverse effect upon the statistical figures for the Province, but as a public health measure it was felt to be justified. A certain number of these patients are now being diagnosed as " non-specific " infections provided that extensive and repeated examinations are negative for gonorrhoea, but treatment is given nevertheless. Free diagnostic and treatment facilities continue to be given at the various clinics of the division, while private physicians are making use of the free consultative service provided at these clinics to an ever-increasing extent. Particularly does this apply in the Vancouver area. Free drugs for the treatment of venereal disease are available to all persons in the Province through their physicians, as well as free consultative service by letter or telephone whenever a physician requests it. The co-operation of private physicians in notifying fresh cases of infection, as well as in carrying out procedures recommended by the division, appears to be improving, though there are still some areas in which difficulties occur. TREATMENT. A new treatment schedule for syphilis was drawn up in February, 1949, and distributed to every physician and hospital in the Province. At that time, the older prolonged courses of treatment with arsenic and bismuth were discontinued. Penicillin became the drug of choice in all stages of syphilitic infection, though this was followed in most instances by a short course of arsenic and bismuth, since it was felt that in the present stage of our knowledge it was unwise to discard completely the old, well-proven remedies. Owing to the shortage of beds during the summer months there has been a tendency to use, to an ever-increasing extent, the ambulatory form of treatment with " delayed absorption " types of penicillin. Results with this method of treatment appear to have been as effective as with the more inconvenient three- hourly injections of aqueous penicillin. KK 112 BRITISH COLUMBIA. Admission to hospital for treatment is now used almost exclusively for cases of cardiovascular or neurosyphilis. Treatment of gonorrhoea has undergone some modifications in the Vancouver Clinic. In view of the fact that a small percentage of patients with gonorrhoea must be considered as having been contacts also to syphilitic infection, it was felt desirable in conformity with the most modern accepted practice, to treat all gonorrhoea cases admitted to the Vancouver Clinic with 1.2 million units of delayed-absorption type of penicillin. It is hoped that by this means a cure will be effected in a certain number of syphilis cases in their incubation stage, thus cutting down the spread of infection. Intensive investigation is being carried out at the Vancouver Clinic on so- called non-specific urethritis, but it will be some months before any definite conclusions are available from this study. Vancouver Clinic attendances are showing a steady decrease, even though the number of patients brought in for investigation remains fairly constant. This reflects the greater effectiveness of modern forms of treatment for venereal disease. Streptomycin is being used for treatment of resistant cases of gonorrhoea, both in the clinics and by private physicians throughout the Province. EPIDEMIOLOGY. The epidemiological section of the Division of Venereal Disease Control is responsible for directing and advising on problems relating to case-finding and case-holding throughout the Province. There is a growing tendency, however, to delegate an ever-increasing responsibility to health unit directors and public health nurses in the field, who have indeed rendered valuable and efficient service. There has been most gratifying co-operation from the metropolitan authorities and from all the divisions of the Provincial Department of Health in all matters relating to epidemiology. Meetings continue to be held at intervals of three to four months for discussion of outstanding problems relating to the facilitation of the spread of venereal diseases. Attendances at these meetings have been excellent and have included representatives from the Vancouver and Victoria City Police Departments, the British Columbia Provincial Police, Indian Health Services, Department of National Health and Welfare, British Columbia Hotels Association, Liquor Control Board, and the Vancouver City licence inspector, as well as the senior medical health officers from Vancouver and Victoria. These discussions have covered a wide field and have been most helpful to the division, as also has been the co-operation shown throughout by the various individuals and groups concerned. In view of the moral and social factors underlying the spread of venereal disease, it was decided to invite representatives of various religious denominations to the facilitation meetings in an endeavour to enlist their help. The enthusiastic co-operation of the clergy in matters relating to venereal disease control has been more than gratifying, and it is felt that much can be done by them in attacking the problem in moral and social directions. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 113 Special mention should be made of the assistance given by the Vancouver City Police Force, headed by Chief Constable Walter Mulligan, and by Detective- Sergeant Fish and his morality squad. Their efforts, combined with the Male and Female Diagnostic Clinics held in the Vancouver City Gaol, have been responsible for the detection of a large number of cases which had lapsed from treatment, as well as almost 8V2 per cent, of all the neiv cases of venereal disease notified among females each year throughout the Province. Two blood-testing surveys were carried out during the year, as a result of which a total number of sixty new syphilis cases were discovered out of 680 persons examined. As a result of this survey forty-nine patients were placed on treatment. SOCIAL SERVICE. The role of the social service worker is assuming a place of steadily increasing importance in the venereal disease control programme. It is appreciated that social factors, such as unhappy homes, poverty, frustration, loneliness, and many other forms of emotional stress, play a considerable part in contributing to promiscuous sexual relationship. In view of this, every new patient reporting to the Vancouver Clinic is granted an interview with a social service worker, by whom an attempt is made to detect and assess any underlying social or psychological problem. Such problems are dealt with at this level whenever possible, but certain of the more serious problem patients, as well as habitual " repeaters," are referred to a psychiatrist for further psychological investigation and, if necessary, treatment. It is felt that the services rendered by the social service workers have been of considerable value in many instances, while their work is affording some insight into many of the underlying problems associated with promiscuous sexual relationship, particularly in the Vancouver area. EDUCATION. The Division of Public Health Education is primarily responsible for general public education in venereal diseases throughout the Province. There has, however, been close liaison throughout with the Division of Venereal Disease Control, the latter Division taking most of the direct responsibility in the Vancouver area. Much valuable assistance has been given by the Health League of Canada, under whose auspices there has been a series of radio programmes on venereal disease broadcast from local stations throughout the Province. These programmes have consisted of recordings made by Columbia University dealing with venereal disease from various aspects. Talks and discussions have been held with small lay groups from time to time, as well as lectures to groups of students of nursing and social welfare and to nurses engaged in industrial medicine. There is a regular venereal disease instruction course for student nurses at various training hospitals throughout the Province, which, in the case of the Vancouver General Hospital, includes an intensive period of practical work in the Vancouver Clinic. KK 114 BRITISH COLUMBIA. There has been a revision of the Reference Manual for Clinic Physicians, incorporating recent developments in diagnosis and treatment, as well as a new and revised edition of the booklet " Procedures and Services in Venereal Disease Control." A copy of this latter publication has been sent to every practising physician in the Province. It gives information on criteria of diagnosis and on the various services available to the private physician in the investigation and treatment of venereal disease cases. A booklet has been prepared setting forth various " Factors in Venereal Disease Control," wherein an attempt is made to show the wider moral and social implications which must be taken into consideration in any control programme—venereal disease and promiscuity being considered as symptoms of much deeper faults in our social, moral, and educational systems. At regular weekly clinical meetings held throughout the year, lectures have been given and problems discussed by attending clinic physicians on matters relating to venereal disease. Papers were read by Dr. C. L. Hunt, Director of the Division of Venereal Disease Control, at a meeting of the Vancouver Medical Association and at the refresher course in medicine given at the Vancouver General Hospital on " The Interpretation of Positive Blood Serology " and on " Penicillin in the Treatment of Syphilis " respectively. One of the highlights in the educational field was the visit of Dr. John Stokes, the world-renowned authority on venereal disease, for three days in May. He devoted the entire period of his visit to the affairs of the Division of Venereal Disease Control, giving valuable assistance and advice in diagnostic, treatment, and administrative problems, as well as lectures to the Vancouver Medical Association and at Medical Ward Rounds at the Vancouver General Hospital. His visit proved highly educative and instructive, not only to physicians employed by the division but also to many outside physicians and public health personnel. The British Columbia Medical Centre Library has now been established in the new building of the Division of Tuberculosis Control. A proportion of the necessary funds has been made available by the Division of Venereal Disease Control for its foundation and operation, the Director of the division having been made a member of the library committee. There is thus some assurance that adequate up-to-date literature on venereal disease is available for both medical graduates and for those in training. The Director of the division has made various journeys to other centres and outlying areas of the Province for the purpose of discussing with medical groups and individual practising physicians any outstanding problems relating to venereal disease. It is felt that these visits have been particularly helpful in establishing good-will as well as in clarifying problems on both sides. Visits have also been made by the Director and by the consulting syphilolo- gist to this division to other venereal disease centres for the purpose of exchanging information in an endeavour to improve the services offered by our own division. Projects have also been approved and funds provided through Federal health grants for special training of medical and nursing personnel in public health and venereology at approved schools in the United States. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 115 Mention should be made of the excellent paper read by Chief Constable Walter Mulligan, of the Vancouver City Police Force, at the Chief Constables' Convention at Windsor, Ontario, in September. This paper, describing the part played by the Vancouver City Police in co-operating with the Division of Venereal Disease Control, has been widely read and approved by health authorities throughout Canada and has served as a pattern for similar efforts in other centres. GENERAL. The physician in charge of clinics attended the Conference of Provincial Directors of Venereal Disease Control, which was held in Ottawa in February. This conference was concerned primarily with administrative problems, with an endeavour to bring some measure of uniformity into general Provincial policies. Figures were produced at this meeting to show that approximately 10 per cent, of new cases of venereal disease notified in British Columbia were transient persons or persons who had been diagnosed elsewhere prior to taking up residence in British Columbia. The need for new and more convenient quarters for the division is becoming ever more urgent, frequent minor repairs being needed to keep the present premises fit and safe for occupation. Owing to difficulties engendered by the poliomyelitis epidemic during the summer, all beds normally placed at the disposal of this division for the treatment of venereal disease cases were unavoidably surrendered for the emergency period. There have been some changes in personnel in all branches of the division, notably the transfer of Dr. G. R. F. Elliot from the position of Director to that of Assistant Provincial Health Officer. Every good wish goes with him to his new fields, which, fortunately at present, are not far removed. His inimitable, driving personality as well as his wise counsel and advice will be sadly missed, but will fortunately, still be available to the division when the need arises. The division has been fortunate in adding to the full-time medical staff a well-qualified physician, who holds his diploma in public health, and who has taken over the duties of physician in charge of clinics, the previous holder of that title having now assumed the directorship, following Dr. Elliot's transfer. Following upon the resignation of Miss Jean Gilley, Miss I. Dryden has been appointed branch secretary to the division. Her wide knowledge and experience should prove valuable to the division. Miss Alice Beattie, senior epidemiologist, has been given a year's leave of absence in order to take up her studies for a higher degree in public health nursing at Washington State University. Miss Enid Wyness, senior social service worker with the division has returned from the university at Portland, Oregon, where she has been engaged in a postgraduate course in social studies. Federal grants, which have made many of these educational projects possible, have done much to augment and improve the efficiency of the venereal disease control programme in this Province. Finally, an expression of deep appreciation is due especially to all those in other divisions and departments whose generous and unstinted co-operation has been responsible for the successful operation of this division, especial mention being made of the Deputy Minister of Health, whose generous help and understanding have ever been a constant source of encouragement. KK 116 BRITISH COLUMBIA. REPORT OF THE DIVISION OF TUBERCULOSIS CONTROL. W. H. Hatfield, Director. INTRODUCTION. The Division of Tuberculosis Control has made some advances in its programme during 1949, but has continued to work under the serious handicap of lack of sufficient beds. It had been hoped that the new sanatorium planned for Vancouver would be started during the year, but this hope has not been fulfilled. It is now expected that it will be sometime in the spring of 1950 before construction gets under way. The other facilities of the division have now been quite well rounded out, but until an adequate number of beds is available for the treatment of all the tuberculous patients who require hospital care very little further progress can be made in the control of this disease. The most outstanding improvement within the division during the year was the opening of the new surgical and teaching facilities at the Vancouver Unit. This has provided the division with the most up-to-date surgical facilities to bring to the patient every modern method of therapy. This addition has shown the place it can play in the teaching programme of doctors, nurses, and lay people interested in health work, and the improved set-up for surgery will allow full opportunities for the newer developments in chest surgery to be offered to the tuberculous patients in this Province. At Tranquille further improvements in the physical plant were made during the year. Considerable thought has been given to the expenditure of money coming to the Province under Federal health grants. Projects continued from the previous year were occupational therapy for out-patients, home-care service, medical library, postgraduate training for members of the medical and nursing staff. During 1949, expansion in services of the division provided by these grants was as follows:— Additional staff: Senior interne, Vancouver Unit; nursemaids, Vancouver Preventorium; instructor in tuberculosis nursing; senior executive nurse, surgical department, Vancouver Unit. Payment for the administration of streptomycin. Payment for admission X-rays in general hospitals. Rehabilitation programme. Clinical research in electrocardiography. In-service training. The problem of obtaining properly trained medical personnel still remains with us. It would appear that the main reason for this is the low salary range paid by the Department for specialists. All our institutions have been somewhat understaffed from the standpoint of physicians, and it has not been possible to carry out anything except the most essential consulting service in the rural areas. It has been previously recommended that there should be a complete review of medical salaries, and it is hoped that some action will be taken in this regard this year. DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 117 Despite the handicap of insufficient beds, there is still some improvement in the over-all tuberculosis picture in the Province. The total death rate shows a further drop, although when this is broken down into racial groups it is found that there is some slight increase in the white death rate. It is to be noted further, when this is analysed, that the increase is in the group between 60 and 80 years of age. The number of new cases discovered during the year amounts to 2,201, which is an increase over last year. This broken down into racial groups shows the following: Indians, 577; other than Indians, 1,624; and into age-groups:— Indians. Other than Indians. 0- 4 79 0- 4 48 5- 9 94 5- 9 42 10-14 96 10-14 33 15-19 75 15-19 71 20-24 45 20-24 169 25-29 33 25-29 216 30-39 -.__. 46 30-39 300 40-49 45 40-49 229 50-59 22 50-59 214 60-69 23 60-69 189 70-79 10 70-79 82 80 over 3 80 over 13 Not stated 6 Not stated 18 During the year, an assessment has been made of the methods of case- finding and it is planned to make considerable changes in this regard during 1950. It has been decided to eliminate the mass X-ray survey programme as presently being carried out by the division and in its place to install X-ray equipment in general hospitals and local health units so that rather than sporadic mass X-ray surveys there will be available X-ray facilities on a day-by-day basis. The responsibility then of the case-finding programme is transferred where it logically belongs—to local health services. It is further planned to carry out fairly extensive tuberculin-testing programmes in certain areas in an endeavour to establish the present incidence of infection for comparison with previous large tuberculin-testing surveys. The rehabilitation programme which was initiated by the British Columbia Tuberculosis Society as a demonstration was taken over during the year by the Division of Tuberculosis Control, this being made possible by the Dominion health grants. During the year, the division was pleased to have a number of visitors from various centres throughout the world, a number of whom spent some time here looking into our methods of tuberculosis control. These visits usually proved to be mutually advantageous. A number of the doctors of the division attended scientific meetings during the year, and seventeen papers were prepared for presentation at these meetings. CLINICS. The number of clinics operated by the division remains the same, but the extent of the work within these clinics continues to grow and some of them are KK 118 BRITISH COLUMBIA. becoming distinctly overcrowded. More space is required in both the Vancouver and New Westminster Clinics. Travelling clinic work has continued to be carried on mainly by X-ray technicians. A considerable number of X-rays have been taken throughout the Province and were referred to our main centres for interpretation. This is not a satisfactory consultative service and can be made satisfactory only by obtaining specialists who are able to travel to the patient and consult with local physicians. During 1949, 197,096 people were X-rayed in the survey clinics. It is expected that with the new programme at least an equal number will be X-rayed and that some of the groups that are now missed will be examined. In the mass X-ray surveys, it has been noted that there are a fair number of people with heart-disease found. A study made during the year uncovered approximately four times as much heart-disease as tuberculosis. This is being studied further. Of the 197,096 persons examined in survey clinics, 3,196 or 1.6 per cent, were referred to diagnostic clinics, which is lower than the previous year. Of the group referred for further study, 524 or 16.4 per cent, were diagnosed as tuberculous. These tuberculous diagnoses were as follows: Primary, 2.9 per cent.; minimal, 68.7 per cent.; moderately advanced, 24.2 per cent.; far advanced, 4.2 per cent. There were 41,203 examined in the diagnostic clinics, which is an increase over the previous year. The out-patient pneumothorax work remains about the same with 10,993 refills given. The total number of examinations, including both survey and diagnostic clinics, was 238,299. Including out-patient treatments, the total number of patient-visits to all clinics and survey units was 248,701, which is an increase from the previous year of 17,580. INSTITUTIONS. Certain improvements were made in existing institutions during the year. Some of these have already been mentioned. The most notable improvement was in Vancouver, with the opening of the institute provided by the British Columbia Tuberculosis Society through Christmas seals. At Tranquille the new home for nurses was opened and is proving a valuable addition. Alternating current has been made available and a new telephone system with a private switchboard installed. Windows have been placed in the porches throughout the infirmary building, allowing patients to use this part of the building during the winter. One section of two porches has been renovated to form two wards, giving accommodation for nine patients instead of five. It is planned to continue with the alterations in this building during the forthcoming year. New furniture has been supplied throughout the staff quarters, which has made a great difference in the appearance of the accommodation and in the comfort of the employees. The administration building has been remodelled throughout and is now a modern office building. Over a mile of cement sidewalks has been laid and there has been a considerable addition to the hard-surfaced roads at the institution. There are further much-needed improvements which have been planned at Tranquille, and it is hoped that at least some of these will be accomplished during 1950. It had been hoped that the new sanatorium would at least have been started during 1949, but there were continued delays and not until the end of the year DEPARTMENT OF HEALTH AND WELFARE, 1949. KK 119 had the specifications been finally written. It is expected that the plans will go out for tender the first of the year. Unfortunately, it is necessary to once again report that St. Joseph's Oriental Hospital, which is considered by the division to be an unsatisfactory hospital for the care of tuberculous patients, is still in operation. During the year, due to the epidemic of poliomyelitis, it was necessary for the division to remove its patients from the Vancouver Isolation Hospital for a period of fourteen weeks. This deprived us of thirty-five beds during this time and was a very disturbing situation to many patients. NURSING SERVICE. Tuberculosis nursing, like other specialties and nursing generally, is in a transitional stage due to the current changes and expanding needs. Encouraging progress is noted as the year's activities are reviewed. The nursing department will benefit from projects under the Dominion health grant plan. Three senior nurses are taking postgraduate courses, and provision is made for the establishment of two new nursing positions at the Vancouver Unit. These are a supervisor for the new surgical unit and a second instructor for the affiliation course in tuberculosis nursing. The expansion in the teaching department is necessary due to the increased number of affiliate and postgraduate students and to the reorganization of the curriculum and clinical assignment of the course. The closer integration of theory and practice throughout the course has resulted in a more confident approach and greater satisfaction and interest in tuberculosis nursing on the part of the students. Isolation technique is standardized in the various units except for a few minor adaptations to suit local conditions. Completion of the definition of nursing positions by the Civil Service Commission will be helpful to the Provincial and local administration for purposes of recruitment and placement. Although the quota of nurses varies, particularly at Tranquille, the nursing service in all of the units met the demands without serious curtailment or closing of beds. A considerable number of nurses have come to British Columbia during the past year, but shortages are general and still acute, particularly in rural and small-town areas. As there has been an increasing tendency for nurses to be interested in surgical rather than medical wards, increased attention is being given to showing the interest and value of nursing care in the non-surgical case. SOCIAL SERVICE. During the past year the staff situation improved and, although there were several changes in social service staff, the numbers remained up to strength. There have been three major developments due to the Federal health grants which have affected the social service work. The first was the appointment to the division of a full-time rehabilitation officer, who works very closely with the social workers and has given a great deal of help in the work done with the patients. The second was the appointment of a full-time occupational therapist to the Metropolitan Health Committee staff. Occupational therapy in the home is now an additional resource for patients when they leave hospital. The third development is the establishment of a proper home-making service for tuber- KK 120 BRITISH COLUMBIA. culous patients. The money for this service was granted to the Metropolitan Health Committee, but the actual service is administered by the Family Welfare Bureau. Members of the social service department act on the technical advisory committee. The social workers feel that they benefit from the plan almost as much as the patients, as the time and energy that used to be spent on make-shift plans can now be used in other ways. At the end of the year, there were seven full-time home-makers and four part-time home-makers in patients' homes. BUDGET. There will be no increase in the services rendered by the Division of Tuberculosis Control during the ensuing year. Any increase in budget is due to factors beyond the control of this division, such as increased commodity prices, increased wages, and cost-of-living bonus. CONCLUSION. As has been reiterated on previous occasions, the great need of the Division of Tuberculosis Control is increased bed accommodation. When this is provided, the programme of the division will be well rounded out. The other great problem is obtaining properly trained physicians, and this cannot be solved until the salary situation with reference to physicians is altered. The voluntary agency continues to play an important part in the tuberculosis programme in the Province of British Columbia. There has been complete co-operation between the division and the British Columbia Tuberculosis Society, and much has been achieved which would not have been possible without the Society. It is felt that the private agency still has an important place in a programme such as that of the Division of Tuberculosis Control. VICTOBIA, B.C.: Printed by Don McDiabmid, Printer to the King's Most Excellent Majesty. 1950. 745-350-7286
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PROVINCE OF BRITISH COLUMBIA Fourth Report of the DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH) (Fifty-third… British Columbia. Legislative Assembly [1950]
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Title | PROVINCE OF BRITISH COLUMBIA Fourth Report of the DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH) (Fifty-third Annual Report of Public Health Services) YEAR ENDED DECEMBER 31ST 1949 |
Alternate Title | DEPARTMENT OF HEALTH AND WELFARE, 1949. |
Creator |
British Columbia. Legislative Assembly |
Publisher | Victoria, BC : Government Printer |
Date Issued | [1950] |
Genre |
Legislative proceedings |
Type |
Text |
FileFormat | application/pdf |
Language | English |
Identifier | J110.L5 S7 1950_V03_06_KK1_KK120 |
Collection |
Sessional Papers of the Province of British Columbia |
Source | Original Format: Legislative Assembly of British Columbia. Library. Sessional Papers of the Province of British Columbia |
Date Available | 2017 |
Provider | Vancouver : University of British Columbia Library |
Rights | Images provided for research and reference use only. For permission to publish, copy or otherwise distribute these images please contact the Legislative Library of British Columbia |
CatalogueRecord | http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1198198 |
DOI | 10.14288/1.0340942 |
AggregatedSourceRepository | CONTENTdm |
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