PROVINCE OF BRITISH COLUMBIA Eighth Report of the DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH) (Fifty-seventh Annual Report of Public Health Services) YEAR ENDED DECEMBER 3 1st 1953 VICTORIA, B.C. Printed by Don McDiarmid, Printer to the Queen's Most Excellent Majesty 1954 Office of the Minister of Health and Welfare, Victoria, B.C., January 8th, 1954. To His Honour Clarence Wallace, C.B.E., 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, 1953. ERIC MARTIN, Minister of Health and Welfare. Department of Health and Welfare (Health Branch), Victoria, B.C., January 8th, 1954. The Honourable Eric Martin, Minister of Health and Welfare, Victoria, B.C. Sir,—I have the honour to submit the Eighth Report of the Department of Health and Welfare (Health Branch) for the year ended December 31st, 1953. 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. Eric Martin ------- Minister of Health and Welfare. SENIOR PUBLIC HEALTH ADMINISTRATIVE STAFF G. F. Amyot, M.D., D.P.H. ----- Deputy Minister of Health and Provincial Health Officer. J. A. Taylor, B.A., M.D., D.P.H. - - G. R. F. Elliot, M.D., CM., D.P.H. - A. H. Cameron, B.A., M.P.H. G. F. Kincade, M.D., CM. - Deputy Provincial Health Officer and Director, Bureau of Local Health Services. Assistant Provincial Health Officer and Director, Bureau of Special Preventive and Treatment Services. Director, Bureau of Administration. Director, Division of Tuberculosis Control. Director, Division of Laboratories. Director, Division of Venereal Disease Control. Director, Division of Vital Statistics. Director, Division of Public Health Engineering. T. H. Patterson, M.D., CM., D.P.H., M.P.H. - Director, Division of Environmental Management. C. E. Dolman, M.B., D.P.H., Ph.D., F.R.C.P. A. J. Nelson, M.B., Ch.B., D.P.H. - - J. H. Doughty, B.Com., M.A. - R. Bowering, B.Sc.(CE.), M.A.Sc. - - Miss M. Frith, R.N., B.A., B.A.Sc, M.P.H. F. McCombie, L.D.S., R.C.S., D.D.P.H. - R. H. Goodacre, M.A., C.P.H. - - MissD. Noble, B.Sc.(H.Ec), C.P.H. - - C. R. Stonehouse, C.S.I. (C.) - Director, Division of Public Health Nursing. - Director, Division of Preventive Dentistry. - Director, Division of Public Health Education. - Consultant, Public Health Nutrition. - Senior Sanitary Inspector. TABLE OF CONTENTS Page General— The Population and Its General Composition 11 The Health of the People 12 Health Services Provided to the Public 13 Personnel 16 Accommodations 16 National Health Grants 18 Report of the Bureau of Local Health Services— Administration 19 Health-unit Expansion and Development 20 Community Health Centres r 21 Nursing Home-care Programme 23 School Health Services 25 The Health of the School-child 27 Table I.—Physical Status of Pupils Examined, Showing Percentage in Each Group, 1946-47 to 1952-53 28 Table II.—Physical Status of Total Pupils Examined in the Schools for the Years Ended June 30th, 1949 to 1953 29 Table III.—Physical Status of Total Pupils Examined in Grades I, IV, and X for the Years Ended June 30th, 1949 to 1953 29 Table IV.—Summary of Physical Status of Pupils Examined, According to School Grades, 1952-53 29 Table V.—Physical Status by Individual Grades of Total Schools, 1952-53 30 Table VI.—Number Employed and X-rayed amongst School Personnel, 1952-53 30 Table VII.—Immunization Status of Total Pupils Enrolled, According to School Grade, 1952-53 30 Disease Morbidity and Statistics 31 Table VIII.—Notifiable Diseases in British Columbia, 1949-53 (Including Indians) 35 Table IX.—Notifiable Diseases in British Columbia by Health Units and Specified Areas, 1953 36 Report of the Division of Public Health Nursing— Status of Service 37 Consultant Service 38 Public Health Nursing Training 38 Advisory 39 Local Public Health Nursing Service 40 Statistical Summary of Certain Public Health Nursing Services 42 Report of the Division of Environmental Management— Rehabilitation 43 Occupational Health 43 Medical Care—Research 43 General 44 A. Report of the Nutrition Service— Consultant Service to Local Public Health Personnel 44 Consultant Service to Hospitals and Institutions 46 Co-operative Activities with Other Departments and Organizations. 46 Y 8 BRITISH COLUMBIA Report of the Division of Environmental Management—Continued page B. Report of Sanitary Inspection Services— Food-control 47 Eating and Drinking Places 48 Frozen-food Locker Plants 48 Slaughter-houses 48 Meat Inspection 48 Horse-meat 48 Housing 48 Summer Camps 49 School Sanitation 49 Plumbing 49 Garbage and Refuse Disposal 50 Rodent-control and Sylvatic Plague Survey 50 Barber-shops 50 C. Report of Civil Defence Health Services— Regional Conferences 50 Emergency Medical Supplies 50 First-aid Stations 51 Study Forum 51 Emergency Blood Service 51 Training 51 General 51 Report of the Division of Preventive Dentistry— Prevention 52 Dental Personnel 57 General 59 Report of the Division of Public Health Engineering— Water-supplies 60 Sewage-disposal 61 Stream-pollution 62 Shell-fish 63 Swimming and Bathing Places 64 Tourist Accommodation 64 Frozen-food Locker Plants 64 General 64 Report of the Division of Vital Statistics— Registration of Births, Deaths, and Marriages 66 Documentary Revision 67 Microfilming of Documents 68 Administration of the " Marriage Act " 68 Registration of Notices of Filing a Will 68 Certification Services 69 District Registrars' Offices 69 General Administration 70 Statistical Section 71 Cancer Registry 73 Table I.—Number and Percentage of New Cancer Notifications by Site and Sex, British Columbia, 1953 74 Table II.—Number and Percentage of Reported Live Cancer Cases by Site and Sex, British Columbia, 1953 74 DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 9 Report of the Division of Vital Statistics—Continued page Cancer Registry—Continued Table III.—Cancer Notifications by Sex and Age-group, British Columbia, 1953 (Age Specific Rates per 100,000 Population) 75 Table IV.—Live Cancer Cases Reported by Sex and Age-group, British Columbia, 1953 (Age Specific Rates per 100,000 Population) 75 Crippled Children's Registry 75 Population Characteristics of the People of British Columbia 76 Principal Causes of Mortality in British Columbia 77 Mortality amongst the Indian Population 77 Mortality Improvements in Terms of Life-years Lost 78 Chart.—Comparison of Actual and Expected Life-years Lost Due to Specific Causes of Mortality, British Columbia, 1953 79 Birth and Stillbirth Rate 80 Report of the Division of Public Health Education— Local Health Educators 81 Consultative Services 81 Materials 82 In-service Training 84 Publications and Publicity 84 Staff 84 Report of the Health Branch Office, Vancouver Area— Buildings 85 Faculty of Medicine, University of British Columbia 85 Voluntary Health Agencies 85 Civil Defence 87 General 87 National Health Grants 88 Acknowledgment 93 Report of the Division of Laboratories— Table I.—Statistical Report of Examinations Done during the Year 1953, Main Laboratory 94 Table II.—Statistical Report of Examinations Done during the Year 1953, Branch Laboratories 95 Tests for Diagnosis and Control of Venereal Disease 96 Tests Relating to Tuberculosis-control 97 Salmonella-Shigella Infections 97 Other Types of Tests 98 Branch Laboratories 99 General Comments -. 100 Report of Division of Venereal Disease Control— Treatment 101 Epidemiology 102 Social Service 103 Education 104 General 105 Report of the Division of Tuberculosis Control— Bed Situation 106 Mortality 107 Morbidity 107 Miniature X-ray Programme 108 National Health Grants 109 General 110 Eighth Report of the Department of Health and Welfare (HEALTH BRANCH) Fifty-seventh Annual Report of Public Health Services YEAR ENDED DECEMBER 31st, 1953 G. F. Amyot, Deputy Minister of Health and Provincial Health Officer During 1953 the Health Branch encountered some few problems and disappointments but also had the happy experience of seeing many improvements in the public health services. It is the intention in this Annual Report to describe the major problems, the progress, and the general status at the year's end. The first, or general, section of the Report deals with those events and activities which had a broad influence and also summarizes the more important happenings described in the later sections. Detailed descriptions of the various services and programmes are presented in these later sections beginning on page 19. In previous years it has been the practice of the Health Branch to publish its Report on the Medical Inspection of Schools separately from the Annual Report. This year, however, the information concerning schools has been included in this volume as a part of the Report of the Bureau of Local Health Services. In studying problems and devising solutions, in making plans for continual improvement in the service, and in conducting the daily routines of Health Branch business, the Deputy Minister of Health once again received the willing co-operation of other departments of Government, professional groups, and voluntary agencies, as well as the firm support of his co-workers and advisers in the Health Branch itself. Although these are too numerous to name individually, the Deputy Minister extends to them his sincere thanks. GENERAL A. H. Cameron, Director, Bureau of Administration THE POPULATION AND ITS GENERAL COMPOSITION The population of British Columbia was estimated to be 1,230,000 in 1953, an increase of approximately 32,000 over the previous year. Over 40 per cent of this increase occurred among the population under 10 years of age. However, British Columbia has a greater proportion of older people than has Canada as a whole. This characteristic is illustrated by the fact that almost 16 per cent of British Columbia's population was 60 years of age and over, whereas the Canada-wide figure for this same age-group was only slightly more than 11 per cent. On the other hand, people under 20 years of age comprised approximately 34 per cent of the Provincial population and 38 per cent of the population of Canada. The average number of persons in a British Columbia family was slightly more than three. Of all Provinces in Canada, British Columbia had the smallest average family group. Over 68 per cent of the people resided in urban areas (metropolitan areas and communities with populations of more than 1,000). Only Ontario had a greater proportion of urban residents. 11 Y 12 BRITISH COLUMBIA More than 366,000 square miles in area, the Province as a whole had only 3.2 persons per square mile. This population density was the second lowest among the Provinces of Canada. (Newfoundland had the lowest with 2.4 persons per square mile.) In the vast regions of the Province outside the highly populated Lower Mainland and Vancouver Island, the density was slightly less than one person per square mile. All of these characteristics had, and will continue to have, an important bearing on the approach to public health services and the costs of these services. THE HEALTH OF THE PEOPLE The health status of any group of people is generally, and possibly most meaningfully, reported in negative terms; that is, in terms of death rates, causes of death, and sickness experience. This will be the principal method used in this Report. Notwithstanding the fact that there has been a steady ageing of British Columbia's population—a fact which might be expected to produce a steady increase in the death rate—the crude death rate has remained almost constant over the past ten years. The preliminary figure for 1953 was 10.0 per thousand population, compared with the final figure of 10.1 for 1952. Numerically, the three leading causes of death continued to be heart-disease, cancer, and vascular lesions of the central nervous system, in that order. However, the Director of Vital Statistics again directs attention to the interesting and important concept of life-years lost, which indicates that the three conditions listed as leading causes, on a numerical basis, may not have been the most important causes. This concept takes into account the fact that the death of a young person is usually a more serious event than the death of an older person because more years of the anticipated life-span have been lost. Calculations made on this basis place heart-disease, cancer, and vascular lesions of the central nervous system in the third, fourth, and seventh positions of importance and raise diseases of early infancy and accidents to the two most important positions. An encouraging change in the tuberculosis death rate has taken place in recent years. In 1947 approximately 51 persons in every 100,000 died from this disease. In 1953 this rate had dropped to less than 12 per 100,000. (These rates include the Indian population.) The Director of Tuberculosis Control attributes this decline in deaths chiefly to improved methods of treatment, including the use of streptomycin and other antimicrobials. The decline in the incidence of tuberculosis has not been so marked as the reduction in deaths from this disease, although the number of new cases discovered in recent years has decreased. This is particularly encouraging in view of the increased efforts to discover new cases. Analyses of the records over the past ten years reveal that the morbidity rate is slightly higher for females than males up to age 39. Among the group over 50 years of age, however, the morbidity rate for males is almost twice as high as that for females. The Director of Venereal Disease Control states that the number of venereal-disease cases reported in 1953, including non-specific urethritis, was 3,671, some 240 fewer than the number reported in the previous year. Infectious syphilis has become a clinical rarity, and late syphilis and prenatal syphilis, as reported to the Division, have also shown a marked decline. Non-specific urethritis presents an increasing problem, and the Division is taking the necessary steps to cope with it. It is encouraging to note that at the Vancouver City Gaol examination centre the number of newly diagnosed gonorrhoea infections decreased to an all-time low. The Director feels that this reflects accurately the prevalence of gonorrhoea in Vancouver. Although many of the foregoing data indicate gratifying trends, there was a large number of cases of poliomyelitis. The incidence, which was 64.0 per 100,000 population, was the highest of any year to date. (The highest rate previously recorded was 49.6 for DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 13 1952.) The epidemic was not concentrated in any one particular area, and it continued over a longer period of the year than those of other years. However, notwithstanding the greater number of cases during 1953, the case-fatality rate was lower than in any previous recorded epidemic. The incidence was decreasing slowly toward the year's end. Drawing upon earlier experience, particularly that gained during 1952, Health Branch officials, the Poliomyelitis Committee composed of experienced physicians, and other agencies had already made co-ordinated plans to meet the problem and to provide patient-care as efficiently as existing facilities would permit. Private physicians, the Vancouver General Hospital, the Royal Jubilee Hospital in Victoria, the British Columbia Poliomyelitis Foundation, and the Royal Canadian Air Force worked in close co-operation with Provincial and local health services. Further plans are being made to deal with the situation should there be many cases next year. An earlier reference has been made to cancer as a cause of death. Although the statistics, based on cases reported, may vary from year to year, there is good reason to believe that the problem actually remains quite constant in magnitude. In helping to combat this disease, the Federal and Provincial Governments share equally in meeting the operating expenses of the British Columbia Cancer Institute and the nursing home, both located in Vancouver, and the consultative and diagnostic clinics operating at ten centres throughout the Province. With this assistance, the British Columbia Cancer Foundation is able to provide very modern facilities and services. The total incidence of notifiable diseases, including the four discussed above, was 3,104.9 per 100,000 population for 1953. (Indians are included in the calculation.) A comparison with the incidences of 3,565.2, 4,092.7, and 3,312.3 for 1950, 1951, and 1952, respectively, indicates that there has been an improvement in 1953. Among school-children there was the usual number of cases of chicken-pox, measles, mumps, and rubella, with definite upward trends in certain instances. The incidence of major infection among school-children was not serious. The Director of Local Health Services reports that the health of school-children during the academic year 1952-53 was, on the average, satisfactory and differed little from that exhibited over the previous four years. A good immunity-level has been achieved. More than 60 per cent of the pupils have been immunized against such major communicable diseases as diphtheria and smallpox, and a smaller proportion have been immunized against scarlet fever, whooping-cough, and typhoid fever. Studies conducted by the Consultant in Nutrition supported earlier findings that the chief deficiencies in children's meals were milk, a Vitamin D supplement, and foods rich in Vitamin C Although meat, potatoes, and bread are eaten in satisfactory amounts by the majority of children, there is an excessive consumption of sweet foods, such as candy, soft drinks, and cake. Records of the past year again revealed that dental decay in children is a serious problem. The Director of Preventive Dentistry emphasizes the great need of more dentists, particularly in the rural areas, and the hope which may be placed in fluoridation of water-supplies in meeting the problem. HEALTH SERVICES PROVIDED TO THE PUBLIC In British Columbia the treatment and prevention of disease and the promotion of positive good health are a co-operative effort on the part of private physicians and dentists and several official and voluntary agencies. It is a source of pride to all concerned that these groups work well, each with the others, in co-ordinating their programmes. Local health services constitute one of the most important parts of the public health programme. In Greater Vancouver and Victoria-Esquimau these services are rendered by the city health departments, which do not come under the direct jurisdiction of the Provincial Health Branch, although they co-operate effectively with it. Broad objectives Y 14 BRITISH COLUMBIA and basic policies are the same in the two large cities as they are in the rest of the Province. The Provincial Government, through the Health Branch, renders substantial financial assistance to the public health services of these two metropolitan areas. Outside the boundaries of Greater Vancouver and Victoria-Esquimalt, local health services are provided by teams of Provincially employed public health workers. Each team consists of a public health physician, several public health nurses, at least one Sanitary Inspector, and the necessary clerical staff. If qualified personnel are available, a public health educator, a dental officer, and a dental assistant may be added to provide a more complete service. Each team constitutes the staff of a local health department, or health unit, serving a defined geographical area which includes rural territory and one or more population centres. During 1953 the local public health services in the area adjacent to Slocan Lake, the Arrow Lakes, and Kootenay Lake were organized as the Selkirk Health Unit, with headquarters at Nelson. There are now sixteen such units outside Greater Vancouver and Victoria-Esquimalt, and the organization of the Province into these local health departments is almost complete. Only the Squamish-Howe Sound area, where there has been public health nursing and sanitary inspection service for some time, remains to be included in a health unit. Because of this, and certain other relatively less important developments, practically all of the people of British Columbia now receive public health services. Excluding Indians, for whom services are provided by Federal authorities, the percentages of the Province's population receiving public health service at the end of 1953 from the sources named were as follows:— Source of Service Per Cent City health departments of Greater Vancouver and Victoria- Esquimalt 46.7 Provincial health units 50.3 Non-health unit areas (public health nursing and sanitary inspection districts) 2.6 Total 99.6 Certain specialized services, for economic or other reasons, cannot be provided on the local level to communities, nor even groups of communities. Included in these specialized programmes are the services rendered by the Divisions of Tuberculosis Control, Venereal Disease Control, and Laboratories. Numerically the Division of Tuberculosis Control is the largest part of the Health Branch and employs more personnel than all other Health Branch divisions and services combined. With headquarters in Vancouver, it provides approximately 925 treatment beds in the Willow Chest Centre, the Pearson Tuberculosis Hospital, and the Jericho Beach Hospital in that city; the Vancouver Island Chest Centre in Victoria; and Tran- quille Sanatorium near Kamloops. Making full use of these beds, the Division was able to reduce the length of time that applicants for admission remained on the waiting-list and to admit many applicants immediately. The Division continued to operate clinics, both stationary and travelling, in strategic areas of the Province. In the programme designed to X-ray admissions to general hospitals, thirty-four hospitals are operating miniature-film equipment. Although some of these hospitals participated well in the programme, the percentage of admissions X-rayed by others was smaller than it might have been. It is hoped that these hospitals will be able to take a greater part in the provision of this service to the people of their areas. At the beginning of the year the admission X-ray programme was extended to the smaller general hospitals. These hospitals, in which miniature-film equipment has not been installed, are paid a per capita rate for X-rays taken on their own equipment. J DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 15 Although this part of the programme is only in the organizational stage, the percentage of admissions X-rayed is encouraging. It is gratifying to be able to report that a chest X-ray is now available to any person admitted to hospital in British Columbia. The Division of Venereal Disease Control, with its staff of some thirty-three full- time and seventeen part-time employees, continued to maintain its headquarters and principal clinic and treatment centre in the old building which it has occupied for many years on Laurel Street in Vancouver. Other clinic and treatment centres were operated in Victoria, on the grounds of the Royal Jubilee Hospital; in Vancouver at the city's Health Unit No. 1 and at the City Gaol; at the Prince Rupert and Prince George City Gaols; at the Juvenile Detention Home, Girls' Industrial School, and Male and Female Oakalla Prison Farms; and in New Westminster. Like all other specialized services in the Health Branch, the venereal-disease control .programme was conducted in close co-operation with the personnel of local health services. Through the Division, drugs, free of charge to the patient, were again made available to all private physicians for the treatment of venereal disease. The Division of Laboratories again provided service of a very high standard in spite of the poor accommodations in the buildings on Hornby Street, Vancouver, which have for many years served as headquarters and main laboratory. The staff of the Division numbers approximately forty-seven, and all but a few of these work in the Hornby Street buildings. Branch laboratories were operated at Victoria, Nelson, and Prince George. The Division as a whole performed some 440,000 tests relating to communicable-disease control during 1953. The increase of approximately 7 per cent over the 1952 total was the largest annual increment experienced by the Division in several years. Using data compiled by a sub-committee of the Technical Advisory Committee on Public Health Laboratory Procedures, the Director of the Division makes some interesting and important observations concerning laboratory costs in British Columbia. These data, which are based on units of work performed rather than on tests undertaken, show that the work-load per staff member in the British Columbia laboratory is considerably higher than it is in other Provincial laboratories in Canada. Consequently, the cost per unit is considerably lower. Voluntary health agencies once again provided outstanding services. These were so integrated with those of the official agencies that duplications and omissions in services were kept to a minimum. The Assistant Provincial Health Officer, aided by the Departmental Comptroller, devoted much time and thought to effecting this integration and assessing the requests of the voluntary agencies for financial assistance from Provincial and Federal sources. Elsewhere in this Report he describes briefly the programmes of the British Columbia Cancer Foundation, the Western Society for Rehabilitation, and the Canadian Arthritis and Rheumatism Society (British Columbia Division). Certain other voluntary agencies also played significant roles in meeting health needs. Included in these were the Vancouver Preventorium, the British Columbia Poliomyelitis Foundation, the British Columbia Tuberculosis Society, the Canadian Red Cross Society, the John Howard Society, the Cerebral Palsy Association, the Canadian Cancer Society (British Columbia Division), the Alcoholism Foundation, and the Multiple Sclerosis Society. Special mention must be made of the Canadian Red Cross Society's blood transfusion service. In view of the serious nature of the poliomyelitis epidemic, this sendee assumed an even more important position in the public health programme. In this, its seventh, year of operation, the service continued to collect blood from human donors— the only source—and to make it available, free of charge, to those whose medical condition required transfusions. Because gamma globulin, which has proven to be useful in Y 16 BRITISH COLUMBIA the prevention of poliomyelitis, is obtained from human blood, the great need of blood donors became even more apparent. However, notwithstanding the efforts of the Red Cross personnel and public health workers, the supply of blood, blood plasma, and gamma globulin remained too low. PERSONNEL The Health Branch, in its Province-wide field services, clinics, laboratories, hospitals, and administrative offices, employs more than 1,200 people. During 1953 the number of employees who, for one reason or another, became problem cases was small. Practically all such individual problems were resolved satisfactorily. However, a general problem, relating to a large group of employees, nurses, and seriously affecting the entire public health service, created much difficulty and remained unsolved at the end of the year. Both public health nurses and institutional nurses are in short supply in so far as the Health Branch is concerned. Officials responsible for recruiting have strong reason to believe that the relatively low salaries are the main cause of the problem. In any event, it has been necessary to leave some positions vacant and to fill many others with nurses who lack the qualifications or attributes required. The Health Branch and the Civil Service Commission have conducted extensive studies of the problem, and the Civil Service Commission has submitted recommendations to the appropriate authority. The professional qualifications of a number of Health Branch employees, and their usefulness to the Service, were improved by courses of training supported by the National health grants. Some employees received postgraduate training of at least one academic year's duration, while others attended shorter courses. Graduate nurses, undertaking training in public health to qualify for positions in health units, formed a large proportion of the former group. In the opinion of the Director of Public Health Nursing, only this advantage, which she was able to offer to prospective employees, enabled her to recruit sufficient nurses to maintain a minimum service. The professional status of health-unit personnel and senior officials of the Health Branch was enhanced by the Public Health Institute which was held in Vancouver in April. The guest speaker was Dr. Hugh Leavell, Professor of Public Health Practice at Harvard University, who presented a series of lectures on several aspects of public health. The programme also included lectures and panel discussions in which Health Branch personnel took prominent parts. The five-day work-week, with a compensatory increase in the daily hours of work, was inaugurated in August, 1953, when it was put into effect for Provincial Civil Servants generally. Although it was not possible to extend the benefit to the employees of institutions in which service must be maintained twenty-four hours per day through the seven days of the week, the new work schedules were established with a minimum of administrative difficulty in the Health Branch. ACCOMMODATIONS During 1953 several construction projects, designed to provide much needed accommodation, were either completed or well advanced. After many years of planning, the construction of the new Provincial Health Building in Vancouver was finally undertaken. The excavation and foundations were completed in August, and the work on the superstructure was begun soon afterwards. It is estimated that it will be ready for occupancy early in 1955. Situated on Tenth Avenue near the Division of Tuberculosis Control's Willow Chest Centre, the Provincial Health Building will meet several long-felt and serious needs. The most important of these is the need of modern accommodation for the Division of Laboratories which, for twenty-one years, has been located in a series of old houses on Hornby Street. The new building will also bring together, under one roof, other important DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 17 Provincial health services, including the headquarters and main clinic of the Division of Venereal Disease Control, the Vancouver office of the Division of Vital Statistics, and the office of the Assistant Provincial Health Officer. According to the terms of an agreement made several years ago between the Canadian Red Cross Society and the Provincial Government, one floor of the building will be allocated to the Red Cross blood transfusion service as a blood-processing depot. Of extreme importance also were the plans to provide facilities for the care of those who had been stricken with poliomyelitis and who were destined to spend long periods in institutions even after they had passed the acute stage of the disease. During the 1953 epidemic the poliomyelitis centres at the Vancouver General Hospital and the Royal Jubilee Hospital in Victoria became so overcrowded with such patients from all parts of the Province that the situation became critical. Public health and hospital authorities became concerned because it would be virtually impossible, with existing facilities to care for the additional cases which might result from another epidemic. However, Health Branch officials took definite action to cope with the problem of inadequate facilities. On the basis of recommendations submitted by the Poliomyelitis Committee, plans were made for the construction of accommodation for patients requiring long-term care. Expenditure of the funds required to construct and equip this building, which will accommodate approximately fifty patients, was approved by the Executive Council. Every effort will be made to have the new facilities in operation by the summer of 1954, to receive patients now in the Vancouver General Hospital and the Royal Jubilee Hospital and so release space in these hospitals for the treatment of new, acute cases. In Pearson Tuberculosis Hospital, capacity operation was achieved early in 1953 when the last ward of this new institution was opened. The landscaping of the grounds is well under way. At Tranquille Sanatorium the new laundry has been in operation for almost a year. The final steps in converting from a coal-burning to an oil-burning power plant were taken when the necessary storage-tanks and pumps were installed. Remodelling of the ground floor of the Infirmary Building to provide improved facilities was nearing completion at the end of the year. Renovations at the Vancouver Island Chest Centre will soon provide a separate X-ray survey clinic at this centre. The New Westminster Stationary Clinic will, in the near future, occupy new and enlarged quarters in the Gyro Health Centre. This development in New Westminster, which will also provide more suitable accommodations for the staff of the Simon Fraser Health Unit, exemplifies the co-operative planning which has been evident in several parts of the Province. The general method of financing the construction of such community health centres is based on a division of the costs among the Federal, Provincial, and local governments. Service clubs and voluntary health agencies often assist the local government in providing its share. On this basis, community health centres or health-unit sub-offices were built in Armstrong and Maple Ridge. The Kelowna Community Health Centre, which was completed and occupied in December, 1952, was opened officially by the Minister of Health and Welfare in May, 1953. In Vancouver the construction of a building to accommodate health and welfare personnel in one section of the city was well advanced at the year's end. At Nanaimo, however, construction of the proposed building itself will probably have to be deferred owing to shortage of local funds, although the site has been prepared. The required Federal and Provincial funds have been allocated for the construction of a sub-office in Oliver in the South Okanagan Health Unit. It is anticipated that this project will be undertaken as soon as the local share has been raised. At the end of the year, Revelstoke and Salmon Arm were giving consideration to building sub-offices for the North Okanagan Health Unit in their areas. Y 18 BRITISH COLUMBIA Notwithstanding the proposals and actual developments described briefly above, certain areas are still lacking in adequate accommodations for their health-unit services. Cranbrook, Nelson, and Trail present the most urgent needs. Although some improvement may be anticipated in Nelson, the outlook is not bright in the case of the other two cities. NATIONAL HEALTH GRANTS Many of the developments described in this Report have been made possible through the use of Federal funds under the National health-grants programme. May, 1953, marked the end of the first five years of the history of the programme. Federal authorities reviewed the progress which had been made, assessed the needs which remained to be met, and modified the programme accordingly. The most important change was the inclusion of three new grants. The Laboratory and Radiological Services Grant is the largest of these, and British Columbia's share is approximately $360,000 during the first year, with larger amounts to be made available in subsequent years. The Medical Rehabilitation Grant makes available to British Columbia approximately $43,000 per annum. Although certain portions of these two grants are governed by a matching principle and can be utilized only if the Provincial Government spends at least equal amounts in financing the enterprises, it is understood that Provincial moneys already being expended in the two fields of endeavour will be viewed as the required matching funds. It is fortunate that these are sufficiently large to preclude the necessity of providing additional Provincial funds. The Child and Maternal Health Grant makes available to British Columbia some $35,000 per annum. There is no matching principle involved. The Hospital Construction Grant was reduced by approximately $1,000,000, and the Health Survey Grant was discontinued because the survey and the report which resulted from it were completed in 1952. The amounts of the other seven grants remain almost the same as they were in previous years. Excluding the Public Health Research Grant, which is not distributed among the Provinces on the basis of a definite formula, the total amount of National health-grant funds available to British Columbia for the fiscal year 1953—54 is approximately $3,850,000. This is some $600,000 less than the amount that was available in the previous fiscal year. In his report which is presented elsewhere in this volume, the Assistant Provincial Health Officer describes the more important uses to which each grant was put. His report also provides more detailed information concerning administrative procedures and actual expenditures. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 19 REPORT OF THE BUREAU OF LOCAL HEALTH SERVICES J. A. Taylor, Director ADMINISTRATION The Bureau of Local Health Services continues to act as a liaison between the various technical divisions and services of the Health Branch, Department of Health and Welfare, and the local health departments, while offering, in addition, supervisory and consultative services to the staffs of those local health departments. The actual provision of public health services on a local level is vested in the local Union Board of Health, which, as provided in the " Health Act," becomes a legally qualified body responsible to the Councils and School Boards for the administration of the services, receiving technical advice and assistance as required from the Bureau of Local Health Services, on request. For several years now there has been a gradual transition within local health services from a part-time basis to a full-time basis, during which new health units were becoming established under Union Boards of Health. The increase in the number of Union Boards of Health, coupled with the fact that the complement of the Board changes annually with changes in Councils and School Boards, has emphasized the need for some type of brochure which will explain the relationships of the Union Board of Health to local Boards of Health and to the health unit, while outlining the duties and responsibilities of the Union Board of Health. Preliminary drafts of this material were prepared by the Health Branch, Department of Health and Welfare, for consideration of the Medical Health Officers at one of their recent conferences. Arising from their study of the draft have been a number of criticisms and suggestions. These are now receiving consideration, and will be incorporated into a specimen pamphlet which will be presented to the various Union Boards of Health for their further opinion. Arising from this, it is hoped to finalize a pamphlet which will be satisfactory to all concerned and can be usefully distributed to all incoming members of a Union Board of Health, so that they will have some guidance in respect to the work that can be carried on by a Union Board of Health. At the same time, in attempting to outline the duties and responsibilities of a Union Board of Health, some deficiences in the present "Health Act" are brought to light. This is not surprising considering that the present Act has been in existence, with only minor change, for some sixty years, and it has long been felt that a complete revision of the " Health Act" was indicated; it is proposed that a start be made to this end immediately. Contingent upon that revision is dependent also revision of the sanitary regulations, which are considerably outmoded. Biannual meetings of the Medical Health Officers, convened in April and September, continued to serve as advisory bodies advancing suggestions for modification and changes in existing policies and programmes, while introducing the need for development of completely new policies and programmes. It has now become common practice, as the group has become more stable, to refer such matters as proposed new legislation and new administrative materials, such as the brochure on duties and responsibilities of Union Boards of Health, to the full-time Health Officers for their serious study and comment before finalizing the details. Recently material on a proposed draft of Milk Regulations for Unorganized Areas was submitted for consideration, resulting in a number of very practical amendments being presented. As a result, the proposed regulations will be considerably revised in content. Similar action was taken in conjunction with the proposed revision of the Barber-shop Regulations, which were being finalized for approval by Order in Council. In addition to their practical function in this way, these bi-annual conferences of Health Officers serve as a clearing-house in which exchange of ideas leads -to uniformity of public health practice throughout the Province, while promoting pilot studies of new practices in specific areas. One other significant revision in legislation Y 20 BRITISH COLUMBIA was also given consideration during the year. This stemmed from suggestions advanced by the Health Officers, in the field of communicable-disease control, and resulted in modifications of the existing Regulations for the Control of Communicable Diseases. Most of these were, more or less, minor changes to bring them in line with practical control measures in the field, but one major feature was in relation to more adequate control of persons infected with tuberculosis, which would require their strict isolation in an institution, or in a manner satisfactory to the Medical Health Officer. These revisions have been completed and submitted for approval. During the year, discussions were held with representatives from the Department of National Health and Welfare relative to uniform reporting of notifiable diseases across Canada. Attempts are being made to bring the reporting more in line with practical experience to omit those minor conditions which are very infrequently or sporadically reported, and in which little, if anything, can be gained in attempted control measures, while concentrating on the major communicable infections which have a serious effect on mankind and in which control measures can lead to potential control. Negotiations in this direction are to be continued and, it is hoped, will be reviewed at the Federal- Provincial Conference on Notifiable Disease Reporting, when Provincial epidemiologists will discuss the whole matter from the point of view of practical epidemiology. In the whole field of general administration in local health services, the Local Health Services Council continues to serve a vital function through its regular meeting. The various divisions functioning with the Bureau of Local Health Services maintain representation on that Council, which serves as a clearing-house for information, so that each is informed on changes and developments occurring in each division while serving to unify the consultative and supervisory services provided to the various local health units. HEALTH-UNIT EXPANSION AND DEVELOPMENT It became evident over a year ago that final steps could be taken toward the establishment of a health unit in the area between the Slocan Lake, Arrow Lakes, and Kootenay Lake. The return of a former Health Officer from postgraduate training in public health at the School of Hygiene, University of Toronto, permitted the final attainment of that goal when in June an organizational meeting of the respective Councils and School Boards resulted in the endorsement of these proposals and the establishment of the Selkirk Health Unit, under a Union Board of Health. Since then the Municipal Councils of the Cities of Nelson, Kaslo, and Slocan, and the Villages of Salmo, New Denver, and Silverton have passed the necessary health-unit confirmation by-laws, while School Districts No. 7 (Nelson), No. 8 (Slocan), No. 6 (Kootenay Lake), and No. 10 (Arrow Lakes) have passed the required resolutions transferring the school health services to the Union Board of Health. The first meeting of the newly organized Union Board of Health has still to be convened, but in the meantime the Unit Director and his staff of senior public health nurse, five staff public health nurses, a Sanitary Inspector, and a statistical clerk have been reorganizing the public health services into a unit programme to provide uniform service throughout the whole health-unit area. The groundwork is being exceptionally well planned and should lead to an effective, efficient programme for the future. This move establishes the sixteenth health unit in British Columbia, practically completing the planned coverage of health units for the Province. There remains only the Squamish-Howe Sound area uncovered, but in this there are employed two public health nurses and a part-time Sanitary Inspector. Plans are under way to engage the employment of a full-time Sanitary Inspector, and following on this graded step will be consideration of inclusion of this area in the North Shore Health Unit to complete the organization. For a number of years there have been repeated requests from School District No.- 58 (McBride) for public health nursing services for that area, but these have always had DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 21 to be denied because of the unavailability of qualified public health nurses. During the year a very definite appeal to the public health nursing group resulted in the transfer of a public health nurse from Keremeos to McBride, and the initial introduction of public health nursing services in that community. At the same time it was felt that the sanitary inspection services from the Cariboo Health Unit should be extended to the McBride area, and it was proposed that the Village of McBride and School District No. 58 become incorporated into the Cariboo Health Unit. This action was finalized during the summer. Thus the Cariboo Health Unit, already the largest unit from point of size, further extended its boundaries to provide unified public health services across the whole of the Cariboo area. With the industrial developments which are occurring in the Kitimat-Kemano areas, there is a parallel growth in the community settlement, and as the construction phase gives way to manufacturing activity, increased family stability in population occurs, necessitating educational and public health needs. Thus a new school district became established at Kitimat during the year and led to the request for some type of public health service. This was answered for the moment by the employment of a former public health nurse, on a part-time basis, and the appointment of a practising physician as part- time School Medical Inspector and Medical Health Officer. Consideration will have to be given to the future public health needs of this growing community, as to whether it can be adequately supervised under the already existent health-unit service or whether it will attain a size sufficient to warrant its own health unit. The local health services in the metropolitan areas of Greater Vancouver and Victoria-Esquimalt continued to provide the same excellent co-operation with the Health Branch, Department of Health and Welfare, and to co-ordinate their services with the services provided in the other areas of the Province. As a result of this co-operation and co-ordination, there is a uniform type of service over the whole of the Province, so that residents of British Columbia can obtain the same degree of public health supervision and service regardless of their residency, be it metropolitan city or unorganized hamlet. Further, residents can move from one locale to another without interruption of service, since the records in respect to each individual follow that individual to the degree that continuity of service can be obtained soon after settlement in the new locality. The negotiations that were proceeding toward consolidation of public health services in the Greater Victoria area have become stalemated, although the principle has been endorsed in part, but there seems to be no forward negotiations under way. COMMUNITY HEALTH CENTRES The plan whereby joint financing on a one-third basis by Federal, Provincial, and local governments would provide construction of more suitable community health centres proved so satisfactory during the previous year that it has been continued again this year. In so far as the local government's share is concerned, contributions by local service clubs or voluntary health organizations, or by public subscription, have been accepted, and in most cases, with the exception of the City of Kelowna, where the municipality bore the entire local share alone, this has been the method of local financing. In a considerable number of instances the British Columbia Tuberculosis Society contributed from the funds raised through the Christmas Seals campaign, recognizing the part that local health services played in the broad programme of tuberculosis-control, while at the same time acknowledging the contributions that had been made over the years to that fund by these local communities. In much the same way, contributions from the British Columbia Cancer Society have aided the construction of local health centres. In addition to providing accommodation for the health-unit staff, and a board room for the meetings of the Union Boards of Health, these community health centres are recognized as centres co-ordinating all the health services in a community, voluntary and Y 22 BRITISH COLUMBIA official. Thus facilities are provided in them for storage of supplies by voluntary health agencies, while, at the same time, auditorium space is available for meetings of these organizations, whether it be executive or group. As the previous year ended, the Kelowna Community Health Centre became completed, permitting the staff to move into that fine new building in December, 1952. During May, 1953, the building was officially opened by the Minister of Health and Welfare. This is a credit to the City of Kelowna, which bore the major share of the financing, becoming the first municipality to participate to this extent in the plan. The Armstrong Community Health Centre, which was jointly financed by the City of Armstrong and the Municipality of Spallumcheen, in co-operation with the Federal and Provincial Governments, provided a sub-office for the North Okanagan Health Unit to accommodate the resident public health nurse for that area. Clinic quarters become available, while separate offices for the nurse and Sanitary Inspector are included, as well as a small laboratory space, usable as an immunization clinic. This building was officially opened during October by the Deputy Provincial Health Officer. The Municipality of Maple Ridge participated in the plan, assisted by the British Columbia Tuberculosis Society, British Columbia Cancer Society, and the Maple Ridge Lions Club, to provide a sub-office for the North Fraser Valley Health Unit at Haney. The building, constructed on the same site as the Municipal Hall, in the same type of architecture, is exceptionally well planned to provide administrative and clinical services under one roof, providing accommodation for the voluntary health agencies, such as the Cancer Society, the local branch of the Arthritis and Rheumatism Association, the British Columbia Tuberculosis Society, the local branch of the Canadian Red Cross, and so forth. Operation of the building is vested in a board composed of representatives from the municipality, the health unit, the Lions Club, and others, space being rented on occasion to establish a fund which will be used for maintenance and repairs, while actual operation costs will be borne by the health unit. The official opening of this building occurred in October, 1953, at which the Deputy Minister of Health officiated. At the moment, construction is under way toward a considerable enlargement of the Gyro Health Centre in the City of New Westminster to provide more suitable space for the operation of the Simon Fraser Health Unit and the New Westminster Clinic of the Division of Tuberculosis Control. In this plan the British Columbia Branch of the Canadian Red Cross, the British Columbia Tuberculosis Society, the British Columbia Branch of the Canadian Cancer Society are also participating, in co-operation with the City of New Westminster. The former building, constructed some years ago by the New Westminster Gyro Club, had become crowded and inconvenient, so that certain renovations and construction of an addition became necessary to provide a building suitable to house all the community health services in more spacious quarters. Construction is also under way in the City of Vancouver for a health and welfare building to house health and welfare services for one portion of the City, and the space allocated to health services is to be jointly financed through contributions from the Federal and Provincial Governments on the Community Health Centre Formula basis. Consideration has been under way for some time in Nanaimo for construction of a Nanaimo Community Health Centre to house the headquarters of the Central Vancouver Island Health Unit. The land has been donated by the City of Nanaimo, and certain excavations have been already undertaken, but complete financial arrangements have not been effected. The plans call for construction of a two-story building, designed to fit the needs of all the voluntary agencies as well as the official agencies, and will require an amount considerably in excess of the one-third portion by the three branches of government. While funds have been earmarked to this project from the Federal and Provincial Governments, the British Columbia Tuberculosis Society, the British Columbia Cancer Society, and other agencies, and donations in kind by numerous firms, nevertheless the DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 23 total estimated cost has yet to be subscribed. It seems likely that this project will await yet another year before it can be completely financed and construction completed. Funds have also been earmarked by the Federal and Provincial Governments toward construction of a sub-office for the South Okanagan Health Unit in Oliver to house two public health nurses and provide clinic space for the various clinical services carried on in that area. Arrangements for the local share, which it is contemplated will be raised through public subscription and will permit commencement of the construction of the planned building, are vested in the hands of a local board. As the year closes, preliminary thought is being given for possible consideration of community health centres in Revelstoke and Salmon Arm, under the same formula, to provide additional sub-offices for the North Okanagan Health Unit in those areas. Completion of these possible projects would mean that both the North and South Okanagan Health Units would be the most satisfactorily housed of all the health units. The most urgent need in respect to office accommodation seems to lie in the East and West Kootenay areas of the Province, where the three health units—namely, the East Kootenay Health Unit with headquarters at Cranbrook, the Selkirk Health Unit with headquarters at Nelson, and the West Kootenay Health Unit with headquarters at Trail — are most inadequately accommodated. At the moment it is probable that more ideally suited space will become available for the Selkirk Health Unit in Nelson, where rented space in the second story of a down-town block will become available early in the new year, as renovations to meet the needs of the unit will attain completion. There does not, however, appear any hope in so far as the East Kootenay Health Unit and the West Kootenay Health Unit are concerned, unless the municipalities or some community-minded service club assumes some interest therein. The staffs of the units are searching for some means of obtaining suitable space and would welcome such assistance, if at all possible. NURSING HOME-CARE PROGRAMME The nursing home-care programme, which was started as a pilot study in the Vernon area to determine if home care could be provided to convalescent patients who might be discharged from hospital earlier, if such care were available, thereby releasing hospital beds for more acute cases, has now been in operation for over a year, and it is possible to analyse the programme better on a year's figures. As originally set up, the programme was expected to benefit the hospitals, provide service to the community, and effect an economic saving by releasing patients from the hospital earlier in the convalescent stage to carry on their convalescence at home under visiting nurses. It is necessary for a patient to be admitted from hospital to this service by the attending physician, and thus the home-care service can be considered an extension of hospital care to the home. The health-unit staff is prepared to give nursing care in the home on an hourly basis, while a housekeeping service is also available to patients requiring home help. A small daily charge is made for both nursing and housekeeping service. During the period from October, 1952, to October, 1953, 116 patients were admitted to the service, with hospital-days saved amounting to 1,559, or an average of 13 days per patient. It is evident that as the service becomes better established, more patients are being discharged to it, and also, since the average length of time per patient on the service has increased, their discharge from hospital to the service is occurring earlier in the patient's convalescence as the physicians become more familiar with the service and confidence in it increases. This may be borne out by the fact that each patient requiring nursing care has received a greater number of visits over the past year than during the previous six months' period. On an average, patients receive 5.6 nursing visits in fourteen days or one nursing visit every two and a half days, indicating that a fairly acute type of service is being maintained. However, future trend of this ratio of nursing visits to days saved should be carefully noted, since it can reveal any tendency toward a chronic type of service. Y 24 BRITISH COLUMBIA In the annual report, 116 patients included 74 per cent medical, 22 per cent clinical, and 4 per cent obstetrical cases. The type of nursing care required has been injections, dressings, irrigations and other treatments, supervision of diet and exercise, observation of progress, including temperature, pulse, respiration, and blood-pressure. To date there has been no demand for time-consuming general nursing care or bed baths. Regarding housekeeping care, patients on this type of service required an average of forty-six hours per patient. This was an increase in housekeeping time required, which would seem to indicate patients are being discharged much earlier in their convalescence when less able to look after their household duties. It must be pointed out that the housekeeping service alone has saved hospital-days to the extent of 5 per cent of the total days saved, while the number of patients requiring only housekeeping service has been 8 per cent. The cost of the service was in the neighbourhood of $4 per day during the initial stages of the study in the period November, 1951, to May, 1952, but since costs were reckoned on a different basis during this time, comparisons cannot be made between that figure and the one of $2.06 per day on service for the period from January, 1953, to September 31st, 1953. Both figures, however, compare favourably with the hospital per diem cost of $11.35. It seems evident that this service has proved to be of value far in excess of its cost, and much less time-consuming than was at first anticipated. It has demonstrated the fact that during the year October, 1952, to October, 1953, the service has increased the facilities of the Vernon Jubilee Hospital to the extent of 4.3 beds in continuous use; i.e., 1,559 hospital beds for 365 days. During the year, efforts were made to publicize the programme in general to the patient; signs were displayed in the hospitals and pamphlets were prepared which could be left on the bedside table of patients, thereby encouraging them to inquire about the plan from their physician or the hospital staff. Since the programme seems to have definitely proven the original contention that discharge of patients from hospital during their early convalescence would save hospital beds, it is now felt that consideration should be given toward extension of the programme to see if patients might not be referred to the plan by their family physician prior to admission to hospital, thereby obviating the admission of a number of patients to hospital. This proposal is now to be investigated, since, as time goes on, the generalized public health programme is expanding to include an increasing amount of the ordinary bedside nursing load in addition to that of convalescent home-care service. This development has occurred without any particular encouragement. However, future assessments should reveal whether or not the need to enter hospital has been obviated for some patients by this development in the programme. As a matter of fact, the need for nursing home-care programmes seems to be increasing throughout the Province and there have been a number of requests for the services of the Victorian Order of Nurses. These must, of course, be carefully assessed to determine whether there is definite need for such service in the requested areas or whether they are only felt to be needed. In many cases the need can be absorbed by the existing public health nursing programme, either by the present staff or by the addition of one or more nurses to the staff, and it must be judged whether this is the more economical approach rather than the introduction of duplicate service under the Victorian Order of Nurses. However, the decision rests with the municipalities concerned, since the decision to bear the major share of the financing of the additional service must be theirs. This decision has recently been faced by the Nanaimo area, where requests for Victorian Order of Nursing services have been repeatedly forthcoming, and the decision reached indicated a desire for the Victorian Order of Nurses providing the home-visits, and a community appeal has been made to subscribe the funds necessary to finance this service. It is anticipated that such a service will commence early in the new year. Co-operation of the public health services will be extended to the new service so that they can work side by side, the one serving to complement the other. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 25 Similar proposals are being advanced for extension of the Victorian Order of Nursing service from Victoria to the Municipality of Saanich. There again the request is sparked by the local women's organizations who are pressing for an introduction of the service to provide home-nursing care to elderly patients suffering from chronic disease but who do not actually require acute care in the hospital. The decision will have to be faced by the municipality to determine whether they wish to support this type of service financially or whether they prefer to seek an extension of the public health nursing services to meet this anticipated need. SCHOOL HEALTH SERVICES It has been repeatedly emphasized that school health services cannot be divorced from community health services, since the school-child is a member of the community duly influenced by conditions within the community. Actually the average child is in the school for less than six hours a day, and is in contact with the family and the community for the remaining eighteen hours of the day. It is primarily for this reason that it is recommended that school health services be operated as part of the total community health services rather than as a separate entity. In the past it has been customary to publish a separate Report on School Health Services outlining the scope of the services carried on in the schools. However, it has become increasingly difficult, and somewhat impractical, to continue this practice in view of the fact that it is hard to distinguish where community health services cease and school health services start. For example, in community health service, it is usual to provide health supervision of the child from infancy through the pre-school years, which supervision it is felt has a definite effect on the improved health of the school-child. It seems an anomaly to make a special report dealing with that same child as he commenced school and ignore entirely the public health supervision that was given during the infancy and pre-school years without indicating that the service was influencing the school health services. Consequently, it has been argued that a special report on school health services is not justified and that each report should be embodied in this Annual Report. From this year forward it is proposed that the Report of the Medical Inspection of Schools will be incorporated in these Annual Reports, thereby giving a better interpretation of the co-ordination of the school health services with community health services, indicating the interrelationship of the two. The school health programme concerns itself with the promotion of health, the protection of health, and correction of physical defects and departures from normal health. In carrying this out, such services as medical examination of the pupils, immunizations, control of communicable diseases, inspection of the school environment, and health education are embodied into the programme. The programme is designed to attain certain objectives; these are probably extremely well stated by the Illinois Joint Committee on School Health in the following list:— To inspire the child with a desire to be well and happy. To convey to the pupil the public and personal health ideal, designed to ensure for him the continuation through life of wholesome and effective living, physical and mental. To educate the child, according to a definite plan, in the cultivation of those habits of living which will promote his present and his future health. To impart health knowledge and attitudes to the child, so that he will make intelligent health decisions. To develop in the child a scientific attitude toward health matters, and an understanding of the scientific approach to health problems. To maintain adequate sanitation in school, the home, and the community. To protect the child against communicable and preventable diseases and avoidable physical defects by providing effective public health control measures, both individual and social, throughout the school and the community. Y 26 BRITISH COLUMBIA To bring each child up to his optimal level of health. To extend the school health programme into the home by obtaining family and community support for the programme. To discover early any physical defects the child may have, secure their correction to the extent that they are remedial, and assist the child to adapt himself to any individual handicap. To provide healthful school living for the child. To relate the school health programme to the health programme of the community so that it may deal with real, current, and practical problems. To organize effectively not only the programme of direct health instruction, but the equally important direct learning experiences of the child in the field of health. Somewhat the same goals are being sought in the school health programme in this Province, as the staff engaged in school health services attempt to analyse what has been done in the past, what are the objectives, and how they can best be met. It is becoming more and more evident each year that with the growth in the school population it is not practical to expect to provide individual attention to each school-child, and it is questionable whether this is desirable. Analysis of annual statistics has shown that well over 93 per cent of the school-children are in a satisfactory physical classification and probably do not require routine annual examinations, but could benefit from screening methods in which those requiring more intensive attention would be selected for detailed and careful examination. Each year this question of revision of the school health programme has been raised at meetings of the Medical Health Officers, and as an attempt is made to analyse the service throughout the Province, it becomes evident that there are variations from area to area in the eighty school districts. It seems desirable to set a definite goal which will provide a uniform policy in school health services so that the staff know what is expected of them, School Boards know what to expect from the staff, and the educational authorities become aware of the objectives of the health programme. With these thoughts in mind, then, the school health programme was set up this year under the chairmanship of the Director of the North Fraser Valley Health Unit, composed of representative School Medical Inspectors, public health nurses, and public health administrators, to analyse the service and recommend a revised programme. It is suggested that this committee should hammer out provisions of the programme, discuss these with Inspectors of Schools and school principals, present them to the next Medical Health Officers' conference, and endeavour to decide upon a definite Departmental policy which can then be discussed with the Department of Education as the recommended policy for the future in British Columbia. This, then, can be taken to the various School Boards represented on the Union Boards of Health, and also discussed with the school staffs to enlist their support. In the field of school environment some consideration has been given to an attempt to correlate the standard of construction between the Department of Education and the Health Branch, Department of Health and Welfare, so that there would be uniformity in the planning of new school buildings. It is felt that there should be some recommended similar standard for such items as lighting, cubic air-space per pupil, heating, ventilation, sanitary facilities, and so forth. Consequently, a joint committee of the Department of Education and the Health Branch, Department of Health and Welfare, has been working on a pamphlet of recommended standards which could be used by the School Inspectors and Sanitary Inspectors in the field as desirable features of all school buildings. In addition, it would serve as a guide for architects designing new school buildings in developing the layout of the building, and the equipment to provide conditions in keeping with recommended standards. This work is progressing extremely slowly but is being carried forward as time permits. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 27 THE HEALTH OF THE SCHOOL-CHILD It seems desirable in discussing the school health programme to endeavour to analyse the health of the school-children in British Columbia, as revealed by the various reports submitted by the School Medical Inspectors over the past year. During the attempt at evaluation of the health of the school-child, it becomes evident that it is difficult to find a satisfactory measure of health status, and even if a much better measure was available than now exists, it would still be difficult to determine which elements in the school or community health programme are responsible for the improvement. There is no exact objective and quantitative measure of the health of an individual, although an extensive science of testing has been developed to measure growth status and organic, muscular, and athletic efficiency. Further, it must be mentioned that while it might be important to measure results wherever possible, there are still many values arising from the school health programme that cannot be measured quantitatively. The benefits of the programme will be felt by the individual throughout his whole life. This might well be maintained if the school health programme contributes enough to the health of the future adult to make it worth while, even if no specific health improvement could be measured during the years in school. Improvement in the health and nutritional status of the child is often evident to the physician and sometimes to the teacher, even though this improvement cannot be recorded by an objective health index. There are also some values in the improvement of home conditions, through the indirect education of parents, that result from the health programme in the school. There presumably will be a direct effect upon the health of the next generation through the improved attitudes in health status of the present group of public-school pupils when they become parents. Attitudes are difficult to measure, and yet the contribution of the public school to the development of sound attitudes is one of its most important services. Health education makes many contributions to the vigour, efficiency, contentment, cheerfulness, community health, and race betterment that can never hope to be measured. In the reports of school health services over the past four years in British Columbia, an attempt has been made to analyse the health of the school-child on the basis of immunization status, physical status, and morbidity figures of notifiable diseases. Based upon an analysis of those factors, it has been evident that the health of the school-child has been extremely satisfactory. For the purposes of comparison, and for lack of a better measuring-tool, it is felt that this same approach should be made this year in analysing that individual. During the academic year of September, 1952, to June, 1953, the school health programme was carried throughout the eighty school districts in 898 schools. Enrolled in the grades examined were 186,912 school-children, a definite increase over the enrolment for previous years. Of this number, 27.8 per cent received medical examinations, a percentage which is admittedly low but is explained upon the basis that the medical examinations are being concentrated in Grades I, IV, VII, and X on a priority basis, with special attention being proffered to those referred by screening methods, whether these screening methods consist of such things as the Wetzel Grid or teacher-nurse conferences. Indeed, a study of the results of the medical examinations by grades reveals a much more reassuring situation in the fact that 84.2 per cent of the pupils in Grade I were examined, with lesser but corresponding majorities in the selected subsequent years. The results are presented in detail in the various statistical tables. In scrutiny of these tables, it becomes evident from Table I that the physical status of the school-children has revealed that the medical examination shows them to be in good physical condition clinically. It becomes evident that somewhat over 93.0 per cent of the pupils are in A Group, with a lesser number, 6.8 per cent, in B Group and, 0.2 Y 28 BRITISH COLUMBIA per cent, in C Group. As was already mentioned, so many features affect physical status, it is difficult to determine any definite reason behind this, but it is indicative of the fact that the routine physical examination of pupils does not seem justifiably practical when so many of them are in a satisfactory A Group. It points up the fact that a screening method throughout the school would select the pupils requiring detailed examinations and on whom concentration of medical services in the school health programme can be devoted in an endeavour to improve their health. In addition to the excellent physical status of the average school-child in British Columbia, the majority of pupils (more than 60 per cent of each group) are immunized against such major communicable diseases as diphtheria and smallpox, maintaining their immunity status during their school-life. This bespeaks a satisfactory trend in the immunity status of that population group, but the fact that diphtheria cases were recorded during the year at a rate of 0.7 per 100,000 population emphasizes that immunization of the total school population would be most desirable. A significantly smaller proportion of the school population was immunized against scarlet fever, pertussis, and typhoid fever. This is understandable, as administration of scarlet fever toxin and typhoid fever vaccine is governed by the vagaries of disease incidence, particularly since the immunity so conferred is less permanent. In the case of pertussis, concentration of protection toward this disease is emphasized in the early infant and pre-school years, in which population group the disease is most serious and often fatal. Consequently, as the child becomes older, there is less need for immunity protection to pertussis, and this is reflected in the gradually decreasing immunity status to this disease in the higher grades. The third factor reflecting the health of the school-child is the communicable-disease incidence, the majority of which are childhood infections. During the year there were the usual number of cases of chicken-pox, measles, mumps, and rubella, with definite upward trends in certain instances. Many of these infections recur with a cyclic epidemic periodicity as new susceptible groups enter the school, and communicable-disease control measured seem to bear little effect upon the trend. Poliomyelitis showed a marked increase during the year, with a rate of 64.0 per 100,000 population, but the incidence was equally confined to adult groups as it was to school-aged groups, so that the effect on the general health of the school-child was not too marked. In general, the health of the school-child during the academic period 1952-53 coincided with that obtaining over the past four years as being, on the average, satisfactory. Although an average number of minor communicable diseases was recorded, the incidence of major infection was not serious, while the immunity status on the whole was satisfactory, and the medical status was excellent. Table I.—Physical Status of Pupils Examined, Showing Percentage in Each Group, 1946-47 to 1952-53 Academic Group Percentage of Pupils, A Group1 Percentage of Pupils, B Group2 Percentage of Pupils, C Group3 194647 1947-48 91.1 91.7 93.3 93.4 93.1 93.5 93.0 8.3 7.8 6.4 6.5 6.8 6.4 6.8 0.6 05 1948-49 0.3 1949-50 - 1950-51 0.1 0.1 1951-52 0 1 1952-53 0.2 1 A Group: A, Ad, Ae, and Ade categories 2 B Group: Bd, Be, and Bde categories. 3 C Group: Cd, Ce, and Cde categories. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 29 Table II.—Physical Status of Total Pupils Examined in the Schools for the Years Ended June 30th, 1949 to 1953 1948-^9 1949-50 1950-51 1951-52 1952-53 137,536 54,682 39.8 42.2 48.9 0.8 1.4 5.6 0.2 0.6 0.1 0.1 0.1 128,724 45,049 35.0 38.8 52.5 0.8 1.3 5.6 0.1 0.8 0.1 154,517 46,028 29.8 34.4 56.3 0.7 1.7 5.8 0.1 0.9 0.1 161,408 42,401 26.3 36.5 54.2 0.8 2.0 5.4 0.2 0.8 0.1 186,912 52,296 28 0 Total pupils examined Physical status—percentage of pupils examined— A Ad - - 33.6 57 2 Ae Ade - ..~ - - 0.6 1 6 Bd . 5 8 Be Bde..... 0.1 09 Cd_ 0 1 Ce Cde 0.1 Table III.—Physical Status of Total Pupils Examined in Grades I, IV, VII, and X for the Years Ended June 30th, 1949 to 1953 1948-49 1949-50 1950-51 1951-52 1952-53 50,519 38,377 76.0 40.6 50.7 0.7 1.3 5.9 0.1 0.5 0.1 41,688 30,515 73.2 38.8 53.3 0.6 1.0 5.6 0.1 0.5 0.1 56,491 36,468 64.6 34.8 56.3 0.6 1.7 5.5 0.1 0.8 0.1 58,930 33,118 56.2 36.7 54.7 0.7 1.7 5.2 0.1 0.8 0.1 70,222 38,273 54.5 Physical status—percentage of pupils examined— A 34 9 Ad Ae 57.1 0.5 Ade Bd ... Be - 1.4 5.1 0.1 Bde Cd Ce - 0.7 0.1 Cde 0.1 0.1 0.1 Table IV.—Summary of Physical Status of Pupils Examined, According to School Grades, 1952-53 Total Pupils, All Schools Examined in Grades Grade I Grades II-VI Grades VII-IX Grades X-XIII Total pupils enrolled in grades examined- Total pupils examined- Percentage of enrolled pupils examined Physical status—percentage of pupils examined— Ad... Ae.-. Ade. Bd... Be.-.. Bde- Cd— Ce ... Cde- 86,912 52,296 28.0 33.6 57.2 0.6 1.6 5.8 0.1 0.9 0.1 0.1 23,919 20,289 84.8 32.5 59.6 0.5 1.3 5.2 0.1 0.6 0.1 0.1 96,046 15,210 15.8 30.8 57.6 0.8 1.8 7.4 0.1 1.3 0.1 0.1 43,673 10,678 24.4 36.5 54.4 0.7 1.9 5.3 TT o.i 23,274 6,119 26.3 39.5 53.3 0.5 1.3 4.8 0.1 0.5 Y 30 BRITISH COLUMBIA Table V.—Physical Status by Individual Grades of Total Schools, 1952-53 All Schools Grade I Grade II Grade III Grade IV Grade V Grade VI Total pupils enrolled in grades examined Total pupils examined _ Percentage of enrolled pupils examined Physical status—percentage of pupils examined— A Ad Ae - Ade Bd Be Bde Cd _ Ce Cde ... 86,912 52,296 28.0 33.6 57.2 0.6 1.6 5.8 0.1 0.9 0.1 0.1 23,919 20,289 84.8 32.5 59.6 0.5 1.3 5.2 0.1 0.6 0.1 0.1 20,130 3,279 16.3 31.6 56.2 1.2 1.8 8.0 0.1 0.9 0.1 0.1 20,012 3,644 18.2 23.1 64.4 0.5 1.8 8.2 0.2 1.5 0.2 0.1 19,949 4,845 24.3 34.7 55.0 0.7 1.6 6.9 0.1 0.9 0.1 18,727 1,969 10.5 31.4 56.9 0.6 2.5 6.4 0.1 1.9 0.2 17,228 1,473 8.6 34.4 53.8 1.3 2.2 6.6 0.1 1.3 0.2 0.1 Grade VII Grade VIII Grade IX Grade X Grade XI Grade XII Grade XIII Total pupils enrolled in grades examined . Total pupils examined.. Percentage of enrolled pupils examined Physical status—percentage of pupils examined- A - Ad... Ae ... Ade. Bd... Be .... Bde. Cd... Ce ... Cde. 16,394 8,107 49.5 38.2 54.2 0.6 1.9 4.0 0.1 0.9 0.1 14,659 1,379 9.4 32.0 54.3 1.3 2.0 8.3 2.0 0.1 12,620 1,192 9.4 29.9 54.9 0.5 1.8 10.8 1.8 0.2 0.1 9,960 5,032 50.5 39.6 53.6 0.6 1.2 4.4 0.5 0.1 7,149 563 7.9 41.3 49.4 0.2 1.4 6.9 0.4 0.4 5,548 473 8.5 35.5 55.2 0.2 1.7 7.2 0.2 617 51 8.3 41.2 54.9 3.9 Table VI.—Number Employed and X-rayed amongst School Personnel, 1952-53 Total Organized Unorganized 7,779 4,120 6,684 3,733 1,095 387 Table VII.—Immunization Status of Total Pupils Enrolled, According to School Grade, 1952-53 Total Pupils Enrolled by Grades Percentage Immunized Smallpox Diphtheria Tetanus Typhoid B.C.G. 186,912 23,919 20,130 20,012 19,949 18,727 17,228 16,394 14,659 12,620 9,960 7,149 5,548 617 61.5 64.4 64.4 66.8 65.9 67.1 67.3 61.2 55.4 49.9 51.9 49.6 45.3 44.7 69.7 73.4 75.1 76.9 75.0 76.4 73.7 67.6 61.8 59.1 58.4 54.0 49.8 43.3 21.6 37.4 30.6 27.6 22.0 19.2 19.6 15.7 12.8 11.1 11.4 10.7 10.5 8.6 0.8 0.6 0.7 0.9 0.9 . 1.0 0.9 0.6 0.9 1.1 0.8 0.5 1.2 2.8 0.1 0.2 Grade II 0.1 Grade III 0.1 Grade IV .. _ - 0.1 Grade V 0.1 Grade VI 0.1 Grade VII 0.1 Grade VIII 0.1 Grade IX 0.1 0.2 Grade XI 0.1 Grade XII 0.5 Grade XIII - 0.8 DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 31 DISEASE MORBIDITY AND STATISTICS During 1950 and 1951 British Columbia, in common with the other Provinces, participated in a National Sickness Survey, in co-operation with the Department of National Health and Welfare. The statistics on that survey have been in the process of compilation in Ottawa, and during the last year some of the preliminary figures have been issued. These dealt with the costs of sickness at varying family economic levels, indicating the amounts spent on medical care, hospitalization, dental care, treatments, and drugs. These figures are shown on a National basis, indicating the average amounts of money required for each of the services and the total amount involved in medical care. Further compilations are being prepared which will detail the expenditures and, it is hoped, bring it down to a Provincial level, so that information can be gained on the costs of medical care, types of sickness involved, and the amount of sickness receiving no particular medical or nursing attention. Thus the work that was done throughout the Province in previous years mainly by the public health nurses, who so diligently followed the gathering of the material among a sample of the population, is beginning to show results. Bulletins are being released to provide interim information until the final report containing more detailed information, together with a fuller description of the methods used, is prepared. The tests that were conducted during the fall of 1951 and the spring of 1952 into the possible use of an oral vaccine, contained in caramel lozenges as a method of immunization for raising immunity to diphtheria, have since been analysed. Specifically the test consisted of analysing the immunity-level of a number of school-children prior to consuming these lozenges and again after a lapse of eight months to one year. This was to test the initial level of immunity with the second to find out how much the level had been increased, following consumption of the lozenges. The result indicated roughly that 50 per cent of the pupils participating showed an increase in protective level, 38 per cent showed no increase, and 12 per cent showed an actual decrease. There seemed to be a slightly better result in the older age-group than in the younger, although this was too slight to be significant. In general, it was felt that efficacy of use of oral vaccine in caramel-lozenge form as a means of bolstering immunity against diphtheria was questionable. It was likely that where full dosage had already been administered, the ease of shipping caramels to carry on as booster might be appreciated, but, taking into consideration the extreme cost of the caramels, the results obtained were so small as to hardly justify the costs involved. It did seem that oral immunization as a reinforcing antigen against diphtheria had some merit, but it was useless as a primary immunizing agent. During 1953 the total incidence of notifiable disease was 3,194.9 per 100,000 population, which is compared to the incidence over the past five years in Table VIII. In so far as the morbidity statistics for the Province are concerned this year, probably the most outstanding feature is in relation to the poliomyelitis picture, in which the highest incidence of any year to date is exhibited in the rate of 64.0 per 100,000 population, in contrast to the rate of 49.6 per 100,000 population for 1952, which had been the highest recorded incidence previously. The incidence this year does not seem to have been concentrated in any one particular area of the Province and has been prevalent over many more months of the year rather than being confined to late summer and early fall. As the year ended, there was indication that the incidence was decreasing gradually. There is some evidence on the basis of stool cultures that new strains of virus may be creating this higher incidence, presumably on the basis that the population, which had formerly been exposed to a Lansing strain, to which immunity had materialized, is now faced with the necessity of building up population immunity to the newer strains, known as the Brunhilde and Leon strains. If this is the case, it may be expected that annual recurrent epidemics of poliomyelitis may be anticipated until disease experience confers population immunity to them, in the same relation as now apparently exists to the Lansing strain. Y 32 BRITISH COLUMBIA While there were 787 cases of poliomyelitis reported throughout the Province during the year, it is of interest to note that almost half of these—namely, 358 cases—were mild, exhibiting no paralysis. At the same time, because of the number involved, there were 296 cases of severe bulbar type of paralysis and a remaining 133 cases with other types of paralysis. In spite of the higher incidence a very creditable picture was obtained from a mortality view-point, as only 26 deaths were recorded this year, compared to 37 deaths the previous year. As a matter of fact, the case fatality rate for 1953 was 3.3, compared with a similar rate of 6.8 in 1952 and 3.8 in 1947, the other years of high incidence. Actually the following table indicates a very creditable showing in the case of fatality figures, indicative of a remarkable improvement in deaths from poliomyelitis over the years. Poliomyelitis Case Fatality Rates Year Cases Deaths Case Fatality Rate 1927 182 102 43 34 42 313 584 787 37 19 13 8 11 12 37 26 Per Cent 20 3 1928 18.6 1929 — 30.2 1930 - 23 5 1931 - 1947 26.2 3 8 1952 ... 6.3 1953 3.3 This improvement may be more significant than real if improved reporting in the last few years has promoted recording of the non-paralytic cases, but, at the same time, improved methods of treatment can be stated to have occurred and probably have had a definite effect. In any case, it does bear out the argument that poliomyelitis is not a particularly fatal disease, even in the face of increasing incidence. On the basis of experience gained a year ago, it can be recorded that a programme was evolved for this year which permitted better handling of the epidemic in providing for care of poliomyelitis patients. This has only been possible through the remarkable degree of co-operation by the private physicians, the Provincial and local health services, the Vancouver General Hospital, the Royal Jubilee Hospital, the Royal Canadian Air Force Air-Sea Rescue Unit, and the British Columbia Poliomyelitis Foundation. The need for a Province-wide programme arose from the fact that the specialized services were located almost entirely in the Infectious Disease Unit of the Vancouver General Hospital and, to a lesser degree, the Royal Jubilee Hospital in Victoria. Up until last year these two hospitals were able to meet the demands for admission of patients from outside the metropolitan areas of Vancouver and Victoria. The programme was originally drafted by the Poliomyelitis Committee of the Vancouver General Hospital in conjunction with representatives of the Health Branch of the Department of Health and Welfare, and later concurred in by the full-time Medical Health Officers throughout the Province. Poliomyelitis Committees were set up in Vancouver and Victoria in conjunction with the two hospitals, composed of physicians specializing in the various branches of medicine. The members of the Committee had to accept the treatment of cases of poliomyelitis referred to the hospital and to serve as consultants to the private physicians for the proper care and rehabilitation of their patients. The co-operation of the Royal Canadian Air Force Air-Sea Rescue Unit stationed in Vancouver has been outstanding. As soon as a request for transportation was cleared through the necessary channels, every effort was made to complete the evacuation, despite hazardous flying conditions in some cases. A medical officer and a nurse of the Royal Canadian Air Force are included in the crew of the aeroplane, which carries a portable J DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 33 respirator. Certain it is that without their material assistance, many of the evacuations would have been impossible, since commercial aircraft could hardly have undertaken flights under such conditions. Specialized equipment required for the care of poliomyelitis patients is located almost entirely in the Vancouver General Hospital and the Royal Jubilee Hospital, with the larger share being in the former. A number of hospitals in other parts of the Province do have respirator equipment, but this is not all up to date or the type which can be used for any length of time. Because of the cost of such equipment, it is considered more economical to concentrate it in the two larger centres of population. It has been necessary this year to purchase twenty-eight respirators of the tank type in addition to other equipment, such as rocking-beds, positive-pressure breathing-therapy units, and so forth. Approximately $75,000 has been expended on equipment, just over half the expenditure being from the National health grants and the remainder from the British Columbia Foundation for Poliomyelitis. The British Columbia Foundation for Poliomyelitis is a voluntary agency supported largely through the efforts of the Kinsmen's Clubs throughout the Province. In addition to the provision of equipment, funds have been given toward the purchase of equipment for one or two other institutions, the provision of additional physiotherapists, and research. Because of the greater flexibility in the use of voluntary funds, it has also been possible for this organization to assume certain extraordinary expenses. The cost of hospitalization is covered by the British Columbia Hospital Insurance Service as long as the patient is in the acute stage of the disease. After this stage is passed, the cost of hospital care becomes the responsibility of the individual. More specialized rehabilitation services are given at the Western Society for Rehabilitation, but some services are available at the Royal Jubilee and Vancouver General Hospitals, and, in addition, through the co-operation of the British Columbia Division of the Canadian Arthritis and Rheumatism Society, physiotherapists on its staff throughout the Province are giving treatments to post-poliomyelitis patients at the request of the private physician. In general, patients are expected to pay for rehabilitation services. Toward the latter part of September a supply of gamma globulin was made available to British Columbia and is being distributed to physicians for prophylactic administration to familial contacts who are 16 years of age or less or who are pregnant. The new serum globulin is an antibody concentrate prepared from the fractionation of human plasma and is only permitted for the prophylaxis of paralytic poliomyelitis in so far as present use is concerned because of the shortage of available stocks. Between the time this became available and the end of the year, some 823 vials of gamma globulin were distributed for administration to 447 such contacts. Provision for research in poliomyelitis is a recent innovation in this Province and has been due to the support of the Kinsmen's Club and the British Columbia Foundation for Poliomyelitis. Prior to this year an amount of $12,500 was given to the University of British Columbia for the purchase of research equipment. This year the Kinsmen's chair of neurological research has been established in the Faculty of Medicine, University of British Columbia, through the contribution of $5,000 per year for five years. Additional research into the epidemiological aspects of poliomyelitis is carried on under the direction of the Consultant in Epidemiology to the Health Branch, Department of Health and Welfare. With the co-operation of health units in the field and the Provincial Division of Laboratories in Vancouver, a number of studies into the spread pattern of epidemic poliomyelitis, identification of virus in epidemic areas, and field evaluation of gamma globulin are under way. There were a number of cases of diphtheria reported, to give a case rate of 0.7 per 100,000 population, approximately the same as in the previous year, when a rate of 0.9 was reported. It is still significant that this disease should occur in a Province where public health services are so widespread and opportunities for immunization against the Y 34 BRITISH COLUMBIA disease are constantly available. Upon investigation, these invariably occur among non-immunized persons who have been exposed to diphtheria carriers. It continues to emphasize the need for maintained diphtheria-immunization status amongst all members of the population, both in the child and adult. An extremely high incidence of bacillary dysentery of the Shigella type was reported in the case of 588 persons, to yield a case rate of 47.8 per 100,000 population. This was anticipated, as it had been indicated by the Director of the Division of Laboratories that a reservoir of unidentified carriers of Shigella sonnei was very likely as a result of outbreaks of bacillary dysentery at certain summer camps in the Howe Sound area during the summers of 1950 and 1952. There was also a major upswing in the incidence of epidemic hepatitis, in which 789 persons suffered illness, to promote a case rate of 64.1, much the highest incidence ever recorded in British Columbia. This is an acute virus infection in which the usual mode of transmission is not clear, since several epidemics have been reported caused by contaminated water, food, or milk, or by direct personal contact. Susceptibility is general, and a single attack seems to confer a considerable degree of immunity as second attacks are infrequent. The incidence tends to be highest in the autumn and early winter, occurring most commonly amongst children and young adults. Prophylaxis seems to depend upon good community sanitation and personal hygiene, with particular emphasis on sanitary disposal of respiratory and bowel discharges. The incidence of epidemic influenza was about average with a case rate of 65.7, which is considerably less than the case rate in the peak year of 1951, when it was recorded as 956.9 per 100,000 population. Preparations were made in the early spring months to provide for typing of specimens from patients in the Laboratory of Hygiene at Ottawa, but, as the incidence was not significant, these procedures were not invoked. One case of leprosy was recorded during 1953, in the case of a young Chinese, who was immediately transferred to the jurisdiction of the Department of National Health and Welfare for hospitalization at the leper centre on Bentinck Island. A considerable number of cases of salmonellosis were reported, particularly of the paratyphoid type. Investigations were conducted in the Prince Rupert area, where there has been a considerable amount of paratyphoid reported among the Indian population group, in which it was finally proven that carriers were creating the situation. Control measures are under consideration which, it is hoped, will decrease the annual incidence in that locale and bring about a much better Provincial picture for the future. Streptococcal infections were considerably decreased, resulting in a much improved situation from that point of view over the Province generally. There was a much lesser number of scarlet fever cases, and considerably less septic sore throat reported. Two persons contracted tetanus during the year, to present the same incidence this year as in the previous year. Fortunately, no fatalities were recorded, as anti-toxin was administered immediately diagnosis was established. The incidence of minor communicable infections, such as chicken-pox, measles, mumps, pertussis, and rubella, was apparent throughout the year, accounting for a considerable proportion of the notifiable diseases reported in the Province. There seems to be so little that can be done to promote control of these minor infections that consideration is being given to discontinuance of their reporting. This situation has been under discussion with the Department of National Health and Welfare, which is endeavouring to gather the opinions of the various Provinces in respect to notifiable-disease reporting for the future. The results of notifiable-disease reporting are presented in the statistical tables that follow, showing the totals and the rates for the past five years, as well as the breakdown of the incidence throughout the Province by health unit for the year. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 35 Table VIII.—Notifiable Diseases in British Columbia, 1949-53 (Including Indians) 1949 1950 1951 1952 1953 Notifiable Diseases Number of Cases Rate per 100,000 Population Number of Cases Rate per 100,000 Population Number of Cases Rate per 100.000 Population Number of Cases Rate per 100,000 Population Number of Cases Rate per 100.000 Population I 0.1 1 1 16 3,509 7,370 287 12 0.1 0.1 1.4 315.0 661.7 25.8 1.1 2.1 0.1 1.0 4.2 0.1 0.1 966.4 1.6 387.4 19.2 20.2 50.9 1.5 0.1 8.5 2.9 44.1 9.2 0.1 0.3 0.2 0.8 0.4 197.7 1 22 3,125 5,001 280 63 1 189 1 46 460 0.1 1.9 274.6 439.5 24.6 5.5 0.1 16.6 0.1 4.0 40.4 Brucellosis Cancer 18 2,850 6,671 374 5 1.6 247.2 578.5 32.4 .0.4 12 3,366 6,266 346 11 1 102 2 212 548 1.0 281.0 523.1 28.9 0.9 0.1 8.5 0.2 17.7 45.7 5 2,785 6,869 193 8 1 588 4 789 808 1 1 7,646 42 8,071 717 787 1,095 10 23 83 24 2,220 206 1 2 0.4 226.5 558.6 15.7 Diphtheria- Dysentery— 0.7 0.1 Bacillary (Shigella) 23 1 10 47 1 1 10,765 18 4,314 214 225 567 17 1 95 32 491 102 1 3 2 9 4 2,202 253 21.9 47.8 0.3 90 11,033 2 7.8 956.9 0.2 64.1 Influenza, epidemic 65.7 0.1 2 8,227 33 7,088 976 594 1,986 30 8 109 26 4,163 536 0.2 686.8 2.8 591.8 81.5 49.6 165.8 2.5 0.7 9.1 2.2 347.6 44.7 0.1 Measles- - Meningitis, meningococcal. Mumps- Pertussis.. Poliomyelitis.. Rubella Salmonellosis— 5,648 15 8,634 1,740 73 7,935 11 35 152 36 871 183 1 1 5 496.3 1.3 758.7 152.9 6.4 697.3 1.0 3.1 13.4 3.2 76.5 16.1 0.1 0.1 6,269 30 5,835 1,134 92 2,288 18 7 149 38 4,146 300 543.7 2.6 506.1 98.4 8.0 198.4 1.6 0.6 12.9 3.3 359.6 26.0 621.7 3.4 656.3 58.3 64.0 89.0 0.8 1.9 Unqualified Streptococcal infections— Erysipelas Scarlet fever 6.7 2.0 180.6 16.7 0.1 2 0.2 0.2 0.4 8 0.7 3 0.3 13 1.1 Tuberculosis— 1,828 160.6 1,662 144.1 1,411 117.8 1,494 | 1 | 2,969 | 691 | 11 1 26 | 121.5 0.1 Venereal disease— Gonorrhoea Syphilis (includes nonspecific urethritis— venereal) 3,833 859 344.2 77.1 0.3 3,579 630 314.5 55.4 3,301 568 286.3 49.3 3,057 | 541 | 19 1 255.2 45.2 241.5 56.2 0.9 3 6 0.5 48 4.2 1.6 2.1 Totals 35,036 3,145.5 40,572 3,565.2 47,189 | 4,092.7 39,677 | 3,312.3 38,185 1 3,104.9 Y 36 BRITISH COLUMBIA m m < W ft < Q W U ■- fi- 00 Q Z < H a <: w « O S3 H 2 pq z W w 1-1 « < 6 H O X w to < aDUIAOJd uospu JJO.J puB[sr iSAnoouEA jo jsboo }S3A\ JSE03 1S3A\ pUBUUEJAJ Xeusjoo^ issaa jo piEog uoiun jrEuimbsg-EuopiA 33HUUUI03 II11B3H UEJIIOdOflSIM 13' -nobuEA J3JE3JQ puEisi jsddfi J3SBJJ jsddfi UESEUBTO HJn0S IEKU33 U.WOS EU335fS assEjj uouiis Wil^S PUBIS! JSAUOOUEA tflnos pub uoiuebs J3AIH 33B3,! UEgEUE5(0 lllJ°N J3SEJJ U.1JON xUSunEnbc, -punos »*oh xeu3}oox iSBa pUBlSI J3An03 -UEA IEJIU33 AJEpunog IBJOl 11 11 tnvo a\as—<c* SOCS-h^O ilo OS *H <M :r^ !Sr : fN r- *-h © oo oo -^ <* (SfN |N rtiHN,H ; *£> \>rt ! its -i th tj oo ro t> O ! OO tH OO © VO OS ICO OsvOtNVO its *h it- in !? r Tf th iflO\Om r- Hr-g^crn h rn h -rf cot r- <n ION1* ■<* ! !th lOl It--* ; m cots Ith |00\ © »h r> cn «*vt> . . ro coos'-1 (N i-hth , ;cO h |*h thvoos ! iro iwiosrooo OOvOOS r-co i-i i-h OO ■■* ON OO i-( r 00 00© <n r-oo vorN i-1 r~r- >n ©mm tj-©\p,-<r*m **Ttr---iooos i-rioo cmcno *-» \c ©^r- r- ©, ri cn r- oo" tH? rl rO'd VOrsli-H^OCN 6.2 rt 0 M a B £ !V91&ft J-oflj i « rt-S w cS I s^ * h* a u 5 P >•§ S.S'Oo a. a a s?.s s§si g^s sa^as-g,f-a ess s § a 3 B.a csm <P0l S g &<§ S'5 s g = 2?-§iA25-w i-i-i; log a 0 9 < <Sz-' te CO rt "So OmOZ.i DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 37 REPORT OF THE DIVISION OF PUBLIC HEALTH NURSING Monica M. Frith, Director The Division of Public Health Nursing forms an integral part of the Bureau of Local Health Services. The completion of health-unit development within the Province has resulted in almost all the public health nursing districts being incorporated into health units, and accordingly it has been possible for the Division to modify its programme to fit the present situation. Formerly a great deal of time was spent on the organization of public health nursing districts and on the provision of direct public health nursing supervision to these districts. At the present time the responsibility for direct public health nursing supervision has been transferred to the local health-unit staff. The Division now concentrates its activities on recruiting, placing, transferring, and training nursing personnel and providing consultative nursing service to local health units to assist them in developing their public health nursing programmes to meet local needs. The work of the public health nurse in the field is carefully assessed in order to give the best possible service to the people of each district. STATUS OF SERVICE In order to meet the ever-increasing demand for public health nursing service brought about by the increased population in certain areas of the Province, and also to meet the demand for new types of public health nursing service, it has been necessary to increase the number of public health nurses in the field. Even with an increase of ten new positions over those of last year, it has not yet been possible to return to the ratio of one nurse to 4,000 population which existed in 1949. Therefore, it will be necessary to continue to add public health nursing staff if a high standard of service is to be maintained and if the public health nursing needs are to be met. During the year ten additional public health nursing positions were approved under National health grants. With the exception of the new district, McBride in the Cariboo Health Unit, all new positions were extensions of existing services. The new positions are located in the following health units: Central Vancouver Island Health Unit at Duncan and Port Alberni; Cariboo Health Unit at Williams Lake and Quesnel; Upper Island Health Unit at Courtenay; East Kootenay Health Unit at Creston; Saanich and South Vancouver Island Health Unit at Saanich; South Okanagan Health Unit at Oliver; Simon Fraser Health Unit at Coquitlam. In addition, a part-time public health nursing service was established for School District No. 80 at Kitimat. During the coming year it is hoped that additional public health nursing staff may be located in the North Fraser Valley, Boundary, and Simon Fraser Health Units. The demand for public health nursing service has increased the recruitment problem, as it is now necessary to find nursing staff for 139 positions, compared with 56 positions ten years ago. At the present time there are seven vacant positions, with two more being held on a very temporary basis. The number of resignations during the year has remained about the same as last year, but it has not been possible to recruit sufficient numbers of public health nurses to the service to fill the positions. It is believed that this is largely due to the unfavourable salary levels in the Provincial service. During the year thirty-six appointments were made to the public health nursing staff. Of this group, ten were public health nurses who returned to the staff following leave of absence for public health nursing university training, fifteen were qualified public health nurses, while the remaining eleven were nurses without public health nursing qualifications. It is interesting to note that this year it was possible to interest only one public health nurse, who was completing her training independently at the University of British Columbia, to join the service. Y 38 BRITISH COLUMBIA There were twenty-two resignations from the staff. Sixteen nurses left the service for family reasons or marriage, two to obtain further education, and four for other positions. Twelve nurses were granted leave of absence. Of this group, eight nurses are completing the certificate course in public health nursing, two experienced public health nurses are completing degree programmes in public health nursing, and two public health nurses are on extended leave of absence due to illness. Eighteen nurses transferred within the service. Five of these involved supervisory or senior personnel. CONSULTANT SERVICE The Division of Public Health Nursing is constantly striving to improve the quality of the public health nursing service. This is accomplished by public health nursing consultant field visits and by analysis of the work done. To determine whether the service is being rendered in an efficient and economical manner, a critical analysis of the service is made each year using statistical methods. Each public health nurse submits a case-load analysis and, in addition, participates in a three weeks' time study. In this way it is possible to determine how much time is being devoted to certain services, and to make changes to provide more efficient services where this is indicated. The statistical information collected is utilized by the public health nursing consultants during their field visits. Information obtained by statistical analysis along with the field report of the consultant assists the Division of Public Health Nursing to make recommendations to the Bureau of Local Health Services concerning such matters as staff, new types of programmes, equipment, etc. The Division of Public Health Nursing provides public health nursing consultative service to the health units and nursing districts in the conduct of the generalized public health nursing programme. The consultants visit the health units regularly, and during these visits assist the director of the health unit and senior nurse to analyse the public health nursing service being rendered in the unit and to plan modifications as the situation indicates. The public health nursing consultants provide assistance in special fields of work such as mental hygiene, maternal and child health, medical-nursing care programme, and Civil Defence, on a request basis. Since consultant service has been available, an improvement has been shown in the development of the public health nursing programmes on the local level, not only in the special fields of work, but also in the routine public health nursing programmes. Special assistance is available to the public health nursing service in the field of tuberculosis from the public health nursing co-ordinator assigned to the Division of Tuberculosis Control, Vancouver. On request to the Bureau of Local Health Services, arrangements may be made for a field visit. The senior epidemiology worker at the Division of Venereal Disease Control is available to the Bureau of Local Health Services to guide the field staff in the development of the public health nursing aspects of the venereal-disease programme. Records Committee The Provincial Public Health Nursing Records Committee has met regularly throughout the year and has been able to revise many records to suit the changing needs of local health services. A pilot study on the family folder system of filing records has been in operation for over a year, and it is expected that major changes in office procedure may result from this study during the coming year. PUBLIC HEALTH NURSING TRAINING The in-service training of nurses prior to the completion of the public health nursing course at the University has been an important aspect of the recruitment plan for obtaining public health nurses for the Provincial service. It was possible this year to send eight DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 39 nurses to the University to enrol in the certificate course in public health nursing with the assistance of National health-grant bursaries. Following the University course, these nurses are available for placement throughout the Province. This group of nurses makes a valuable contribution to the service, as they return to a service with which they are familiar and, therefore, can be placed in more responsible positions than those without this experience or training. The nurses who accept financial assistance under this plan agree to remain in the Provincial service for at least two years. Nine public health nurses returned to local health services following their basic academic training in public health nursing, while one nurse returned to the staff, having completed a course in public health nursing administration and supervision. Seventeen per cent of the qualified public health nurses on the staff at the present time have been trained under this plan. As 20 per cent of the staff nurses do not have public health nursing qualifications, it is necessary to depend very substantially on this type of training in order to maintain the quality of public health nursing service. During the year, field-work facilities were provided for twenty-one students from the University of British Columbia during the month of January and again in May. In addition, observation periods have been made available to undergraduate nurses in health units adjacent to schools of nursing as follows: Students from the Victoria schools of nursing, St. Joseph's and Royal Jubilee, went to the Saanich and South Vancouver Island Health Unit; the South Central Health Unit was used for students from the Royal Inland Hospital, Kamloops; and the Simon Fraser Health Unit was used for students from the Royal Columbian Hospital, New Westminster. This opportunity of observing the work of the public health nurses in a district has helped to recruit nurses to public health nursing and has given undergraduate nurses a better understanding of the function of a local health unit. A continuous in-service educational programme is carried on in each health unit to assist public health nurses to keep abreast of new developments and procedures in the public health field. This is accomplished largely through staff and study-group meetings, where relevant problems are discussed in relation to the public health nursing service. At the annual Public Health Institute a full day's programme was devoted to public health nursing, and a number of the nursing field staff were able to participate in the programme. The agenda included " The Use of Records," " Classes for Foster Parents," "A Programme for Over-weight Girls," and " Screening of Health Problems in High School." The Institute provides an excellent opportunity for interchange of ideas, and for stimulating the development of certain health programmes. With the help of National health grants the Division of Public Health Nursing was fortunate in being able to send seventeen senior public health nurses to the University of Washington to participate in a two-week course in mental hygiene. The course was conducted by Miss Ruth Gilbert, Co-ordinator, Course for Mental Hygiene Consultants, and Associate Professor of Nursing Education at Teachers College, Columbia University. On return to their health units, the public health nurses gave general summaries of the course content to the members of the public health nursing staff, and followed this up with staff education, general supervision, and guidance to utilize the new background of information received. It is expected that this course will have been of help to all public health nurses in the field by assisting them to incorporate mental-hygiene principles into the generalized public health programme. ADVISORY The Division of Public Health Nursing has continued to function in an advisory capacity to the bureaux within the Health Branch—the Bureau of Administration, the Bureau of Special Preventive and Treatment Services, and the Bureau of Local Health Services. Y 40 BRITISH COLUMBIA Members of the Division have been active on a number of Provincial committees. These include Junior Red Cross Nursing, the Junior Red Cross Crippled and Handicapped Fund, Public Health Nursing Labour Relations and Educational Policy Committee of the Registered Nurses' Association of British Columbia, the Advisory Committee to the University of British Columbia School of Nursing, and the St. John Ambulance Nursing Committee. LOCAL PUBLIC HEALTH NURSING SERVICE The public health nursing group makes up the largest number of health-workers in local health service. Because of their regular and frequent contact with all age-groups, in homes, schools, and clinics, they are important members of the public health team. The public health nurse in a local health unit gives a generalized service which is available to every age-group irrespective of economic and social circumstances. She is concerned with the health of all members of the family and is prepared to assist with the solution of health problems confronting individual members. The public health nurse gives guidance to the mother during her pregnancy, in order that she may make the best possible preparation for the birth of the new baby. This guidance may be carried out through mothers' classes or through visits to the mother in the home. She encourages expectant mothers to seek early and continuous medical care. She interprets the doctor's orders and teaches the family how to carry them out. She explains about such things as diet, rest, breast feeding, dental hygiene, clothing, and exercise. She helps the mother in planning the baby's layette. She assists in developing and maintaining wholesome family attitudes toward the arrival of the new baby. During the year a total of 2,475 visits was made to expectant mothers. Prenatal classes showed an attendance of 1,286. Plans are under way for classes to be started in a number of health units. Assistance in carrying out daily routines is given by the public health nurse after the mother returns from the hospital. Included in this may be demonstrations of approved methods of infant-care, such as bathing the baby and preparing the formula. Seventeen thousand one hundred visits were made to mothers at home within six weeks of the birth of the baby. The child-health programme is concerned with the physical and mental well-being of all children, and is continued throughout the growing period from infancy to adulthood. The programme is effected through child-health conferences, health supervision in the schools, and through visits to the mother in the home. Information is given to the family on understanding the child as well as planning for his physical care to enable the child to develop a sound, healthy mind and body. During childhood many physical defects and behaviour problems can be prevented or corrected. Frequently it is the public health nurse who brings these matters to the attention of parents in order to assist them in securing the necessary help. A total of 44,829 infants and 38,721 pre-school children attended child-health conferences during the year. Public health nurses made 28,990 home-visits regarding infants and 29,539 visits regarding pre-school children. The public health nurse supervises the health of the school-children in the schools of her district. She visits the schools regularly and offers certain nursing services to the school-children and provides consultative assistance to the teachers in health matters. In the school the public health nurse assists with school medical examinations, screening tests such as vision and hearing tests, arranges for immunizations, chest X-rays, etc. She advises concerning the control of skin infections, communicable diseases, and first-aid measures in the school. Through conferences with teachers, parents, and pupils, she works toward the improvement of the health of the school-child. While visiting in the home she is in an excellent position to interpret health matters, while at the same time she assists parents to understand the need for specific action. She encourages parents to correct defects and refers children needing financial assistance for this purpose to suitable agencies. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 41 During the year public health nurses assisted with 26,910 medical examinations and completed 55,469 nurses' examinations. The public health nurses held 47,385 conferences with members of the school staff, 44,550 with school pupils, and 10,903 with parents. There were 5,172 first-aid demonstrations. A total of 30,562 visits was made by public health nurses to homes of school-children. Of these, 22,826 were for general health supervision, 959 were for mental hygiene, while 1,236 were for skin infections and communicable diseases. During the year public health nurses used the resources of the Child Guidance Clinic by referring 130 children to the Clinic for guidance. The public health nurses continued to supervise tuberculosis cases in the homes and to arrange for examination of contacts to cases. As tuberculosis patients are now being discharged earlier, because of continued chemo-therapy carried on in the home, the amount of work in connection with the tuberculosis programme has increased over that of last year. Public health nurses have been giving an average of 1,200 injections of streptomycin per month since this programme was taken over by the public health nurses. During the year 9,784 visits were made to tuberculosis patients, and 8,421 visits were made to tuberculosis contacts. B.C.G. vaccinations were given to 712 individuals. Public health nurses in certain areas have been concerned with arrangements for the mobile chest X-ray and tuberculin surveys. The public health nurses continue to provide nursing care in the home on a short- term basis. This includes such procedures as hypodermic injections, enemas, treatments, dressings, etc. Demonstration of nursing-care procedures may include instruction on how to bathe a patient in bed, prepare a formula, etc. The public health nurse renders nursing care in the home in an emergency and teaches someone else to carry out routine care when it is necessary to arrange for long-term care. During the year 516 nursing-care demonstrations were given. A total of 4,224 visits was made for nursing care in the home. Kelowna in the South Okanagan Health Unit continues to give a full bedside- nursing programme, while Vernon in the North Okanagan Health Unit provides a pilot study on home care. It should be noted that these two areas provide housekeeping service in conjunction with the nursing-care programmes. As it is felt that housekeeping service is needed in most communities, it is encouraging to note that the Local Council of Women in Kamloops, in the South Central Health Unit, has just organized a housekeeping service which will supplement the service provided in the home by the public health nurse. In the South Okanagan Health Unit at Keremeos, a special committee has been set up to arrange for nursing care to be given on an emergency basis as this area does not have a resident physician nor a hospital. The public health nurse assists in the communicable-disease control programme by organizing and operating immunization clinics which are located at strategic areas throughout her district. There were 10,003 completing the series of injections for protection against whooping-cough, 14,081 for diphtheria, 13,330 for tetanus, 924 for typhoid, while 27,617 were vaccinated against smallpox during the year. Public health nurses have assisted with epidemiological investigations of communicable diseases, and this year have been particularly active in the poliomyelitis programme. The public health nursing staff has played an active part in the organization of consultative travelling clinics and in the follow-up of referred cases. These clinics include the Tuberculosis Travelling Clinics, the Children's Hospital Clinic, the Cancer Consultative Clinic, and the Child Guidance Clinic. The staff has been grateful for the financial assistance received from the Junior Red Cross Crippled and Handicapped Fund. This was rendered to children who would not otherwise have been able to have physical defects corrected. The variety and scope of the public health nursing programme has continued to increase as the need for new services becomes evident. Tribute should be paid to the Y 42 BRITISH COLUMBIA public health nurses, who have adapted themselves to changing conditions and accepted and expedited new programmes promptly and efficiently. The following statistical summary shows the volume of work in certain public health nursing services during the year:— Home Services Infants 28,990 Pre-school children 29,539 School-children 30,562 Adults 20,614 Expectant mothers 2,344 Tuberculosis cases and contacts 18,205 Venereal-disease cases and contacts 874 Mothers within six weeks after the birth of their babies 16,189 Clinic A ttendance Attendance at prenatal clinics or classes 1,368 Attendance at child-health conferences— Infants 44,829 Pre-school children 38,721 Immunizations Whooping-cough 10,003 Diphtheria 14,081. Tetanus 13,830 Typhoid 924 Smallpox 27,617 B.C.G 712 Total inoculations 175,369 DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 43 REPORT OF THE DIVISION OF ENVIRONMENTAL MANAGEMENT Thomas H. Patterson, Director This is the second year of operation for this Division, and although some progress has been realized, it has been slow. The Nutrition and Sanitary Inspection Sections of the Division, being well established, continue to give their special service, as outlined in the following separate reports. Civil Defence Health Services Section has also become reasonably well established and, because of the amount of activity in this field, merits the more detailed report, which follows. REHABILITATION The other phases of environmental management are largely in the early developmental stage. Therefore, it is found in the field of rehabilitation that plans are still in the process of being discussed among senior staff members of the Provincial and Federal Governments for the purpose of establishing a sound basis on which the programme can be developed and methods of financing the employment of a suitable Rehabilitation Co-ordination Officer. OCCUPATIONAL HEALTH In the occupational-health field, of which industrial hygiene is a part, final steps have been taken toward the establishment of an industrial nursing service for Government employees located in Victoria. This unit is being established in the Douglas Building, and, besides providing a direct service to the employees, will provide a limited amount of consultative service to private industry. This is accepted as a very sound principle to follow in developing a good industrial-nursing consultative service. The growing use of insecticides and other toxic chemicals, both in industry and the home, has continued to present problems that can only be dealt with to a very limited extent by the present facilities. When space becomes available for the provision of proper industrial-hygiene laboratory services and the employment of qualified persons to give this service, more progress in dealing with these hazards may be expected. Another occupational hazard, in the form of the growing use of radioactive substances in industrial processes, is receiving increased attention. The Division of Occupational Health of the Department of National Health and Welfare has established a Radiological Section, which co-operates with this Division by giving notification of the destination of all shipments of radioactive substances into this Province. Study has also been given to the formulation of regulations governing the use of radioactive isotopes, for the sole purpose of protecting the persons working with these materials and the general public who may inadvertently be exposed to dangerous radiation. A programme of surveying the X-ray shoe-fitting machines, for the purpose of detecting possible dangerous radiation exposures both to operators and customers, is being developed in co-operation with a large city health department. MEDICAL CARE—RESEARCH A project of research into the health and care of persons admitted to hospital in British Columbia and the health and care of persons subscribing to medical-care insurance plans has been undertaken. The project has been designed to operate for two years, at which time review of its findings will determine its future course. The study is staffed by two statistical research assistants and one clerk-stenographer, and is guided by a steering committee consisting of the Commissioner and Assistant Commissioner of British Columbia Hospital Insurance Service, the Deputy Minister of Health, and the Director of the Division of Vital Statistics. Y 44 BRITISH COLUMBIA GENERAL During the year the Director of the Division maintained contact with various other developments in the field of public health. Meetings of government and public representatives were held for the purpose of initiating programmes to deal with the problems of drug and alcohol addiction. Besides accumulating valuable data and information on the above subject, study has been given to the statistical data on mortality caused by accidents outside of industry. Unfortunately, very little data on the non-death-causing accidents is available, but it is quite obvious from mortality statistics that steps must be taken to reduce the number of accidents taking toll of our population. A. REPORT OF THE NUTRITION SERVICE The services provided through the nutrition consultant programme have been further developed and extended during 1953. The year's activities have been directed toward meeting the needs and requests of public health personnel, administrators of hospitals and institutions, other Government departments and organizations for consultant service as described in the ensuing report. Consultant Service to Local Public Health Personnel The consultant service provided to the staff of local health units has included technical information and advice, assistance in studying food habits, and recommendations as to methods of nutrition education in the community. During the year eight health units were visited by the Nutrition Consultant. In each unit, conferences were held with public health staff to discuss local nutrition problems and to review the latest information in the field of nutrition. Additional time was spent in each area observing school-lunch programmes and meeting with school cafeteria committees, social workers, parent-teacher organizations, and other key groups, to provide assistance with nutrition-education activities. Dietary Studies The Nutrition Consultants have continued to assist public health personnel in studying the variety of foods eaten by families in the community. The object of these studies was to provide information about the type and extent of dietary problems in the community and to stimulate interest in improving meals. During the year dietary studies were conducted among school-children in seven districts of the Province. It is interesting to note that the results of these studies were very similar to those found from previous studies conducted in schools in many other areas of the Province during the past four years. The chief deficiencies in children's meals continued to be milk, a Vitamin D supplement, and foods rich in Vitamin C. Meat, potatoes, and bread are eaten in satisfactory amounts by the majority of the children. Sweet foods, such as candy, soft drinks, and cake, are consumed in excessive amounts by many children. The need for increased consumption of milk, a Vitamin D supplement for children, and foods rich in Vitamin C has been clearly shown. It therefore remains a prime objective of nutrition education in this Province to encourage people to include adequate amounts of these foods in their daily meals. One of the most practical nutrition and dental-health projects directed toward reducing the excessive consumption of soft drinks and candy among school-children has been the school apple sales sponsored by the Junior Red Cross. A further development of this programme during the year has been the completion of arrangements to make individual 6-ounce containers of vitaminized apple-juice available to schools for sale at a reasonable price. It is recognized that this programme merits the co-operation of public health personnel, and the development of these projects in schools throughout the Province has been encouraged. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 45 Rat-feeding Experiments Another method of nutrition education that has proven particularly effective over the past three years has been the rat-feeding experiment. During 1953 these experiments were conducted in seventy schools outside of the Greater Vancouver area. The purpose of the animal-feeding experiment is to illustrate to children and parents the benefits to be derived from good daily meals. During the experiment one pair of rats is fed a variety of foods recommended in Canada's Food Rules and the other pair receives such foods as soft drinks, white bread, cake, and candy. The difference in weight, appearance, and disposition between the two pair of rats is clearly noted by the children during a period of four weeks. The interest and co-operation of parents have been obtained in many areas by displaying the rat-feeding experiment in community store windows and at group meetings. Reports from public health nurses and teachers during the year have indicated that these projects continue to be one of the most effective methods of encouraging improved food habits. The continual interest and co-operation of the staff of the Animal Nutrition Laboratory at the University of British Columbia in providing white rats for all the experiments have been appreciated. School-lunch Programmes The consultant service requested by public health personnel in relation to school- lunch programmes has increased in line with the continued construction of new schools. Visits to nine school cafeterias were requested during field-trips, to observe the lunch programme in operation and to provide information to lunchroom administrators. Assistance was requested and provided to local School Boards in planning equipment and layout for cafeterias in six new school buildings. Menu plans and quantity recipes were compiled as requested by several school cafeterias. In co-operation with public health nurses, meetings were held with Parent-Teacher Associations in five areas to assist with problems concerning lunch-supplement programmes in schools of the district. A reference manual is now in preparation for the use of local school authorities in planning equipment, space, and layout requirements of school cafeterias of various sizes. Other Services Due to the importance of a good diet during pregnancy, information about wise food selection is an important part of prenatal education. To assist public health personnel in placing additional emphasis on nutrition in the prenatal programme, the Nutrition Consultants have reviewed and collected suitable reference material for use in prenatal classes. A leaflet describing food requirements and how these may be met through family meals is now being prepared for distribution to mothers. Through the kind co-operation of members of the Faculty of Pharmacy at the University of British Columbia, an up-to-date list and description of Vitamin D supplements has been compiled for the reference of public health personnel. A major public health problem of to-day is that of obesity, due generally to the excessive consumption of foods. Since obesity is associated with many serious physical impairments, it is recognized that weight-control plays an important part in the prevention of some of the major crippling diseases of middle and later life. In view of this, the Nutrition Consultants have continued to give considerable attention to studying methods and materials that will assist public health personnel in an educational programme to inform people of the dangers of overweight and the benefits to be gained by weight-control. Y 46 BRITISH COLUMBIA Consultant Service to Hospitals and Institutions Since the Nutrition Consultant service was extended to include hospitals in 1952, there has been a steady development in this phase of the programme. As a result of requests from hospital administrators, the Nutrition Consultant visited twelve hospitals during field-trips this year. Information and advice of the Consultant has been requested on many problems of hospital food service, including dish-washing and other kitchen equipment, reference material for special diets, general layout of new hospital kitchens, assistance with quantity recipes, menu-planning, and methods of controlling food costs. The hospital consultant programme has been conducted in close co-operation with members of the Hospital Insurance Service. Institutions receiving consultant service included the Boys' Industrial School, the Men's and Women's Gaols in Prince George, Oakalla Prison Farm, and New Haven. Following the visit to each institution, a detailed report of observations and recommendations concerning improvements in the food service was submitted to the administrators concerned. In co-operation with the Warden and the Architect's Branch, Department of Public Works, assistance was provided in planning the layout and equipment required for a new main kitchen at Oakalla Prison Farm. An analysis of the annual per capita food consumption was requested by New Haven, and recommendations were made where necessary concerning the reduction or increase of various groups of foods to improve the general diet. The Nutrition Consultant spent some time observing the food service in the Tran- quille Sanatorium and Pearson and Jericho Hospitals of the Division of Tuberculosis Control, and assisting with special studies relating to the organization and operation of the food service in each institution. A number of recommendations relating to changes and improvements in the dietary programme have been submitted and are under consideration at the present time. Co-operative Activities with Other Departments and Organizations At the request of the School Planning Division of the Department of Education, the layout and equipment lists for new school cafeterias were reviewed. Whenever possible a visit was made to the area concerned to observe and study local needs prior to making recommendations about the equipment and layout requirements. In co-operation with the Provincial executive of the Parent-Teacher Federation, a questionnaire was circulated to local Parent-Teacher Associations to obtain information concerning their activities in school-lunch programmes and the type of assistance they require in this field. It is hoped that the information obtained from the questionnaire will provide a basis on which to plan the further development of a consultant service to parent-teacher organizations relative to school-lunch programmes. Assistance has been provided during the year to the British Columbia Hospital Insurance Service in reviewing the layout, and equipment for new hospital kitchens. In co-operation with social workers in several districts, a study was made of the foods eaten for a period of one week by a group of elderly persons in receipt of old-age pensions. Cognizance was taken of those persons wearing artificial dentures and those without a natural dentition and without artificial substitutes. This study has provided useful information regarding the food habits and problems of elderly persons on a limited income and will assist in planning future consultant services for this group. During the year monthly meetings were held with nutritionists from the Metropolitan Health Committee in Vancouver, the University of British Columbia, the Vancouver General Hospital, home service departments, and other agencies for the purpose of group planning and working together on common problems. One project of the group this DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 47 year has been the study and planning of Nutrition Consultant services that could be provided to assist in training courses for key groups, such as nurses and social workers. It has been recognized that persons coming to reside in this Province from other countries encounter many problems in food-purchasing due to differences in food products. In view of this, consideration has been given to methods of providing more assistance to immigrants with their problems of food selection. This has resulted in the preparation of a booklet describing Canadian foods and some of the differences between British and Canadian foods for distribution to persons from Great Britain coming to reside in this Province. It is hoped that in the future similar information might be prepared to assist immigrants from other countries. The public health nutrition programme in this Province has been outlined in talks to the Victoria branch of the Canadian Association of Consumers, the Vancouver Home Economics Association, dietetic interns, and teachers of home economics. B. REPORT OF SANITARY INSPECTION SERVICES The continual improvement and high standards in respect to milk-supplies; industrial, tourist, and summer camps; school sanitation; private water-supplies; private sewage-disposal systems; rodent and insect control; and community sanitation should be attributed to the inspectional and advisory services by the local Sanitary Inspector on behalf of the local Union Board and its Medical Health Officer. The Division of Environmental Management offers advisory, consultant, and administrative assistance on technical matters to the local Medical Health Officer. This Division, through afforded opportunities, is able to provide guidance in developing programmes on the local level and at the same time maintain a uniformity of minimum requirements and interpretation of Provincial regulations. The Director performs liaison duties with other Government departments, industrial and trade organizations. The Director evaluates many sanitation programmes and performs special investigations in the now limited areas beyond the boundaries of full-time local health services. Food-control Milk-control For the third year an evaluation of laboratory reports on samples of pasteurized milk from various points in the Province has been conducted. Observations indicate that the low bacterial counts evidenced during the previous year have been maintained. Included in the evaluation were 1,021 samples from fifty-six dairies, as compared to 732 samples from forty-six dairies the previous year. Fifty-one of the fifty-six dairies averaged were in the allowable limit, and there is an estimated improvement of 4 per cent in this respect during the year. Two municipal milk by-laws were reviewed prior to submission for the required approval of the Lieutenant-Governor in Council. Amongst the problems referred to the Division for consultative and advisory services were the following:— (1) Nine raw-milk vendors distributing milk from premises below the Grade A category required by the " Milk Act." (2) Two premises shipping milk to pasteurizing plants where there were persons suffering from a communicable disease. (3) One small epidemic suspected of being milk-borne. (4) One import and one export milk problem. The quality control and licensing of milk-vendors is the responsibility of each municipality under its local milk by-laws. Consideration is being given to the adoption of a regulation to license dairies and vendors which are outside the boundaries of organized municipalities. y 48 british columbia Eating and Drinking Places Six complaints were processed through the Division during the year. These were, in the main, from persons who continue to look upon the Provincial offices as a place to lodge complaints of this category. All cases were disposed of by the local authorities. Food-handling instruction classes conducted on the local level continue to receive emphasis, as compared to the previous method of complete dependence on routine inspections. Frozen-food Locker Plants Stimulated by requests from the Frozen-food Locker Plant Association, the Department of Agriculture, the Game Commission, and the results of a survey by this Division, the Regulations Governing Construction and Operation of Frozen-food Locker Plants were more rigidly enforced in 1952, and this policy has continued in 1953. Eight complaints of non-conformance to the regulations were referred to local health services. At its annual general meeting, the British Columbia Frozen-food Locker Plant Association expressed appreciation of the increased inspection services now being given to its premises. Slaughter-houses Continued improvement is noted in the sanitary environment of these premises wherein food for human consumption is handled. The arrangement, on behalf of local health services, with the Department of Agriculture whereby, before a licence is issued by the Recorder of Brands, an applicant for a licence must submit an inspection certificate completed by the Medical Health Officer has been carried into its fourth year of operation. This arrangement continues to be an asset to local health services in the improvement programme in slaughter-house construction and maintenance throughout the Province. Eighty such licences were issued in 1953. No less than fifteen of the applicants failed to attach a completed Health Officer's certificate, and these licences were withheld until the completed certificates were submitted. Meat Inspection Interest in a Provincial meat-inspection regulation continues. Inquiries regarding such a regulation have been relayed to the Department of Agriculture, as it is a matter related to veterinary services and the diseases of animals. During the year municipal inspection was instituted by the City of Kamloops. The by-law in that regard was reviewed prior to submission for approval by the Lieutenant- Governor in Council. Horse-meat This product, for human consumption, which came on the market in this Province in 1951 and lost some of its popularity in 1952, has almost totally disappeared from the market in 1953. Housing Industrial Camps This sanitation activity ran quite smoothly during the year, with but twelve complaints registered with the Division. The inspection of industrial camps is an important function of the Sanitary Inspector, and records of the inspection are retained in the health unit. The North Fraser Health Unit made an all-out effort to cover the camps within its district, and was commended by the International Woodworkers' Union for this work. The Skeena Health Unit reports improvements in standards in its area. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 49 British Columbia industrial camps are noted for the absence of double-tier bunks in their accommodations. With the introduction of trailer-camp accommodation in 1951, double-tier bunks were reintroduced under a permit system. Due to dissatisfaction with this type of housing, the permits were cancelled in 1952 and the operators discontinued the practice on January 1st, 1953. One application for permission to use double-tier bunks in 1953 was refused. The use of tent accommodation in semi-permanent types of operation has grown in the past two years, and has been brought to the attention of this Department by the Building Trades Council, with a request to curtail this growing practice. Summer Camps Under the " Welfare Institutions Licensing Act," these camps are operated by church organizations, welfare agencies, service clubs, fraternal organizations, Y.M.C.A., Y.W.C.A., and other charitable organizations. The philosophy of the inspection is to visit the camp at a time when the personnel first arrive in order to discuss good sanitation practices and to emphasize the early recognition of gastro-intestinal diseases, the need of reporting, and the isolation of cases. A special inspection project and a comprehensive report were made on eighteen camps in the Howe Sound area by an advanced medical student who combined the inspections with his summer employment as an epidemiology-worker. A further twenty- seven camps were inspected and reported upon by local health services. In evaluating the total of forty-seven camps inspected, twenty-eight were classified as A (good), twelve as B (fair), three as C (poor), and two as Unsatisfactory. Comparative ratings for the inspections conducted in the years 1951 to 1953, inclusive, are as follows:— Class 1951 PerCent j 1 1952 PerCent 1953 PerCent A - 22 18 6 3 1 46.0 36.0 12.0 | 6.0 35 13 4 4 62.0 23.0 7.5 7.5 29 13 3 2 61.5 B C D. 27.5 6.5 4.5 Totals 49 ■ ■ 1 56 ...... 47 It is proposed by the Departmental representative on the Welfare Institutions Licensing Board that the existing printed material on " Summer Camp Standards " be amended, and that the standards be put forth in terms of requirements pursuant to the " Welfare Institutions Licensing Act." School Sanitation Copies of 239 reports prepared by School Medical Inspectors for submission to School Boards were forwarded to the Department for the school-year 1952—53. Continual improvement in school facilities is to be noted. The new schools constructed have the most modern sanitary facilities and environmental features, and existing schools are being modernized. Sewage-disposal, which was frequently a post-construction problem, has been, to a very large extent, overcome. Lighting facilities continue to receive improvement. The school sanitation reports continue to be used by School Boards as the basis of work-sheets for maintenance and renovation. School authorities express appreciation for the special service given. Plumbing It was expected at the beginning of the year that the National Plumbing Code would be completed and available as a uniform standard for Canada. The Provincial representative on the Technical Advisory Committee on the Plumbing Services to the National Research Council attended one Committee meeting. It is expected that the National Code will be completed early in the new year. Y 50 BRITISH COLUMBIA Three municipalities have submitted requests for model plumbing by-laws, which the Division had hoped would be completed this year, pursuant to the completion of the National Code. The Division intends to prepare a model code based on the Provincial Plumbing Regulations when they have received approval. Garbage and Refuse Disposal Five requests from the Department of Lands and Forests for inspection of Crown lands, prior to lease as disposal-sites, were processed through the local health services as to suitability for use. Interest in replacing nuisance-grounds, usually ravine dumps, with sanitary land fills continues. The neglect in nuisance-dumping is being minimized by improvement in control methods, the extensive maintenance, and the use of machinery in the covering procedure. In the use of Crown land, maintenance requirements under the direction of the Medical Health Officer are being made part of the lease terms. RODENT-CONTROL AND SYLVATIC PLAGUE SURVEY Co-operation between the Department of National Health and Welfare and this Department in the collection of ground-squirrels, marmots, and domestic rodents (rats), and their ectoparasites, continues. Collections and the submission of specimens to the Laboratory of Hygiene at Kamloops continues by the Cities of Vancouver and Victoria. The collections were extended and submissions were also made by the West Kootenay Health Unit and the Selkirk Health Unit. It is planned further to extend the collection by having the other health units in the Province expand their rodent-control activities into the collection of specimens for laboratory purposes. Barber-shops Early in the year the Barbers' Association proposed that the Department rewrite the existing regulations. A draft revision has been prepared and endorsed by the Barbers' Association and the Health Officers at their semi-annual meeting. Hitherto, the Barbers' Association has had a self-inspection arrangement. They appointed their own inspector, who carried out the routine inspections and called upon the Medical Health Officer for occasional assistance with problem cases. The draft revision of the regulations, at the request of the Barbers' Association, provides for the routine inspections being carried out by the Medical Health Officer. C. REPORT OF CIVIL DEFENCE HEALTH SERVICES The development of these services has continued along several lines during the year. Regional Conferences At a regional western conference of Civil Defence officials in Edmonton in January, the problems of organizing hospitals and first-aid stations were thoroughly discussed and recommendations were made for proceeding with this vital programme. Plans are now being made for a Regional Civil Defence Health Services meeting to be held in British Columbia early in 1954 and sponsored by the Federal Civil Defence office and the Canadian Hospital Association. The purpose of this meeting will be to demonstrate hospital disaster planning to selected hospital teams for Alberta and British Columbia. Emergency Medical Supplies Medical and surgical supplies purchased by the Department of National Health and Welfare are to be stock-piled in regional warehouses in British Columbia. These supplies will be maintained at definite levels for use in event of disaster. • DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 51 First-aid Stations Two very large demonstrations of first-aid stations were successfully carried out in Vancouver and Victoria during March. These demonstrations were especially realistic, as each dealt with fifty very impressively made-up casualties. The assistance given to local Civil Defence Health Services by the National office of Civil Defence was invaluable. Three first-aid stations have now been located in the Fraser Valley Mutual Aid and Reception Area. These stations are to be used as emergency medical units, capable of dealing with civil disaster and operating small emergency hospitals as well as functioning as first-aid stations in time of war. In initiating this programme, meetings were held between Provincial and local Civil Defence health officials at Abbotsford. Similar planning is also being carried out in the Vancouver Island Mutual Aid and Reception Area. The total number of first-aid stations being developed in British Columbia is thirty-four. Each station requires a considerable number of doctors, nurses, first-aiders, and other auxiliary health personnel. Therefore, an extensive training programme has continued throughout the year. Study Forum The Provincial office of Civil Defence held two study forums during the year in which health services personnel participated, in order to become familiar with the procedures for dealing with special medical problems in time of disaster. Emergency Blood Service Steps were taken in co-operation with the Red Cross blood transfusion service toward the training and establishment of four emergency bleeding teams to be located in strategic positions in the Province. Not only will these teams serve in time of disaster, but they are expected to aid materially in meeting the new increased demand for blood to be used in the production of gamma globulin for the prevention of poliomyelitis. Training The Registered Nurses' Association of British Columbia, having secured ninety-eight instructors through a course given in 1952, has succeeded in holding many subsequent nurses' training courses throughout the Province. This training is also being given in all undergraduate nursing-schools in British Columbia, where a total of 1,533 graduates took these courses during the year. Three courses on the " Medical Aspects of A.B.C. Warfare " were held at Camp Borden, Ont., during the year, and were attended by eight physicians from British Columbia. In addition, one Sanitary Inspector attended a special Civil Defence Course in Ontario for the purpose of evaluating such training with respect to the future development of emergency sanitation services. The training of first-aiders has been carried on largely by the St. John Ambulance Association, while the Red Cross Association has assumed the major responsibility for training volunteers for home nursing. Both types of trainees are very valuable adjuncts to all emergency medical services, and the training programmes during the forthcoming year must be increased in order to meet the demand for trained persons. General It must be realized that the actual development of these services at the local level is carried out by responsible citizens who, recognizing the need for preparing to meet possible disaster, have voluntarily given much of their personal time. In order that these people may know that their efforts are recognized and appreciated, it is necessary that government at all levels endorse their actions and support them in every way possible. Y 52 BRITISH COLUMBIA • REPORT OF THE DIVISION OF PREVENTIVE DENTISTRY F. McCombie, Director The scourge of dental disease throughout this Province continues to be cause for the gravest concern. During the past year it has been estimated, on the basis of the 1951—52 public-schools enrolment, that to provide dental treatment to all school-children of this Province would cost approximately $9,000,000 in the first year of such a programme. Moreover, to provide such treatment would require no less than 545 dentists working full time. At the close of 1952 there were only 555 dentists registered in British Columbia. Also, during the past year some of the results of the Canadian National Sickness Survey, which was carried out for a twelve-month period during 1950-51, have been published. During that year only 27.6 per cent of the families of Canada received dental care for which they paid directly, and yet they expended some $33,000,000 for such treatment during that period. The shortage of dentists in the rural areas of this Province, though somewhat improved, remains acute; the same situation pertains across the length and breadth of Canada. The most important single factor responsible for this unfortunate situation, it is believed, is the high rate of need and demand for dental services in the metropolitan areas coupled with the over-all shortage of dentists across Canada. Records of the past year of preventive dental services of this Province again reveal the ravages of dental decay amongst our children. The average 3-year-old required four tooth surfaces to be restored; such treatment required one and a quarter hours of the dentist's time. The average 4- and 5-year-olds required six or seven tooth surfaces to be restored, for which an average of one and three-quarters hours of dental treatment was necessary. As the age increased, so the situation deteriorated. The average 6-year-old required seven tooth surfaces to be restored and two hours of the dentist's time, while the 7-year-olds, on an average, required eight to nine tooth surfaces to be restored. Yet, to-day, the vast majority of dental disease, especially dental decay, can be prevented. Furthermore, such prevention is not only possible by individual action, but also, to-day, by community action. The value of improved health, fitness, and appearance to our children cannot be priced. The economical savings to the family and the community as the result of avoiding needless expenditure for the treatment of dental disease can and should be appreciated. Prevention To provide the necessary information to the many people and communities scattered throughout the 360,000 square miles of this Province, it would be desirable for there to be available many dentists especially trained in preventive and public health dentistry. In the past years it has been the policy of the Health Branch to endeavour to provide one such dentist to each health unit of the Province, and to provide financial grants-in-aid toward the school dental services of the metropolitan areas. At the commencement of the present school-year, all appointments were filled within the preventive dental services of Greater Victoria and Greater Vancouver. The importance and size of the programmes undertaken within the metropolitan areas and the commensurate financial grants-in-aid made available thereto through this Division are noted. It is therefore considered likely that at a future date it will not only be desirable, but a requirement for the continuance of such financial aid, and that those directing these programmes have formal postgraduate education in public health and preventive dentistry and have attained a degree or diploma within this specialty. At the close of 1953 it is only possible to report that four health units of the Province have on their staff a full-time dental director. Numerically, this is the same situation as DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 53 at the close of 1952. In addition, one dentist is at university attending a year's postgraduate training in pasdodontia and preventive dentistry. During the school-year 1952—53 preventive dental services operated continuously in three health units, in which the service was provided to eight school districts, and during some months of the year in one further health unit to three additional school districts. These services were in their second year of operation. Two hundred and seventy-six children (including forty-three 3-year-olds and eighty-two 4-year-olds) were restored to dental health; that is, received complete treatment. These children and 344 of their parents were instructed individually in the prevention of dental disease. Of all the pre-school children inspected, only 14.4 per cent were found not to be in need of dental treatment. Twenty-eight per cent of the pre-school children who received treatment had previously visited a dentist, which is an improvement on the previous year's figure of only 10 per cent. Of the 1,484 Grade I pupils within the above three health units, 1,157 were provided with a dental examination, and of those inspected only 11.5 per cent were found not to be in need of dental treatment. Parents of 70 per cent of the children inspected requested that the necessary dental treatment be undertaken by the health-unit dental officer, and virtually all of these received the requested treatment. A further 12 per cent of those inspected arranged for treatment with their family dentist. Therefore, of the children inspected, 93.5 per cent were treated by the health-unit dental officer or by the family dentist, or did not require treatment. These children, who either received complete dental treatment or were not in need of dental treatment, represent 73 per cent of the total enrolment. In addition to the 809 Grade I pupils who received complete dental treatment by the health-unit dental officer, and instruction in the prevention of dental disease, 166 of their parents were similarly and individually instructed at the chairside. Of these, the children who received dental treatment within the health-unit preventive dental services, 42 per cent had previously received dental treatment, which is again an improvement over last year's figure of 22 per cent. The preventive dental services within the above four health units and the school dental services in Powell River, Greater Victoria, and Greater Vancouver provided dental examinations to 1,815 pre-school and 13,226 Grade I children. The total enrolment of Grade I pupils in the Province in the school-year 1952-53 is estimated as 21,500. During the past school-year 509 pre-school children and 7,225 Grade I pupils received complete dental treatment from these services. The high standard of all these services is revealed by the fact that amongst the 1,465 pre-school and Grade I children for whom detailed records are available this year, 11.7 tooth surfaces were restored for every tooth (permanent or temporary) which was extracted. Moreover, a total of only nine permanent teeth were extracted for all these children. In one health unit, as an experimental procedure and to the detriment of other services, dental treatment was offered to a group of children of Grade II who the year before, whilst in Grade I, had received from the health-unit dental officer complete dental treatment. The total enrolment of Grade II pupils was 440, and whilst 194 Grade I pupils were treated the previous year, 179 Grade II pupils this year were eligible for this service. Unfortunately, it was only possible to provide treatment for 54 of these. Nevertheless, it is interesting to note that each of these pupils this year, on an average, required one hour and thirty-four minutes of the dentist's time for complete dental treatment. Community dental clinics for younger children, in which resident or visiting family dentists co-operate on a part-time basis, continued to expand in number and scope beyond all expectations. This expansion is particularly gratifying, since it demonstrates that local communities are not only aware of the problems of dental ill health within their midst, but also are prepared to devote time, energy, and financial support to finding and supporting a practical solution. The continued expansion of these programmes also Y 54 BRITISH COLUMBIA indicates the increasing awareness of this problem by individual members of the dental profession and also their willingness to co-operate in a spirit of public service with the community in solving the problem. During the fiscal year 1952-53, 2,131 children, pre-schools and pupils of Grades I, II, and III, were restored to dental health through community dental clinics in which twenty-five dentists co-operated on a part-time basis. At the close of 1953 no less than forty-three of these clinics utilizing the services of forty-five dentists had been organized, whereas at the close of 1952 there were nineteen such clinics. In summary, full-time dental services were provided throughout the school-year 1952—53 in fifteen school districts, half-time services in one further school district, and during part of the year full-time services in an additional four school districts. Within seventeen school districts, part-time services were provided through community dental clinics. In total, thirty-seven of the eighty school districts of the Province received preventive dental services provided either on a full-time or part-time basis. From the preceding paragraphs it will be appreciated that two major factors warrant careful consideration; that is, the difficulty of attracting suitably qualified dentists to the vacant full-time appointments with rural health units, and the rapid and successful expansion of community dental clinics operated on a part-time basis with resident or visiting family dentists. Consideration is therefore being given to the co-ordination of these two programmes and to their evolution into a programme which will not only combine the best features of both, but also provide for greater flexibility and rapidity of expansion than has been possible before. It is suggested that full-time dental officers in future may be allocated on a regional basis, having responsibility within two or three adjacent health units. Within each health unit the same relationship would pertain with the health-unit director as exists at present. The duties of these dental officers, it is suggested, would be threefold. Firstly, it would be their duty to encourage dental-health education within the area for which they are responsible. This would entail interviews and conferences with School Inspectors, principals, and teachers, meeting collectively and individually with the members of the medical and dental professions of the area, and addressing Parent-Teacher Associations, service clubs, and health-unit staff conferences. The second area of activity would be providing assistance to communities to organize and expand part-time preventive dental services, and to ensure that such services operate at maximum efficiency by meeting with the dentists and sponsoring agencies as required. Thirdly, such dental officers would provide direct clinical services to the younger children in areas where it would not be possible at the time to arrange part-time services. Under such arrangements the majority of the clinical services would be provided by resident or visiting private dental practitioners on a part-time basis. They would be employed by the local Union Board of Health, School Board, or other community organization and would provide treatment to the younger children in their own office, in the health-unit dental clinic, or in a health-unit branch office or school using transportable equipment. Financial grants-in-aid would be available from the Health Branch for such programmes. It is hoped these programmes would provide for clinical treatment to pre-school children and pupils of Grades I, II, and III. The above suggestions were presented to, and found acceptable by, the meeting of full-time Medical Health Officers of this Province held in Victoria in September, 1953. It was explained that a pilot study along the above lines was being undertaken in the Boundary and Upper Fraser Valley Health Units, and also it was hoped that a further experiment would be possible in the South Okanagan Health Unit. It was agreed that for the coming year where no full-time preventive dental services were available in a health unit, and also in the school districts of a health unit where there was a dental officer, but in which he did not provide clinical services, that every encouragement be given to establish community dental clinics on the present basis. It was also agreed DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 55 that in health units where full-time preventive dental services are now operating, planning would commence toward having, wherever possible, existing programmes taken over on a part-time basis by resident family dentists of the community. Financial details of the above programme still need to be finalized and approved; it is hoped they will be available prior to the next meeting of the Health Officers to be held in the spring of 1954. It is to be explained that the above programme would require only six or seven regional dental officers or consultants, each having received postgraduate training. There are now available within the Division two such dentists in health units, another now undertaking postgraduate training, and a fourth who, it is anticipated, will proceed to take such training in the fall of 1954. In an endeavour to improve, by whatever means possible, the standard of clinical services provided in the health units, field trials with transportable dental X-ray units and air-compressors were continued and completed during the past year. Both these items were found to be entirely satisfactory and to fill a definite need. These have now been purchased in quantity and are standard components of the transportable dental equipment used by health-unit preventive dental services. Dental-health Education During the year this Division has continued, in co-operation with the Division of Health Education,, to review all suitable and available dental-health educational aids. Additional coloured film-strips have very kindly been supplied by the New Zealand Department of Health. From the same source, gracious permission was also received to reprint a further one of their most excellent dental-health posters, and copies of these have been distributed to schools throughout the Province. Also, during the past year a further very fine coloured film was purchased from the United Kingdom. The total number of dental-health films now maintained in the central film library of the Branch is thirteen, with, in addition, eleven different film-strips. Again it is pleasant to record the continued activities of Junior Red Cross in the field of practical dental-health education concurrently undertaken with its sale of apples within schools. By personal interviews with school-teachers who have co-operated with these programmes, it is possible to report that the decrease in the consumption of soft drinks, candy, and gum in such schools is indeed praiseworthy and should serve as a definite stimulant to others to encourage similar programmes whenever and wherever such are at all possible. In addition, we may now report that after successful pilot studies arranged in co-operation with the manufacturers and the Nutrition Service of the Health Branch, vitaminized apple-juice is now available in individual 6-ounce containers for sale in school cafeterias. It is hoped that the provision of this item will also assist in the reduction of the consumption of sweetened carbonated beverages, which have negligible nutritional value and which have a proven relationship with dental decay. Fluoridation It will be recalled that during 1952 this Department announced its amended policy regarding water fluoridation, in which it unreservedly endorsed this procedure. During the past year all further evidence in this regard has been most carefully scrutinized, not only by this Division, but by the senior officials of the Branch. All scientific evidence continues to support the belief that this procedure is the greatest advance in preventive dentistry yet discovered. To acquaint the professional staff of the Health Branch with the facts relating to the need for, and the benefits to be derived from, water fluoridation, a speaker especially well qualified in this field was included within the programme of the Annual Institute Y 56 BRITISH COLUMBIA of the Branch held in the spring of this year. Shortly thereafter an interdivisional committee was convened to formulate a programme for the encouragement of the fluoridation of community water-supplies throughout the Province. The Deputy Provincial Health Officer acts as chairman of this committee, and its members are the Directors of the Divisions of Public Health Engineering, Health Education, and Preventive Dentistry. The above committee drew up the following programme. Firstly, it was considered desirable and essential to have all health-workers throughout the Province accurately informed and enthused regarding the necessity and advantages of fluoridation. A newsletter was therefore prepared twice monthly during the period May to September by the Division of Public Health Education and forwarded to all local health departments. The Director of the Division presented a paper on this topic to the fall meeting of full- time Medical Health Officers of this Province. A panel was presented at the annual meeting of the Canadian Institute of Sanitary Inspectors, held this year in Vancouver. Arrangements have been completed for articles on fluoridation to appear in the bulletin of the Vancouver Medical Association, which reaches every member of the British Columbia Branch of the Canadian Medical Association, in the " Canadian Nurse," which reaches every member of the British Columbia Registered Nurses' Association, and in the " Western Druggist," which reaches every pharmacist in this Province. In addition, the committee gave consideration as to how information could reach other Provincial organizations, the individual members of which, it is anticipated, would influence the decision of their local community regarding the installation of fluoridation. Arrangements have therefore been initiated whereby it is hoped that speakers on fluoridation will be included within the programmes of the next annual meetings of the British Columbia Teachers' Federation, the British Columbia Parent-Teacher Federation, and the next Annual Convention of Women's Institutes. A speaker on this topic was also presented to the annual meeting this fall of the British Columbia Municipal Engineers' Association. In addition, it was also agreed by the committee that a brief news-letter should be inaugurated for dispatch to all waterworks personnel throughout the Province. This news-letter will include information as to the technical operation of fluoridation installations and also the benefits to the community to be derived therefrom. Articles for publication in the " B.C. Teacher " and the " B.C. Professional Engineer " have also been submitted. Through the courtesy and co-operation of the Department of Agriculture, suitable notices have been prepared and inserted in their routine publications addressed to the Women's Institutes and 4-H Clubs throughout the Province. In addition, descriptive material has been similarly dispatched to every Farmers' Institute where a community water-supply exists, with a covering letter commending to their attention study of this most important procedure. Suitable films, booklets, and pamphlets have been carefully reviewed and purchased to assist local health departments in presenting the facts of fluoridation to the public. In addition, a small kit of relevant material has been prepared suitable for distribution to persons specifically interested in this project. Furthermore, seven sets of slides suitable for showing during talks on fluoridation are under preparation. These slides have been especially collected, and many especially prepared, by the Division of Health Education. Through the courtesy of the United States Public Health Service, plans for a small activated display on this topic were received, and two such displays are now available on loan to local health departments. The fluoridation committee of this Branch early in their meetings appreciated that one of the most important requirements of a community contemplating fluoridation of its water-supply would be technical data regarding the cost of installation and operation of the equipment. A well-qualified engineer joined the staff of the Division of Public Health Engineering this fall and, after collecting the necessary data and visiting similar DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 57 installations in the United States, has already prepared several detailed cost estimates for communities requesting this service. At the date of writing this report, one Union Board of Health and two other municipalities have endorsed water fluoridation in principle. One further community, it is known, has ordered the necessary equipment. DENTAL PERSONNEL During the years 1950, 1951, and 1952 the ratio of population to dentists in this Province continued to improve. During 1953 the ratio worsened. As at September 30th, 1952, the ratio, including dentists practising under temporary permit, was 1 dentist to 2,034 persons; on September 30th, 1953, the ratio was 1 dentist to 2,041 persons. The change is slight, but it is suggested that it confirms previous forecasts made by this Division and is indicative of a trend now commencing. The situation will steadily and continually worsen until increased training facilities are provided in Canada, and probably until such facilities are established within this Province. The number of dentists practising in the metropolitan areas during the above period increased by six, and in the remainder of the Province by eight. During the same period it is reliably estimated that the population of the Province increased by 33,000 persons. It is noted that on September 30th, 1952, there were nine dentists practising under temporary permits. On the same date in 1953 there were twenty-two such dentists who either were not desirous or not eligible for normal registration, yet had received permission to practise in this Province by the Council of the College of Dental Surgeons of British Columbia in locations or appointments where dental services were inadequate. It will be recalled that, during 1952, rules and regulations for the licensing of dental hygienists were approved by the Lieutenant-Governor in Council. To date, three dental hygienists are registered to assist 587 dentists practising in this Province. Again it is to be explained that facilities for training dental hygienists in Canada are limited to ten graduates each year. Therefore, it is obvious that until further training facilities are provided, as have been repeatedly requested by the Canadian Dental Association and by the College of Dental Surgeons of British Columbia, little increase in the availability of dental services can be anticipated from dental hygienists in this Province. Dental Faculty During the past year it is reported that negotiations have been pressed by the Council of the College of Dental Surgeons of British Columbia for the early establishment of a Dental Faculty within the University of British Columbia. It is understood that it is agreed that it would be desirable for a dean to be appointed two years prior to the dental school being opened. There has also been some agreement that the dean could be appointed in the fall of 1954, providing the necessary finances for such an appointment are available and that financial support is assured for the construction of necessary accommodation. Throughout the year, resolutions in considerable number were received by this office from Chambers of Commerce, Boards of Trade, Women's and Farmers' Institutes, and Parent-Teacher Associations urging the establishment of a faculty within the University of British Columbia at the earliest practicable date. Dental Services to Persons in Receipt of Social Assistance On September 15th, 1953, a new programme for dental care for younger dependents of persons in receipt of social assistance was inaugurated by the Welfare Branch, Department of Health and Welfare, in co-operation with the British Columbia Dental Association. For the present fiscal year this programme will be limited to children of 8 years Y 58 BRITISH COLUMBIA of age and less. During the coming fiscal year it is hoped that moneys will be made available to extend this programme to 9- and 10-year-olds. The British Columbia Dental Association has undertaken not only to administer this programme as a public service, but also has agreed that remuneration to individual practitioners will be less than the normal suggested minimum-fee schedule of the association. It is understood that the detailed administration of this programme, prepared by this Division in co-operation with the Welfare Branch and the association, has been well received by social workers, health-workers, and the dental profession. Integrated within the programme have been arrangements for instruction in the prevention of dental disease to the parents and the children, and encouragement for regular and continuing dental care. This programme, whilst separate and distinct from preventive dental services, has been designed so that it supplements but does not replace these services for these particular children. Dental Services in the Rural Areas The ratio of dentists to population in the rural areas of this Province continues to provide cause for serious concern. The Council of the College of Dental Surgeons continues to provide temporary permits, without the cost or formalities of normal registration, to dentists willing to practise in communities without a resident dentist. The registrar of the Council continues to direct inquiries to that office regarding suitable locations for practice in this Province to such communities. The British Columbia Dental Association continues each year to write to all students from this Province in their final two years at dental school explaining to them the advantages of practising in the rural communities of this Province and listing the larger communities without a resident dentist. Possibly due to these activities, of the twenty-six new dentists writing their examinations in British Columbia this summer, seven located outside the metropolitan areas. Sets of transportable equipment remained on permanent loan to communities without a resident dentist where dentists visit regularly and co-operate in community dental clinics for younger children, as previously reported, with the exception of Slocan City. During the past year further sets were issued for dentists to visit similar communities for periods of two to six weeks. Communities thus benefiting were Alert Bay, Bella Coola, Edgewater, Golden, Nakusp, Salmo, Squamish, Tahsis, Tofino, Ucluelet, and Zeballos. British Columbia and Canadian Dental Associations This Division, during the past year, again enjoyed the unqualified support and cooperation of the British Columbia Dental Association and maintained close contact therewith through the association's Dental Public Health Committee. It is perhaps not generally realized that the untiring and selfless efforts of the chairman of this Committee, Dr. A. Poyntz, are closely related to this situation. Throughout the year, consultations and exchanges of view-point and information have taken place on occasions without number between this office and the chairman. The British Columbia Dental Association has agreed to provide financial support to a programme whereby it is planned that two selected members of the Vancouver Pasdo- dontia Study Club will present clinics and lectures in children's dentistry at Prince Rupert, Prince George, Nelson, and Cranbrook. It is hoped thereby that dentists resident in those areas who are unable by reason of distance to attend Dental Society meetings in the larger cities will have the opportunity to become personally acquainted with the latest techniques in this field of dentistry. As a result, it is anticipated that their services within the community dental clinics for younger children and their willingness to accept child patients will be improved still further. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 59 For the first time, during the past year, the British Columbia Dental Association, as a public service, has carefully prepared and submitted to the daily newspapers of the Province a series of very well-written dental-health education articles. In addition, the office of the association now maintains a panel of speakers who are willing to present talks on dental-health topics to lay groups on receipt of specific requests to do so. During the year this Division was requested by the Dental Public Health Committee of the Canadian Dental Association to provide assistance in the preparation of a pamphlet regarding fluoridation. Though primarily designed for use in reception-rooms of dental offices, this pamphlet has been prepared in such a way, with the assistance of the Division of Public Health Education, that it is hoped that it will also be acceptable for bulk purchase by departments of health of the whole country. The preliminary drafts have been reviewed by experts in this field from across Canada. It is hoped that this pamphlet will be printed and published early in 1954. GENERAL We are pleased to be able to report the continued progress and expansion of preventive dental services within this Province during the past year. Future plans whereby these services may be improved have been suggested. The programme for the encouragement of communities to fluoridate their water- supplies has been described. The importance of this procedure cannot be overemphasized. To provide dental treatment to all school-children of this Province would require approximately all the dentists who are now registered in British Columbia to be working full time for the first year on such a programme. Even for the second and subsequent years, such a programme would require approximately one-third of the total time of all dentists of the Province. Yet school-children represent only 15 per cent of the total population. However, if all community water-supplies were fluoridated, and these serve 82 per cent of the population, it is calculated that only 16.5 per cent of the total dental time would be required to maintain this 15 per cent of our population in dental health. Therefore, for the first time, it can be foreseen that the total need for dental treatment can eventually be met. Nevertheless, the above is dependent upon the present ratio of dentists to population being maintained. This, it is suggested, will not be possible until and after a Dental Faculty is included within the University of British Columbia. Therefore, until the above action is taken, needless suffering and ill health from untreated dental disease will be the fate of many of the citizens of this Province, including the majority of our children. Y 60 BRITISH COLUMBIA REPORT OF THE DIVISION OF PUBLIC HEALTH ENGINEERING R. Bowering, Director The Division of Public Health Engineering is concerned with the specialized field in public health wherein engineering principles and techniques are employed in the practice of public health. It deals essentially with the control of the environment, with those modifications and protective and preventive measures that have been found desirable or necessary in providing optimum conditions for health and well-being. Engineering methods can be used in solving many problems in public health, and thus the Division is involved in a wide range of activity. Within the framework of the Health Branch, the Division of Public Health Engineering functions as a part of the Bureau of Local Health Services. The number of public health engineering problems is increasing mainly owing to the industrialization of the Province. Also, with the increasing wealth of the Province, living standards are improving and there is an increased demand for water and sewerage works in some of the smaller towns and villages. The vacancy that existed on the staff at the end of 1952 was filled by employing an engineer who had the necessary training and experience for the position. WATER-SUPPLIES The Division is responsible for reviewing plans for extensions, alterations, and construction of waterworks systems. The " Health Act" requires that all plans of new waterworks systems and alterations and extensions to existing systems be submitted to the Health Branch for approval. The careful study of these plans, together with inspections on the site in many cases, is one of the major duties of the Division. During the year forty-five plans in connection with waterworks construction were approved, and seven plans were provisionally approved. In addition to approval of plans, waterworks systems in the Province are visited from time to time for the purpose of checking on sanitary hazards and assisting generally in the improvement of waterworks systems. There are very few water-treatment plants in British Columbia. This is because in British Columbia most sources of water provide satisfactory water for domestic consumption without expensive treatment. In many cases only bactericidal treatment is required, and a number of chlorinators have been installed to provide this treatment. Our inspections indicate that in some cases good chlorinating equipment is not being properly operated, and, as a result, the desired improvement in the bacteriological quality of the water is not always attained. Improvements in this situation could be obtained if more advice regarding the operation of equipment could be given to the operators and the owners of water-supplies. It is felt that in future some sort of training for waterworks operators should be initiated. The Division plans in the coming year to institute a series of informative letters to waterworks operators to keep them informed of some of the recent developments in waterworks practice. It is also the hope of the Division that, possibly in co-operation with the American Water Works Association, short schools for waterworks operators may be held in this Province. There are a number of problems in the maintenance and operation of a waterworks system which cause sanitary hazards. Better training of operators and more frequent visits to the waterworks systems in the field by competent engineers would be of much value in overcoming these problems. The local health units are responsible for the regular frequent sampling of water from public water-supply systems. The Division of Laboratories performs the examinations of the samples. In this way a constant check is kept on the bacteriological quality of water served to the public of British Columbia. In addition to the bacteriological DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 61 examination of water, there is also need for chemical examination of water. The Health Branch does not at present operate a laboratory for doing chemical analyses of water. For this service, reliance is placed upon the Public Health Engineering Division of the Department of National Health and Welfare, which operates a laboratory for chemical analyses of water. The establishment of a laboratory for such purposes by the Health Branch would become necessary should the services of the National Health Department in this regard be discontinued. With the increased interest in fluoridation of water for control of dental caries, it was felt that during 1953 some fluoridation would be carried on in British Columbia. However, no fluoridation plans were in operation by the end of the year. A number of Councils have gone on record as being in favour of fluoridation, and a number of cost estimates for fluoridating water have been prepared by the Division. The preparation of these estimates requires a considerable amount of work, since the method of fluoridating water for any individual city or water system has to be designed especially for the particular water system in mind. A number of samples have been collected for fluoride determination, and a study of all past records has been made. These records show that there are no natural fluorides present to any extent in the water systems of British Columbia. The Division receives a number of inquiries each year concerning private water- supplies. It is customary to refer these inquiries to the local health units. Advice is given on request to local health units concerning technical problems that arise in regard to private water-supplies. It is estimated that 80 to 85 per cent of the population of British Columbia receives water through public water-supply systems. The fact that there has been no evidence of water-borne illnesses in British Columbia for the past several years speaks well for the care that is being taken in British Columbia by water authorities to provide a safe water for the citizens. SEWAGE-DISPOSAL The Division has the responsibility of reviewing plans for extensions, alterations, and construction of sewerage systems. The "Health Act" requires that plans of all new sewerage construction be approved by the Minister of Health before construction may commence. During the year twenty-six approvals were given in connection with sewerage- work and one plan was approved provisionally. Study of plans for approval includes the study of profiles and plans of appurtenances so that a good standard of sewerage-work is constructed. Study also includes treatment- works, if any, and studies of the receiving body of water in order to determine the degree of treatment required. The Municipality of Saanich, which had been unsewered though highly urbanized, continued its sewerage-construction work throughout the year. The Village of Vander- hoof had an entirely new sewerage system constructed, which should come into operation about the end of the year. There are relatively few villages in the Province that have a sewerage system. The Vancouver and Districts Joint Sewerage and Drainage Board published its report on the ultimate disposal of sewage from the Greater Vancouver area. This report is the most comprehensive report ever written on a sewerage problem in British Columbia. It charts the course of action for the development of the sewerage and drainage systems of Greater Vancouver for the next half-century. Several conferences were held with the consulting engineers and with members of the staff of the Vancouver and Districts Joint Sewerage and Drainage Board in connection with the report. In addition to the organized municipalities, there are a number of urbanized areas in the unorganized territory. In some of these, nuisances are constantly arising because of lack of sewers. While it is possible for these areas to provide sewerage systems for themselves on a voluntary community basis, it is felt that some legislative machinery Y 62 BRITISH COLUMBIA should be prepared by which sewerage systems could be built and maintained without the consent of the majority of the property-owners in the area in those cases where improper sewage-disposal methods create a health-hazard to adjoining communities. The question of sewage-disposal for private homes comes generally under the direction of the local health services. However, the plans and specifications are provided by the Division of Public Health Engineering. Also, a considerable amount of advice is given to local health services regarding private sewage-disposal problems. The Division also gives advice and approves plans on sewage-disposal for schools. Some research was done during the year in order to determine the maximum discharge of sewage from schools on a per pupil basis. The Division also provides consultative service regarding sewage-disposal problems for the institutions owned by the Provincial Government. The percentage of the population of British Columbia served by sewers is high, being over 50 per cent, but there are still many communities where sewerage systems are needed. The continued growth of the Province will necessitate the building of sewage- treatment plants for some communities which formerly disposed of sewage by dilution. Constant education of the public is necessary in order to have them pay for the sewage services which are necessary. STREAM-POLLUTION Stream-pollution is caused by the discharge of municipal and industrial wastes into surface waters. These discharges may have quite diverse effects on the quality of the receiving body of water because of the extreme variations in the type and strength of the waste and the quality and volume of the receiving bodies of water. The net result of such discharges, however, makes the water less desirable and less useful. The extent of stream-pollution in the Province is not alarming at present as there are only a few instances where waste-discharges have affected down-stream water-users. However, it is recognized by most that adequate control should be established in order to prevent pollution rather than to wait until it becomes a problem and then try to reduce it. The Health Branch has had general legislation for the control of municipal wastes for a number of years. Control of pollution by sewage under this legislation has made it possible to prevent the discharge of sewage from affecting communities in lower stretches in streams and rivers. In addition to the Health Branch, other departments of Government have legislation for the control of industrial wastes. This legislation is of very general nature and is utilized by each department to protect its special interests. As these interests involve such diverse things as fish, navigation, public water-supplies, and irrigation, it is not surprising that different interpretations of the general Acts of legislation are made by each department. In the administration of stream-pollution legislation an effort is usually made to obtain the opinions of officials of all the departments which are interested in the specific discharge before a decision is made. This seems the best possible arrangement under the circumstances, but there are a number of disadvantages. Often the industry concerned is advised of the problem after the problem exists and is thus not able to plan intelligently for prevention. Sometimes the basic data necessary for a reasonable decision are seldom available, and no department has the technical staff to spend sufficient time on gathering such data. Sometimes the most restrictive recommendation is liable to be adopted by the group as there is no one person to decide on the relative value of the suggested requirements. However, as far as public health is concerned, the activities of the Health Branch have prevented discharges of waste into streams from becoming a major public health problem. Work was continued during the year toward seeking a better and more reasonable administration set-up for stream-pollution problems. Representatives from the Division sat in on a number of conferences on individual stream-pollution problems during the DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 63 year. At the Sixth Natural Resources Conference held at Victoria in February, 1953, representatives of the Division took an important part in a panel on stream-pollution. Also during the year a meeting of the public health engineering representatives from all the Provinces was held in Ottawa, together with the Dominion Council of Health, to discuss stream-pollution problems in Canada as a whole. The older settled Provinces of Canada have a much more serious pollution problem than does British Columbia. The correction of these stream-pollution nuisances usually hinges around the question of who will pay for the improvements. It is felt by the Division that in British Columbia, with the co-operation of the other agencies interested in stream-pollution prevention, and with improved methods of administering stream-pollution controls, serious pollution of streams can be kept to a minimum. Another type of pollution that has not been given too much study by the Health Branch in the past is air-pollution. Air-pollution includes the pollution of air by smoke and soot, and also includes the pollution of air by offensive odour-producing gases. One reduction plant closed down during the year because of an odour-nuisance problem. Representatives of this Division will take part in a panel discussion on air-pollution at the Seventh Natural Resources Conference to be held in Victoria in February, 1954. This panel will seek to give guidance, among other things, on what part a public health department should take in air-pollution control. During the year an interesting study of the water-quality conditions in Nanaimo Harbour was made under the leadership of the Pacific Oceanographic Group, Pacific Biological Station, Nanaimo, B.C., with the assistance of a large number of volunteers. The City of Nanaimo and the Provincial Health Branch assisted in the survey. The results of the survey will serve to guide future sewerage developments in the area. This particular survey was unique in that such whole-hearted co-operation was given by the public with many hours of volunteer work being done. SHELL-FISH The Division of Public Health Engineering has the responsibility of enforcing the Shell-fish Regulations in the Province. The inspection of shucking plants and handling procedures now comes under the jurisdiction of the local health units. Reports are made on uniform records issued by this office. The Department of National Health and Welfare also has an interest in shell-fish control, since it has to approve licences for export purposes. The Provincial regulations are such that any shell-fish produced in the Province in conformity with the regulations will automatically conform with the requirements of the Department of National Health and Welfare. Most of the oysters produced commercially in British Columbia are produced on leased ground. Applications for all new leases, and applications for renewal of existing leases, are forwarded to this Division for approval. Any ground found unsuitable for the production of shell-fish on public health grounds will not be leased. In some areas a pollution survey of a proposed oyster lease can be made relatively easily, but in others a considerable amount of survey work is necessary. There are still some areas in the Province where shell-fish cannot be produced owing to local pollution. These areas include portions of Ladysmith Harbour, the tide flats at the south end of Nanaimo Harbour, and the upper reaches of Victoria Harbour, including the Gorge and Portage Inlet. The matter relating to shell-fish toxicity is one that is still before the Pacific Coast Shell-fish Committee. In its meeting in 1953 it was recommended that the west coast of Vancouver Island be opened for the taking of clams and mussels. Assaying of clams by the laboratory of the Department of National Health and Welfare in co-operation with the Federal and Provincial fisheries and health agencies was continued in 1953, with emphasis being placed on more intensive assaying of fewer areas. There is a tendency Y 64 BRITISH COLUMBIA among control agencies to raise the maximum amount of toxicity that may be present in shell-fish to be consumed by the public. There has not been a death due to ingestion of toxic shell-fish in British Columbia since 1942. SWIMMING AND BATHING PLACES A considerable amount of time was spent during the summer in consultation work on swimming-pools. There are no swimming-pool regulations in force in the Province. However, the Division did prepare suggested requirements for swimming-pools, and these have been used for several years. There is a demand on the part of some of the local health authorities for swimming-pool regulations, and a committee will study the problem during 1954 in order to make the necessary recommendations. TOURIST ACCOMMODATION The Director of the Division of Public Health Engineering is one of the five members of the Licensing Authority for Tourist Accommodation. Inspection of tourist camps, auto courts, etc., is done on the local level by local Sanitary Inspectors. The reports of the Sanitary Inspectors are co-ordinated by this Division, and recommendations for or against licensing are made to the British Columbia Government Travel Bureau. There are over 1,300 licensed tourist camps in the Province at the present time, and the work done by the Health Branch has a considerable effect in producing a fairly high standard of tourist accommodation. Three licences were cancelled on health grounds in 1953. The " star " rating of tourist camps is not done by the Health Branch, but is done by Inspectors employed directly by the Travel Bureau. The requirement that tourist accommodation must be licensed has had an excellent effect in the prevention of nuisances in that a local Sanitary Inspector has been able to visit a tourist-camp site before construction and give the owner advice on water-supply, sewage-disposal, and other environmental health problems. FROZEN-FOOD LOCKER PLANTS Under the Regulations Governing the Construction and Operation of Frozen-food Locker Plants, plans of all new construction of locker plants must be approved by the Deputy Minister before construction may commence. The Division of Public Health Engineering studies the plans and recommends approval where such is indicated. Approvals were given to sixteen locker-plant plans during 1953. Most of these were for small installations in already-existing meat-markets and butcher-stores. In review of locker-plant plans, care is taken to see that the required rooms necessary for a locker plant are planned for, and care is also taken to see that the refrigeration equipment is adequate to maintain the temperatures required in the regulations. Periodic inspection of the locker plants is made by the local Sanitary Inspector. GENERAL The Division of Public Health Engineering provides a consultative service to other divisions of the Health Branch and to the local health units on any matters dealing with engineering. This entails a considerable amount of work. During the year all of the health units were visited at least once. During these visits the various problems requiring engineering for their solution are examined in the field. The position of Chairman of the British Columbia Examining Board for the Sanitary Inspectors' Examinations is usually filled by this Division. In 1953 there were no examinations for Sanitary Inspectors conducted in British Columbia, there being no British Columbia candidates. The fact that there were no candidates in British Columbia reflects a change in the method of training Sanitary Inspectors which tended to make it extremely DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 65 difficult for British Columbia persons to become candidates. It is recommended that during the coming year assistance be given to enable desirable candidates to qualify. During the year preliminary studies were made on one sewerage system and one water system for unorganized communities. This type of work is not considered to be among the items of work that should be done by the Division. However, there is no doubt but that certain of the unorganized communities would construct waterworks systems and sewerage systems if they could receive the initial reports and cost estimates without charge. The continued expansion of the economy of the Province will lead to more and more public health engineering problems. It is the intention of the Division to foresee these problems and make plans for their reasonable control so that proper recommendations may be made for adoption by the Government and by local health services for adequate control of the environment. Y 66 BRITISH COLUMBIA REPORT OF THE DIVISION OF VITAL STATISTICS J. H. Doughty, Director The Division of Vital Statistics provides a wide range of service to the general public and to other branches of government. Its duties fall into two main categories—one relating to matters of civil registration and the other to statistical service on behalf of the entire Health Branch. The former duties comprise the administration of the " Vital Statistics Act," the " Marriage Act," the " Change of Name Act," and certain sections of the " Wills Act." The statistical services consist of providing detailed analyses regarding births, deaths, marriages, stillbirths, adoptions, divorces, and of other data stemming from the registration function, as well as providing extensive statistical service required for the administration of other division of the Health Branch. Once again there has been a further increase in the number of birth certificates issued by the Victoria office, in line with the increase in the number of births registered during the year. The demand for certificates was heaviest in the month of June and continued at a high level until the last two months of the year. This is an interesting departure from the pattern experienced in earlier years, when the volume has not reached its peak until August and then has declined sharply. It is evident that the wallet-sized laminated birth certificate which was introduced several years ago has now become very popular and is used extensively by persons travelling to the United States. The total number of birth certificates issued by the Victoria office was 39,100, as compared with 32,360 in 1952 and 26,566 in 1951. There were 3,520 marriage certificates issued and 5,367 death certificates issued. Revenue-producing searches numbered 30,508, while 24,797 non-revenue searches were made, in addition to which 5,621 searches were made free of charge for other Government departments. Revenue received by the Victoria office amounted to $53,246.55, the highest amount ever collected. REGISTRATION OF BIRTHS, DEATHS, AND MARRIAGES Current Registrations Once again it is gratifying to report that the registration system is functioning in a very satisfactory manner and that, with the exception of a certain group of Doukhobors, virtually every birth, death, and marriage occurring in the Province is promptly registered. The Division maintains routine continuous checks on the registration of these events and actively pursues registrations which are known to be delinquent. The increasing demand for proof of birth, death, and marriage in connection with social-security benefits, superannuation schemes, school enrolment, and employment purposes provides a constant incentive to the registration of these events. The registration of births is primarily the responsibility of the child's parents. However, the " Vital Statistics Act" provides for the reporting of all births by the attending physician and also by the hospital in which the births occurred. Returns from these two latter sources are balanced against the birth registrations received in order to ensure that the parents do not neglect their duty in this regard. The responsibility for filing a registration of marriage rests with the officiating clergyman or Marriage Commissioner, while in the case of deaths the undertaker is required to file the completed death registration before he may obtain a permit for burial. Registrations of births, deaths, and marriages constitute important legal documents from which several types of certifications are prepared. Hence, in addition to the checks referred to above and which are designed to ensure the completeness of registration, careful attention is given to reviewing all registrations before they are accepted in the interests of accuracy and validity. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 67 Delayed Registration of Births As noted in previous reports, the greatest proportion of applications for delayed registrations again stemmed from those persons born prior to the year 1920. Extremely few applications for delayed registration are received for events which took place during the last twenty years, indicating that the registration system in this Province has, in fact, been very satisfactory during this time. Realizing the difficulty which often confronts an applicant when he is called upon to produce evidence in support of his application for a delayed registration of birth, the Division has continued its efforts to gather independently material which may be of assistance in this regard. This material consists of baptismal records obtained from the various religious denominations, physicians' records, the records from hospitals and nursing homes. These pieces of information are being tabulated and indexed so that they may be available as occasion requires to assist in providing the necessary evidence. In 1944, at a Dominion-Provincial conference on vital statistics, a schedule of minimum standards of evidence to be used in applications for delayed registration of births was drawn up and accepted by all the Provinces. Briefly, this schedule requires that documentary evidence of good quality verifying the date of birth, the place of birth, and the names of the natural parents must be furnished to the Director before a delayed registration may be accepted. It is unfortunate that sometimes this requirement for independent supporting evidence is not understood or appreciated by the general public, who tend to assume that the request for proof to accompany the registration form is a reflection on their own honesty. However, it must be pointed out that registrations and the certificates which are issued from them are important documents upon which may hinge important rights to the individual. It is therefore very much in the public interest that the utmost of care be taken to ensure the accuracy and validity of all registrations accepted. Toward the end of the year a brief but informative pamphlet was drawn up and placed in use for the purpose of assisting applicants to obtain delayed registration. It is hoped that this action will materially assist the applicants to obtain the required supporting evidence with the minimum of time and effort. With the assistance of the Indian Commissioner for British Columbia and the various Indian Superintendents, efforts were continued toward the completion of delayed registrations amongst the Indians. Good progress was made, although in the older age-groups great difficulty was encountered in obtaining verification of the essential details. DOCUMENTARY REVISION Many types of records remain unchanged once they have been filed, but this is not true in the case of vital-statistics registrations. Through such procedures as adoptions, divorces, changes of name, alterations of given name, legitimation of birth, and others, it is constantly necessary to revise registrations in order to add the additional information. During the year 1,103 adoptions were recorded, 1,574 divorces, 449 legal changes of name, 326 correction declarations, 297 alterations of given name, and 218 legitimations of birth. In each of these instances a notation was placed on the original registration, provided that the birth or the marriage to which it was related had occurred in British Columbia. The revision and correction of Indian vital-statistics registrations was continued. Owing to the fact that, prior to 1943, registration of Indian vital statistics was on a voluntary basis only, many errors and omissions were found to exist among these earlier records. The discrepancies and omissions are being eliminated wherever possible by checking against Indian-band membership records, hospital reports of births, baptismal registers, and various other sources. Y 68 BRITISH COLUMBIA The maintenance of up-to-date registrations for the Indians presents the Division with a particularly difficult problem due to the fairly common practice amongst this group of changing names at will. Efforts are being made, however, through encouraging the use of birth certificates and by comparing school registers with the birth records, to ensure greater continuity and accuracy in names and birthdates on the registrations for Indians, especially for those in the younger age-groups. In the 1952-53 school term, 166 schools submitted reports of 1,130 pupils enrolled for the first time. By checking these school reports against the original birth registrations, it was found that a high percentage of error existed on both sets of records. Steps were immediately taken to determine the correct information and to amend the entries where necessary. MICROFILMING OF DOCUMENTS The microfilm equipment of the Division was in constant use during the year. All current registrations of birth, deaths, stillbirths, and marriages were photographed on a weekly basis. In addition, amendments to registrations resulting from adoptions, divorces, changes of name, and other types of documentary revision were photographed and the amended images spliced into the appropriate rolls of microfilm. Several miscellaneous filming projects were undertaken, as listed hereunder, in order to permit removal of some of the original files and to allow for a better utilization of space:— (a) Delayed-registration files for the period from 1949 to 1952, inclusive. (b) Baptismal records of several churches. (c) The refilming of rolls which had become overloaded due to amendments and additions. (d) Special files concerning delayed registrations of marriages, 1932 to 1952. (e) Marriage-licence applications. ADMINISTRATION OF THE " MARRIAGE ACT " The " Marriage Act" requires that before a minister or clergyman may solemnize marriage in this Province, he must first be registered with this Division. For denominations previously recognized, the registration of a new minister or clergyman is made upon the advice of the governing authority of the denomination. However, denominations not previously recognized must first comply with certain requirements of the Act relative to continuity of existence and established rites and usages respecting the solemnization of marriage before their ministers may be registered. During the year three new religious groups were granted recognition pursuant to the " Marriage Act," thus enabling their ministers to solemnize marriage. Inquiries as to the qualifications for recognition were made by six other groups. By checking marriage registrations received at the central office, it was discovered that five marriages had been performed by ministers who had not been authorized to solemnize marriage. In each case the parties concerned were contacted and the marriages were validated pursuant to section 37 of the " Marriage Act." Fourteen applications for remarriage pursuant to section 47 of the Act were approved. Most of these involved couples who had previously been married to each other, subsequently were divorced, and then wished to remarry each other. REGISTRATION OF NOTICES OF FILING OF A WILL In 1945 an amendment was made to the " Wills Act " making it possible for anyone to file a notice with the Director showing the date of execution and location of his will. Provision was also made for the addition of information regarding changes on account of new wills or the addition of codicils. During 1953, 4,279 notices were filed under sections 34 to 40 of the " Wills Act." This number was almost 300 higher than that for the previous year. Over 19,000 notices have now been filed and are preserved in the records DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 69 of this Division. The notices have all been indexed to permit speedy searching of applications received. CERTIFICATION SERVICES While a great deal of attention is directed toward ensuring that all vital events which occur within the Province are completely and accurately registered, an even greater amount of work is taken up with the issuing of certifications, mostly in the form of certificates, from the some million and a half registrations which are now on file with the Division. The certification services embrace several functions and are closely correlated with the other activities of the office. During 1953 almost 5,000 separate applications for certification were received and cleared each month. Many of these requests are for documents urgently required for court hearings, travel visas, and other legal matters. All applications are therefore screened by the chief certification clerk, who indicates the action which is to be taken in the office and the degree of priority which attaches to the application. An attempt is made to give consideration to all priority requests while at the same time maintaining a good flow of work. In addition, there are statutory restrictions placed upon the furnishing of information regarding illegitimate and adopted children, and the chief certification clerk has the further responsibility of ensuring that all certification is supplied strictly in accordance with the Statutes. Before any certification can be issued, it is necessary that the original registration be located by a search through the appropriate indexes. Not only must the entry be located in the index, but, in addition, the actual record itself must be produced so that the information may be extracted from it. In order to make this searching as simple, yet as thorough, as possible, many refinements have been made in the indexes of the Division. Originally index-books were handwritten, and listings were made alphabetically according to the numerous registration districts of the Province. In later years the books were replaced by typewritten volumes, and these have now been superseded by machine-run indexes prepared from punch-cards set up within the Division. All entries are now arranged in strict alphabetical order and in one continuous sequence for the entire Province regardless of the locality in which the event occurred. Each type of event is indexed according to the year in which it occurred. However, as a further aid in searching, certain indexes have been consolidated into single five-year sequences. Such indexes are particularly valuable when the applicant is uncertain as to the exact date of the event. Within the last three years there has been over a 40-per-cent increase in the yearly total of searches performed. Searches for the year 1953 amounted to over 61,000, including more than 5,600 that were made on behalf of other Government offices. All certificates, other than those involving photographic processes, are prepared by typists from the original registration. Because of the great importance of accuracy in the transcription of these documents, every certificate is checked against the original registration by two independent checkers. Since many registrations are made in handwriting, the interpretation of spelling of names constitutes a major problem. Photographic prints are prepared independently by trained operators. Special machines are used to produce the wallet-sized laminated birth certificate, which has gained great popularity since its recent introduction because of its convenient size and its durability. In spite of the many procedures which are involved in the handling of applications for certification, most certificates are now issued within two working-days of receipt of the application. This service compares very favourably with that provided by registration offices in other Provinces and States. DISTRICT REGISTRARS' OFFICES Changes in Registration Districts With the opening of Government Sub-Agencies at Terrace and Vanderhoof, the Division was able to appoint the Sub-Agents as District Registrars and Marriage Commissioners, and this has resulted in a more satisfactory service in these areas. Y 70 BRITISH COLUMBIA During the year it became necessary to transfer the vital-statistics duties at Trail from the Motor-vehicle Branch to a private firm. This terminated the temporary arrangements which have been in force since November of 1951, when the Mo tor-vehicle Branch took over the vital-statistics responsibilities at Trail in response to an urgent request from the Division. The generous co-operation of the Motor-vehicle Branch enabled uninterrupted service of a very satisfactory nature to be given in this district, and appreciation is expressed for the work done by that Branch. The Division has now been fortunate in securing the services of a firm which has had extensive previous experience in vital- statistics work, and which has an office centrally located in the business section of the city. The sub-office of the Registration District of Stewart located at Alice Arm has been discontinued due to the small volume of business which has been handled through this office in recent years. With the closing of the Government Sub-Agency at Greenwood, arrangements were made for the City Clerk to be appointed as District Registrar and Marriage Commissioner for the Registration District of Greenwood. Inspections Twenty-two offices and sub-offices in the East and West Kootenays and the Fraser Valley were visited by the Inspector of Vital Statistics during the year. Visits were also made to the Vancouver, North Vancouver, and New Westminster offices. These visits have again proved very beneficial both to the Division and to the district offices in maintaining the smooth functioning of the registration system. Several modifications of existing forms and procedures have resulted from the on-the-spot discussion of problems which have confronted the District Registrars. Inspections of the district offices indicate that the standard of work is generally of a very satisfactory nature and that the present organization of district offices appears to be serving the*needs of the people and the requirements of the central office in a very adequate way. The district offices are doing an excellent job of collecting and transmitting vital-statistics returns to the Division, and it is rarely necessary to remind a District Registrar of his responsibilities. It is a pleasure to be able to express appreciation of the work carried out in the district offices. At the close of the year there were ninety offices and sub-offices operating in seventy- one registration districts, this being one less sub-office than in the previous year. Thirty- eight of the offices are served by Government Agencies or Sub-Agencies, while Royal Canadian Mounted Police personnel hold the Registrar's appointment in twenty-three other districts. Eight offices are served by other Provincial Government employees, six offices by Municipal Clerks, and fifteen offices by private individuals, including Game Wardens, Postmasters, Stipendiary Magistrates, business-men, and a Canadian Customs officer. GENERAL ADMINISTRATION Although the incidence of staff changes was less than in 1952, the turnover was still high. Several members resigned, and several others were dismissed when their services were found to be unsatisfactory during the probationary period of employment. Replacements were difficult to obtain, and in a number of cases a period of several weeks elapsed before successors were appointed. Most of those reporting for duty had little or no previous office experience, thus necessitating a longer period of training than otherwise would have been required. The Vancouver office experienced unprecedented difficulties, occasioned by staff shortages and changes throughout most of the year. One of the senior employees retired on superannuation in January, and her departure was followed almost immediately by the resignation of another senior person by reason of marriage. Several employees trans- DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 71 ferred to higher-paid positions or other types of employment. In almost every case the vacancies were not filled for several weeks, and there were instances when several months elapsed before a replacement could be obtained. It was largely through the splendid co-operation of the junior staff with their two seniors that the functions of the office were able to be carried on without a major disruption. The widespread use of ball-point pens has created a problem for the Division in several respects. Of these, the most important is the great range of permanency of the various inks used by the manufacturers. Documents written with a ball-point pen may last for months or years, but some are known to have deteriorated very quickly, and it is doubtful whether they will stand up for the extended periods of time required of vital- statistics registrations. The use of such pens for the completion of registration forms has been strongly discouraged in the ultimate interests of the persons concerned. However, this type of writing medium has gained such popularity that it has become impossible to refuse to accept registrations completed with ball-point pens. The use of ball-point pens causes further difficulties in establishing identification of handwriting. The actual identification of signatures is often of great importance in dealing with registration matters. STATISTICAL SECTION Purpose A public health statistics section can be said to be fulfilling its proper function only when it combines sound statistical routines with critical analyses of the statistics produced and of the policies and procedures underlying them. The Division attempts to perform this function through its statistical section on behalf of the Health Branch in this Province, and, in addition, to give consultative service on all matters involving statistics, recordkeeping, and form preparation. Hence, an important part of the duties of the statistical section is the critical examination and analysis of the statistics which are compiled in order that they may be of maximum value to the various divisions of the Health Branch in the planning, developing, and carrying-out of their programmes. Routine Assignments The extent of the routine work of the statistical section is very broad and includes the completion of numerous reports, listings, summaries, and other statistical compilations and the performance of analyses of the statistics. A detailed list covering the more important of these routine activities was shown on pages 78 and 79 of the 1952 Health Branch Report. Apart from the compilation of extensive statistics from the birth, death, stillbirth, and marriage registrations, the Division's largest routine commitments are to the Divisions of Tuberculosis Control and Venereal Disease Control in the processing of their records for statistical purposes. A great deal of statistical information on morbidity, mortality, natality, and other items of public health significance is kept on file in the statistical section. This has proven to be very useful in the course of the regular duties of the section, as well as in providing a valuable source of reference material to aid in the planning of special statistical assignments. Staff-training Through formal postgraduate training as well as through in-service training, the Division is developing a small but competent staff of biostatisticians. During the summer one member returned from a course of postgraduate training in public health statistics at the University of Minnesota, while another member enrolled for similar training in September at the University of Toronto. Funds for this professional training have been made available through National health grants. Y 72 BRITISH COLUMBIA Statistics for the Mental Health Services Progress was made during 1953 in carrying forward several projects of considerable importance started in the previous year, and, in addition, several new tasks were undertaken. Among the former was the work begun on the reorganization of the record and statistical system of the Mental Health Services. This project has consumed a considerable amount of time of the staff both in Vancouver and Victoria, but satisfactory progress has been made. The first important phase of the job has been completed. This involved the setting-up of a routine for transferring the information appearing on the admission and separation reports of individuals entering and leaving institutions to punch- cards. A number of problems arose in establishing the necessary codes and procedures required for this phase of the work, but by the end of the year the new system was in operation and the routine processing had begun in this Division. Incidental to the foregoing work, it was found that certain nominal rolls required by the Mental Health Services could be prepared mechanically by this Division on a monthly basis, thus saving the Services considerable time in this regard. The organization of the second phase of the statistical system for the Mental Health Services was well under way by the close of the year. A staff member has worked closely with the medical and administrative staff at Essondale and Crease Clinic in determining the nature and extent of the statistics to be produced and in designing the system and routine to be followed. This phase of the work will yield important information on the status of patients in residence in the various institutions of the Services and on the treatments which have been used. This difficult work of replacing and augmenting the recording and statistical procedures of a large service involving a number of separate institutions has been made a pleasure to all concerned by the splendid co-operation and patience of the staff of the Mental Health Services. Standardization of Vital-statistics Tabulations in Canada A major advance was made during the year in the standardization of the vital- statistics tabulations for all Provinces of Canada. Because Canadian vital statistics are presented on a " place of residence " basis, it is necessary to have an interprovincial exchange of registration information relating to births and deaths of residents who are temporarily absent from the Province. Thus no Province has been able to publish its final vital-statistics data for a particular year until the last Province has submitted its registration returns. The Provinces have now agreed upon uniform dates for closing off the separate birth, death, and marriage series of events each year, and this alone will speed up the production of the final tabulations by several months. In addition, the Provinces have all agreed upon a uniform set of basic Provincial tabulations for publication purposes, and this action will further advance the publication date of the annual Vital Statistics Reports. This work on the uniform tabulation programme was undertaken by the Vital Statistics Council for Canada in co-operation with the Dominion Bureau of Statistics. It has involved extensive research and study in order that the tabulations might fully accommodate present statistical needs as well as correctly anticipate future requirements. A system of priority for the production of the specific tabulations was also set up, and this will further expedite the publication of the annual Vital Statistics Reports. These measures will enable a saving of approximately six months in the time-lag in printing the detailed Vital Statistics Report in this Province, and, in addition, it will greatly speed up publication of the preliminary and final reports of vital statistics published by the Dominion Bureau of Statistics which contain national rates and interprovincial comparisons. department of health and welfare, 1953 y 73 Infant-mortality Study As noted in the 1952 Health Branch Report, a special infant-mortality study has been set up to correlate information from the Physician's Notice of Live Birth or Stillbirth and the associated birth and death registrations. A complete year of experience covering 1952 infant mortality was available this year, and tabulations were run from the punch-cards. Information was tabulated revealing many interesting features, but the number of cases involved is still relatively small for detailed analyses, and further data must be collected before reliable inferences may be made. However, the results were important in that they revealed several problems which will have to be overcome before a satisfactory study can be completed. One of these relates to the lack of sufficient detail, for a study of this nature, in the code of the International Statistical Classification covering complications of pregnancy and birth injuries. Population Estimates During the year, counts were obtained from the Census Branch showing populations for each of the census enumeration areas in the Province. These figures were utilized in conjunction with the enumeration area descriptions to produce population estimates by school districts. These estimates are necessary in order to compile vital-statistics rates for the health units of the Province and are also used in health-unit financing. Nutrition Statistics As in previous years, the Division carried out analyses of food studies conducted by the Nutrition Consultants of the Health Branch, and which related to the Provincial gaols. In addition, a pilot study was conducted to determine and compare the nutritional status of those old-age pensioners with and without dentures in the Greater Victoria area. Morbidity Statistics Information on the health status of the people in this Province is, at the best, difficult to obtain and interpret, yet it is of utmost importance to those who administer the programme of the Health Branch. The National Sickness Survey, mentioned in the 1952 Report, was carried out to provide some of the information on a sample basis, and some of the results of this survey became available during the year. These first releases related to expenditures for health services. Estimates of the incidence and prevalence of specific morbid conditions are expected to appear in the near future. During 1953, negotiations have been under way between this Division and the British Columbia Government Employees' Medical Services with a view to obtaining morbidity statistics for this group of the population. A co-operative arrangement is being suggested whereby the Division will process the statistics of the Employees' Medical Services, particularly relating to cost and the utilization, in return for the morbidity statistics which will ensue as a by-product. Information on the sickness experience of this group will help to fill in an important part of the health picture in this Province. Epidemiological Statistics The Division continued to operate the Province-wide notifiable-disease reporting system and to compile statistics therefrom. In addition, special statistical studies relating to the epidemiology of poliomyelitis and of venereal disease were carried out at the request of senior medical personnel. CANCER REGISTRY The Division also continued to supervise the registry of new cases of cancer reported within the Province. This reporting system is designed to make possible the provision of Y 74 BRITISH COLUMBIA up-to-date data on cancer incidence in British Columbia and to make these data available to the medical profession and to other agencies interested in the cancer problem. Reports of new cases are received from private physicians, the British Columbia Cancer Institute, general hospitals, and from pathology laboratories. Death registrations are also used as a source of reporting cases which have not been reported prior to death. Preliminary figures showed that 2,785 new cases of malignant growth were reported during the year, of which 1,366 were reported alive and 1,419 reported for the first time at death. The following tables show the malignant neoplasms reported during 1953 classified according to site, age-group, and sex. Table I.—Number and Percentage of New Cancer Notifications1 by Site and Sex, British Columbia, 1953 Site Male Female Total Number Per Cent Number Per Cent Number Per Cent 520 190 260 4 174 136 123 80 30 5 54 33.0 12.1 16.5 0.3 11.0 8.6 7.8 5.1 1.9 0.3 3.4 370 236 35 279 98 64 45 25 21 9 27 30.6 19.5 2.9 23.1 8.1 5.3 3.7 2.1 1.7 0.8 2.2 890 426 295 283. 272 200 168 105 51 14 81 32.0 15.3 10.6 10.2 Skin — — 9.8 7.2 6.0 3.8 1.8 Bone Other and not stated 0.5 2.8 Totals 1,576 100.0 1.209 1 100.0 2,785 100.0 1 Includes 1,419 cases reported for the first time at death. Table II.—Number and Percentage of Reported Live Cancer Cases by Site and Sex, British Columbia, 1953 Site Male Number Per Cent Female Number Per Cent Total Number Per Cent Skin.. Genital system Digestive system- Breast- Respiratory system- Urinary system Buccal cavity... Blood and hemopoietic tissue. Brain and central nervous system.. Bone Other and not stated- Totals 169 101 116 2 108 77 66 44 10 3 25 721 23.4 14.0 16.1 0.3 15.0 10.7 9.2 6.1 1.3 0.4 3.5 100.0 96 153 114 190 12 24 20 23 3 4 6_ 645 14.9 23.7 17.7 29.5 1.9 3.7 3.1 3.5 0.5 0.6 0.9 100.0 265 254 230 192 120 101 86 67 13 7 31 1,366 19.3 18.6 16.8 14.1 8.8 7.4 6.3 4.9 1.0 0.5 2.3 100.0 DEPARTMENT OF HEALTH AND WELFARE, 1953 Table III.—Cancer Notifications1 by Sex and Age-group, British Columbia, 1953 (Age specific rates per 100,000 population.) Y 75 Male Female Total Age-group Number Age Specific Rate Number Age Specific Rate Number Age Specific Rate 0- 9 10-19. 20-29 30-39 6 9 12 31 93 174 373 564 223 91 4.7 10.8 14.5 34.5 115.0 285.7 646.4 1,532.6 2,654.7 13 6 12 63 148 165 303 305 153 41 10.6 7.6 14.0 64.7 199.2 300.0 623.4 1,013.3 1,865.8 19 15 24 94 241 339 676 869 376 132 7.6 9.2 14.3 50.2 40-49 50-59 - - 155.3 292.4 60-69 . 635.9 70-79 1,299.0 2,265.1 Totals — 1.576 1 250.8 1,209 201.0 2.785 1 226.4 Includes 1,419 cases reported for the first time at death. Table IV.—Live Cancer Cases Reported by Sex and Age-group, British Columbia, 1953 (Age specific rates per 100,000 population.) Male Female Total Age-group Number Age Specific Rate Number Age Specific Rate Number Age Specific Rate 0-9 3 2 7 20 52 92 163 226 70 86 2.3 2.4 8.5 22.2 64.3 151.1 282.5 614.1 833.3 4 3 9 51 104 91 156 145 47 35 3.3 3.8 10.5 52.4 140.0 165.5 321.0 481.7 573.2 7 5 16 71 156 183 319 371 117 121 2.8 10-19 3.1 20-29 9.5 30-39 37.9 40-49 50-59- 60-69 ... 100.5 157.9 300.1 70-79 — 80 and over 554.6 704.8 Totals 721 I 114.7 645 107.2 1,366 111.1 CRIPPLED CHILDREN'S REGISTRY During 1949 and 1950 a survey was carried out to determine the size of the problem which existed in this Province with respect to crippling diseases of children. As a result of this survey, a voluntary registry of crippled children was set up. The purpose of the registry is twofold. In the first place, the registry is designed to provide accurate knowledge of the nature and extent of the problem of crippling diseases of children in British Columbia. Only with such information can there be intelligent planning of the additional facilities which might be required, or of the programme which should be undertaken. The second purpose of the registry is to assist those children with handicaps to receive the best possible treatment available for those specific handicaps. The registry has available the services of an advisory panel of fifteen specialists, the chairman of which reviews all new registrations received with a view to recommending the best possible treatment or disposition of each case. The Division of Vital Statistics supervises the statistical aspects of the registry and assists in tabulating the statistics which derive from it. Physicians throughout the Province have been made aware of the purpose of the registry and have been encouraged to register on a voluntary basis those children under their care who are suffering from any one of a group of specified disabilities which might Y 76 BRITISH COLUMBIA prevent them from completing their education and becoming self-supporting. The registry has established close liaison with all public health authorities in the Province as well as with numerous private agencies concerned with the care of children. The advisory service of the medical panel is available to any physician upon request. The registry also provides what might be termed a clearing-house of medical history regarding each individual case, and this has proved valuable in those instances where the child does not remain under the continuous care of one doctor. Impairments which are noted at birth and reported on the Physician's Notice of Live Birth or Stillbirth are routinely registered by the Division of Vital Statistics with the Crippled Children's Registry. Additional information is obtained where necessary from the reporting physician. A check is later made on these cases to determine whether the condition is still present, has disappeared, or has become inactive. The registry is receiving data on about 150 new cases each month. By the end of the year over 2,000 cases were on the registry files. During the year a follow-up was conducted of all post-poliomyelitis cases with residual paralysis from the epidemic of 1952. An inquiry was made to determine whether or not further treatment was required. When it was found that a case required additional treatment but this treatment had not been forthcoming, the reasons were investigated and, where possible, assistance was made available. In order to enlarge the scope of the registry, it was suggested toward the end of the year that a procedure be set up whereby cases known to the Welfare Branch would be routinely registered. Regular social-assistance cases continue to be handled by the Welfare Branch, their addition to the registry being primarily for record and statistical purposes. It is hoped that the care of border-line social-assistance cases which are sometimes handled by the Welfare Branch would be facilitated if they are made known to the registry. POPULATION CHARACTERISTICS OF THE PEOPLE OF BRITISH COLUMBIA The 1953 estimate of the population of British Columbia was 1,230,000, being 32,000 higher than the figure for 1952. Of this increase, over 40 per cent occurred among the population under 10 years of age. Over one-third of the increase in population which occurred in the last ten years has been in this same age-group. Since the 1952 Report was published, additional information has been made available from the Ninth Census of Canada, and an account of some of the more important features of the population of our Province which were disclosed follows. British Columbia has the lowest average number of persons per family in Canada; namely, 3.3, as compared to 3.4 for Ontario, which has the next lowest average, and 3.7 for Canada as a whole. The 1951 average for the Province represented only a slight decline from the figure of 3.4 determined from the previous census in 1941. With regard to the rural-urban population ratio, it was found that British Columbia has a greater proportion of urban population than any other Province except Ontario. According to the definition of an urban area as given in the 1951 Census (any city, town, or village of over 1,000 population, whether incorporated or unincorporated, and all parts of census metropolitan areas), over 68 per cent of this Province's population is urban. This figure is slightly under that for Ontario, where 70.7 per cent of the population resides in urban areas. The National average is 61.5 per cent. Whereas over half of the rural population in Canada as a whole resides on farms, in British Columbia the proportion is under one-third, which is not surprising in view of the predominantly mountainous nature of the Province. Except for Newfoundland, British Columbia has a smaller proportion of rural farm population than any other Province in Canada. For the whole Province, the population density is 3.2 persons per square mile, a 40-per-cent increase over the figure for 1941, when there were 2.3 persons per square mile. British Columbia ranks ninth among the Provinces of Canada in density of popu- DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 77 lation, only Newfoundland having a lower density; namely, 2.4 per square mile. The National average is only 3.9. If Census Areas 4 and 5, which cover the Lower Mainland and Vancouver Island, are excluded, the population density for the remainder of the Province is found to be just under one person per square mile. The scattered distribution of population is a factor of considerable importance in increasing the expense and difficulty of carrying out public health work in this Province, and the accepted approach to the many problems which arise has had to be modified accordingly. PRINCIPAL CAUSES OF MORTALITY IN BRITISH COLUMBIA A review of more important features of the mortality statistics for the year is pertinent to any report dealing with the health of the people. In last year's Report it was pointed out that the crude death rate has changed very little over the last ten years, and an explanation was given of the fact that the absence of an increase in this rate despite the steady ageing of the population was in itself a most favourable reflection of the improving health of the population. This year the crude death rate again changed only slightly. Preliminary statistics show an over-all death rate of 10.0 per 1,000 population, compared to the final rate of 10.1 for 1952. Of particular interest are the specific rates due to the more important causes of death. The two leading causes—namely, diseases of the heart and cancer—exhibited lower rates of mortality this year than in 1952, the rate for heart-disease having declined from 365.4 per 100,000 population in 1952 to 357.1 in 1953, the corresponding rates for cancer being 158.2 and 154.4. Despite these lower death rates, the proportion of all deaths contributed by these causes continues to increase, being up to 36.7 per cent from 36.2 per cent for heart-disease and up to 15.9 per cent from 15.7 per cent for cancer. The rate of deaths from vascular lesions of the central nervous system, including cerebral haemorrhage, cerebral embolism, and cerebral thrombosis, was 104.0 in 1953, an increase from the rate of 96.4 in 1952. This cause of mortality was responsible for 10.7 per cent of all deaths, an increase from the 9.6 per cent recorded in 1952. The mortality rate for accidents this year was 76.2 per 100,000 population, this being a decrease from the rates which prevailed during the several previous years. The ten-year average for 1943 to 1952 was 79.8. In 1953 the leading cause of accidental deaths was falls, which resulted in over 20 per cent of all accidental deaths. Motor- vehicle accidents were the second leading cause, having taken a toll of 201 lives, a decrease from the 1952 figure of 220. A total of 115 people drowned in 1953, compared to 104 in 1952. The mortality rate from the group of causes referred to as diseases of early infancy was 32.8 per 100,000 population in 1953, the lowest rate yet recorded, and well below the 1952 rate of 38.5. Pneumonia deaths occurred at a rate of 33.8 per 100,000 population. The mortality rates from diseases of the arteries, suicides, and congenital malformations were 17.3, 15.9, and 15.1 per 100,000 population respectively. The tuberculosis mortality rate, which as recently as 1947 was 51.3 per 100,000 population, dropped in 1953 to 11.4 per 100,000 population. MORTALITY AMONGST THE INDIAN POPULATION The foregoing preliminary rates for 1953 cover the entire population of the Province. It has been customary in previous Reports to refer mostly to the mortality rate excluding Indians, since Indians do not come under the jurisdiction of the Provincial Government and in most areas they live on reserves quite apart from the remainder of the population. However, since comparisons with other Provinces and States are generally made on a total-population basis, the rates have been presented herein accordingly. Nevertheless, the Indian mortality experience differs so widely from that of the population excluding Indians that it warrants special comment. Although the Indians constitute hardly more Y 78 BRITISH COLUMBIA than 2 per cent of the total population, their effect on the mortality rates from certain causes is quite marked. Mention has been made of the effect of the ageing population in increasing the proportion of deaths due to the degenerative diseases, such as heart-disease, cancer, and vascular lesions of the central nervous system. This situation is of much less significance in the Indian population, due in part to the different age distribution. Approximately 21 per cent of the Indian population is over the age of 40 years, while 38 per cent of the population excluding Indians falls into this age-group. Furthermore, less than 10 per cent of the Indian population is 60 years of age or older, while more than 15 per cent of the non-Indian population falls into this category. Deaths under 40 years of age during 1953 accounted for over 66 per cent of the total Indian mortality but only 13.8 per cent of all mortality in the rest of the population. The mortality rate in the age-group under 40 years was slightly over 10 per 1,000 population for Indians, compared with 2.2 per 1,000 in the group excluding Indians. The three major causes of death in the population excluding Indians—namely, diseases of the heart, cancer, and vascular lesions of the central nervous system—accounted for approximately 65 per cent of all deaths during the year, with a combined rate of 630.5 per 100,000 population. Amongst the Indians, however, these three causes represented only 17.9 per cent of the total deaths, with a combined rate of only 236.2 per 100,000 population. On the other hand, however, accidents, diseases of early infancy, tuberculosis, and the other respiratory diseases accounted for almost 50 per cent of the total Indian mortality, compared with only 15.7 per cent for the remaining population. In the Indian population under 40 years of age the combined rate for such deaths was 626.6 per 100,000 population but only 147.5 in the cases of non-Indians. The difference between Indian and non-Indian mortality is nowhere more evident than in infant and maternal mortality. During 1953 the infant death rate of the non- Indian population was 23.5 per 1,000 live births, whereas amongst Indians the rate was 101.2. The rate of maternal deaths in the non-Indian population was 0.6 per 1,000 live births, compared to a rate of 1.7 for Indians. Thus the Indian experience adversely affects the rates for the whole population, and when Indians are included the total infant mortality rate becomes 26.7. MORTALITY IMPROVEMENTS IN TERMS OF LIFE-YEARS LOST Reference was made in the Health Branch Report for 1952 of the concept of measuring the force of mortality in terms of life-years lost rather than merely in terms of the number of deaths which occurred. A description of the general method involved was given on page 84 of the 1952 Report. By measuring mortality in terms of life-years lost, account is taken of the age at which the deaths occur, and hence a death at age 10 is considered to be a much more serious event than a death at age 65. This method of measuring mortality has a particular significance in public health which is especially interested in the prevention of untimely or premature deaths. It was shown that the mortality picture appeared radically different when measured in terms of life lost under the average life-span of 70 years. The three most serious causes of death numerically—namely, diseases of the heart, cancer, and vascular lesions of the central nervous system—dropped to third, fourth, and seventh places respectively in terms of life-years lost, and their places were taken by diseases of early infancy, accidents, and diseases of the heart, in that order. It is also revealing to measure the changes and improvements in the mortality picture during the last two decades in terms of life-years lost. One of the simplest ways to comprehend the changes which have taken place is to compute what the mortality would have been in 1953 if the age-specific mortality rates of a year twenty years previous had applied. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 79 COMPARISON OF ACTUAL AND EXPECTED LIFE-YEARS LOST1 DUE TO SPECIFIC CAUSES OF MORTALITY BRITISH COLUMBIA, 1953 INFANT MORTALITY XX^t.% "i --. • :.. - --. "- '. ~- "- '■:.■:.-:-:. -^ -..-.. -_ V -. -- -_ -_-_■;„-_■ i. ■ ^ 'T. -..•;:. -_ •_•■■. -L X V \\ \ ""\ CARDIO-VASCULAR RENAL DISEASES* ACCIDENTS RESPIRATORY DISEASES3 INFECTIOUS AND PARASITIC DISEASES'* TUBERCULOSIS y CONGENITAL MALFORMATIONS J EXCLUDES DEATHS UNDER ONE YEAR Actual life-years lost, 1953. i VH.VKX1 Life-years which would have been "-O lost if 1933 mortality rates had existed in 1953. 40,000 60,000 LIFE-YEARS LOST 1 Under age 70 Intracranial lesions of vascular origin, diseases of the circulatory system, and nephritis Bronchitis, influenza, and pneumonia Excludes respiratory diseases and tuberculosis Y 80 BRITISH COLUMBIA Such a computation takes into account the increase in the population and also any changes in the age composition of the population which may have taken place. Since infant mortality is of special concern to public health workers, infant deaths from all causes are shown in one group on the chart which follows, and, therefore, deaths from the other specific causes which are enumerated apply only to the population over 1 year of age. The chart reveals that mortality of infants during the first year of life is responsible for almost as great a loss of life-years under age 70 as are the cardiovascular-renal diseases, accidents, and cancer combined. It also highlights the impovement that has, in fact, been made in infant mortality since 1933. It can be seen that life-years lost from infant mortality at the present time are only 60 per cent of what they would have been had the mortality rates of 1933 prevailed. Another notable feature indicated by the chart is the precipitous decline in the life- years lost from tuberculosis and other respiratory diseases. The years of life lost through tuberculosis deaths are less than one-tenth of what they would have been had no improvements been made in the past twenty years. Likewise, the life-years lost due to deaths from other respiratory diseases—namely, pneumonia, bronchitis, and influenza—are only 30 per cent of what they would have been had the mortality rates of two decades ago applied. Deaths from the infective and parisitic diseases also show a remarkable decline and now account for less than 50 per cent of the loss of life-years which they would have occasioned had the 1933 experience prevailed. It will be noted that the situation with respect to cardiovascular-renal diseases, accidents, and cancer appears more severe to-day than it would have been if the 1933 mortality rates from these causes had continued up to the present time. However, it is not surprising to find some increases in the degenerative conditions such as the cardiovascular- renal group and cancer, since it is evident that persons saved from premature death in infancy or in young adult ages may fall prey to one of the degenerative diseases in later life. In addition, there is strong reason to believe that the reporting of cancer as a cause of death was understated twenty years ago due to less adequate diagnostic techniques. The less favourable condition shown for the accident group compared to twenty years ago again emphasizes the need for continued and increased measures to combat this unnecessary loss of life. A further analysis of the accident picture reveals that there has been a marked increase in mortality from accidents at ages from 20 to 59, while there has been a substantial decrease in mortality at ages under 20. BIRTH AND STILLBIRTH RATES There was a considerable increase during 1953 in the number of births which occurred in this Province, and the birth rate per 1,000 population rose to 25.8. This is the highest rate ever attained in British Columbia and exceeds the previous high of 25.2 which was set in 1947. The stillbirth rate declined slightly during 1953. There were 11.3 stillbirths per 1,000 live births during this year, compared to 12.6 in 1952. The stillbirth rate has been steadily declining since 1949. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 81 REPORT OF THE DIVISION OF PUBLIC HEALTH EDUCATION Raymond H. Goodacre, Director If asked the question, " What is health education? " the uninformed would probably reply by saying that it consists of telling people about health, giving lectures or showing films, producing pamphlets and posters, or writing press releases. And yet merely telling people about health is only one-third of the battle. They must then learn and act on the information. The object of health education is to improve people's health, and unless their health is improved they have not been educated. Professor Whitehead, the great educator, has defined education as the art of the utilization of knowledge. Thus of the two words "health education," it is the word "education" that is the important one. A person who is a good educator will make a good health educator, but an expert on health does not necessarily make a good health educator unless he takes some trouble to acquire at least the rudiments of the techniques of education. The objective of this Division is, then, twofold: To provide information on health, and to demonstrate the principles of education, not to the public direct, for that is uneconomical, but to those who are or will be dealing directly with the public. These include local health-services personnel, the training institutions for teachers and public health nurses in both Vancouver and Victoria, and the Department of Education. Just as chlorine is applied at the main water-supply rather than at each household, the services of this Division are directed at those who will in turn reach a wider range of groups and individuals in the community. LOCAL HEALTH EDUCATORS The importance of health from the point of view of the individual and the community has been well recognized by the educational authorities in this Province, with the result that health-teaching has been given an important place in the school curriculum. Because of the many opportunities which present themselves in the schools for providing information and for influencing attitudes and habits in a practical manner as they relate to health, teachers are discussing more and more their health-teaching problems with full-time local public health personnel and are making use of the information and assistance provided by them and by the Division of Public Health Education. One of the major problems among teachers who took their teacher-training some years ago is that of information regarding community health and local public health services. Although local public health personnel have been providing information to teachers in their areas, the presence of a health educator in the Central Vancouver Island Health Unit has effected a clearly defined liaison between that unit and the teachers through, firstly, interpretation of health-unit services, and, secondly, familiarization with the visual aids maintained in the library of the Division of Health Education. Apart from her routine visits to schools, the unit health educator continued to provide advisory services to teachers on specific programmes and projects in school health. Two nutrition-education programmes planned for schools in her area consisted of one designed to replace the consumption of soft drinks and candy with milk and apples, and another to help teachers who are confronted with the problem of children arriving at school having eaten either no breakfast or, at best, a poor breakfast. CONSULTATIVE SERVICES Although the majority of routine requests from health units can be met through correspondence, there are, of course, occasions when special visits are required. During the year, trips were arranged to units to discuss public relations, public education with respect to fluoridation, the role of education in public health, pre-school and school Y 82 BRITISH COLUMBIA dental-health education, health-education opportunities open to a nurse making a home- visit, education in accident-prevention, and other similar topics dealing directly with the programme of local health services. Activities outside the Health Branch included representation at a film institute sponsored by the Greater Vancouver Health League and the annual regional meeting of the National Film Board in October. Both meetings provided an opportunity for the main film distributing agencies and users to discuss many of the problems encountered in the distribution, utilization, and care of moving-picture films. Liaison was maintained with the two Provincial Normal Schools at Vancouver and Victoria with periodic meetings to discuss the training of teachers in the fundamentals of health education. As in the past, a talk on Provincial health services and health-education aids was given to the students at Victoria Normal School in the spring. Evaluation of materials suggested for distribution to the public was continued throughout the year. In addition to several publications prepared by divisions within the Health Branch, a number of pamphlets and posters were evaluated at the request of the Department of National Health and Welfare. In each case the comments of persons representing various groups, both lay and professional, were obtained and summarized. Mr. William Mennie, of the Research Division, Department of National Health and Welfare, visited the Health Branch early in the year to discuss revisions in the summary compiled from the Provincial health-survey reports describing health services and facilities as they existed in 1948. Since Mr. Mennie's trip, this Division has been obtaining additional information for the Research Division which will enable it to bring this Province's contribution up to date, as of December, 1952. MATERIALS In education during the past ten or twenty years the " group " has been rediscovered as an educational instrument. By the group is meant the association of a small number of people capable of developing personal relationships, having some continuity of relationships and having some common concern. Educators who cannot possibly reach every individual must work through groups and their leaders in order to economize effort. The group is an educational agent helping the individual to adopt new ideas more readily and, more important, encouraging him to put new ideas into practice. It must be the responsibility of educators to create situations which will help leaders of organizations and groups appreciate the need for more information and training and thus create a state of receptiveness. It was with this in mind that toward the latter part of the year the Division began work on a new booklet designed to provide local field staff with a basic understanding of the techniques of leading group discussions and at the same time double as a refresher for those who are already aware of and apply these principles. It was felt that this booklet might help public health nurses, Sanitary Inspectors, and health-unit directors not only in their staff meetings and study groups, but also in discussions which many of them are required to lead in their programmes of community education. The pamphlet shortage mentioned last year has become more acute during the past twelve months, and was emphasized by the complete absence of two fundamental booklets, " The Canadian Mother and Child " and " Up the Years from One to Six." Information Services Division, Department of National Health and Welfare, producer of these publications, has apparently been experiencing budgetary difficulties, forcing it to cut back drastically its distribution to the Provinces. Furthermore, the pamphlet situation has deteriorated to the point where, contrary to the recommendations made by the Provinces at the Fourth Federal-Provincial Conference on Health Education last year, at least four of the most widely distributed publications are to be placed on general sale by the Federal Government, effective April 1st, 1954, with no free distribution to the Provinces as in the past. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 83 One of the main functions of the Division is that of maintaining a central registry of information on educational programmes in the health units. One example of this endeavour pertains to the series of classes for expectant mothers which are being organized all over the Province. It is the aim of the Division to provide some measure of assistance to units developing maternal- and child-health programmes by producing a basic outline relating how existing classes were organized, the educational approaches used, content of each class in the series, publicity methods, and similar types of evaluated information that will provide a groundwork that might otherwise be developed on a trial-and-error basis by individual units. Although the project is now only in a formative stage, it is hoped that within the next three or four months an information kit will be made available to all areas contemplating parent-craft classes. In conjunction with this programme, the existing twelve-month " baby letters " and the booklet " Feeding the Normal Child," produced by the Health Branch, have been revised by the Consultant in Maternal and Child Health. There is, in the Report of the Division of Preventive Dentistry, a comprehensive description of the fluoridation programme undertaken jointly by the Divisions of Preventive Dentistry, Public Health Engineering, and Public Health Education. To this end, this Division issued a series of eight articles under the heading of " Fluoridation News " to every member of the field staff and to the city health departments of Greater Vancouver and Victoria-Esquimalt. These articles condensed the mass of information that is available from many sources and included up-to-date material that could be utilized in a series of talks on fluoridation. In addition, an information kit was designed for use by local health-services personnel, consisting of materials directed to three levels of consumption. It included " Fluoridation News " for medical-dental, legal, and engineering groups; the United States Public Health Service pamphlet " Better Health through Fluoridated Water" for such community groups as the Women's Institutes, Parent- Teacher Associations, Farmers' Institutes; and the American Dental Association leaflet " Drink Away Tomorrow's Tooth Decay," for general distribution. Additional information on costs of fluoridating, available films, and displays were also included. A modified version of the kit has been made available to community groups concerned with the study of fluoridation and its effect upon tooth decay. Realizing that visual aids help to create a state of receptiveness, the Division is in the process of collecting a series of slides for use in talks on fluoridation by local public health personnel. Based on topics covered by the proposed Canadian Dental Association fluoridation pamphlet, more than thirty slides show illustrated charts, fluoridation equipment, and scenes from cities in the United States and Canada already fluoridating their water-supplies. Further work in this medium of education is also under way. One important function of local health units is that of bringing services to the attention of the people for whom they are provided. As cost is the prime prohibiting factor in producing a film, it was felt that a series of slides taken in various health units would provide a flexible means of visual assistance to nurses, Sanitary Inspectors, and health-unit directors in explaining the services provided in their areas. A project has been drawn up whereby this Division will provide films and flash-bulbs to units with amateur photographers for approved outlines of topics and activities. A similar group of slides depicting tuberculosis, venereal disease, nutrition, and other Health Branch services is also under consideration. Although there was a marked decrease in the availability of new films during the year, twenty new and duplicate items were added to the central film library. Showings to more than 80,000 people reveal that mental health was the most popular topic, followed by dental health, maternal and child care, nutrition, sanitation, and safety. It is not possible to draw many conclusions from attendance figures, but it is interesting to note that safety foots the list, despite the fact that accidents in British Columbia constitute the leading cause of death between the ages of 1 and 31. Y 84 BRITISH COLUMBIA IN-SERVICE TRAINING During the past few years the Division has been represented on the Public Health Institute planning committee charged with the responsibility of planning and operating the four-day in-service training programme each year. Together with representatives from the two metropolitan health departments, all local health-service personnel meet at this time to hear guest speakers and members of both Provincial and local health services discuss topics designed to broaden one's concept of public health. This year the Annual Institute was held in Vancouver from April 7th to 10th. Dr. Hugh Leavell, Professor of Public Health Practice at Harvard University, spoke on topics with a range in scope from accident-prevention to the contributions of the social sciences to public health. The talks were both interesting and valuable in that the subject-matter, although fundamental to one's understanding of public health, is too often pushed into the background by routine procedures. In the latter part of the year, sole responsibility for organizing the Institute was shifted from the committee to this Division. Members of the committee will, however, remain as an advisory council and will therefore continue to contribute their wisdom and guidance in the selection of both speakers and topics. The orientation course for new members of the professional staff in the central office and for new unit dental and medical directors was continued during the year. Orientation was arranged for one health-unit dentist, one statistician, two health educators, one research assistant, and the new industrial nurse serving the Parliament Buildings. PUBLICATIONS AND PUBLICITY In 1931 the Provincial Board of Health began issuing monthly statistical bulletins for the information of District Registrars and the medical profession. Sixteen years later, after the establishment of the Division of Health Education, the bulletin changed its approach, becoming an educational force directed to schools, community groups, newspapers, and to the medical and dental professions. Finally, in January, 1951, the bulletin changed its name to " B.C.'s Health " and appeared in printed form. However, in August of this year, along with similar publications of other departments, " B.C.'s Health," after twenty-two years, was discontinued in accordance with Government policy. Since then the Health Branch has been contributing monthly articles for the new Government publication, " B.C. Government News," which now replaces all publications previously issued by the various departments. STAFF The division continues to experience a mobility in staff due primarily to the difficulties in both recruiting and retaining suitably qualified applicants. Toward the end of the year the vacancy created by a candidate who resigned after six months' service was finally filled. Despite the problems encountered in recruiting, the Division has been able to extend the programme designed ultimately to improve community and school health education. More emphasis, however, must be placed upon the training of those who will be concerned with health educating. This will involve an extension of present co-operation with the nursing and teacher-training schools, and indirectly with present teachers through the Department of Education and local health units. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 85 REPORT OF THE HEALTH BRANCH OFFICE, VANCOUVER AREA G. R. F. Elliot, Assistant Provincial Health Officer This year has been an active one in all phases of the work of the Vancouver Area office of the Health Branch, in charge of the Assistant Provincial Health Officer. The latter is responsible for the Bureau of Special Preventive and Treatment Services, liaison with voluntary health agencies in Vancouver, and the administration of the National health grants to British Columbia. The Bureau of Special Preventive and Treatment Services includes the Divisions of Laboratories, Tuberculosis Control, and Venereal Disease Control. The Assistant Provincial Health Officer is primarily concerned with matters of policy respecting these Divisions, including co-ordination between these services, as well as between them and the local health services. A detailed review of the work of each Division, which has been submitted by the Director, follows this report. Also housed within this office is the Vancouver office of the statistical section of the Division of Vital Statistics, and the usefulness of this arrangement continues to grow each year. BUILDINGS The summer of 1953 saw the start of construction of the new Provincial Health Building, and this can be considered as the important development in this Bureau during the year. The completion of this building some time early in 1955 will vastly improve the services now given by this Bureau to the people of the Province of British Columbia. FACULTY OF MEDICINE, UNIVERSITY OF BRITISH COLUMBIA As mentioned in the 1952 Annual Report, the very satisfactory working relationship with the Dean of the Faculty of Medicine, University of British Columbia, and in particular with the heads of the Departments of Paediatrics and Preventive Medicine, continues to expand. This is emphasized by the fact that the Department of Paediatrics has been named as the official consultant to the Health Branch in child-care, and, further, two members of this Bureau are Assistant Professors of Public Health in the Faculty of Medicine, University of British Columbia. VOLUNTARY HEALTH AGENCIES The voluntary health agencies located in the City of Vancouver which receive grants from the Provincial Government continue to receive close supervision, and once again it is felt that the programmes of these organizations are sound and the money invested in them by the people of this Province, through the Provincial Government, is well spent. The activities of the British Columbia Cancer Foundation, the Western Society for Rehabilitation, and the Canadian Arthritis and Rheumatism Society (British Columbia Division) are outlined separately in this Report. In general, however, the Assistant Provincial Health Officer has actively participated in the programme-planning of these organizations, and a most amicable relationship has existed. Budgets are reviewed with great care, and it is felt that economy is being practised in a reasonably satisfactory manner. In addition to these organizations, limited time was given to the Vancouver Preventorium, British Columbia Poliomyelitis Foundation, British Columbia Tuberculosis Society, Canadian Red Cross Society, John Howard Society, Cerebral Palsy Association, Canadian Cancer Society (British Columbia Division), Alcoholism Foundation, Multiple Sclerosis Society, and other similar organizations related to health matters in the Province of British Columbia. Y 86 BRITISH COLUMBIA During the year, visits were made to many of the larger hospitals in this Province on Departmental matters, such as co-ordination of the Provincial Biopsy Service and requests for assistance from the National health grants. British Columbia Cancer Foundation This organization, named as the agent of the Provincial Government for the treatment and control of cancer in this Province, made forward strides in its programme. Funds are provided by the Cancer Control Grant of the National health grants and by the Province of British Columbia on an equal basis to pay the operating expenses of the main diagnostic and treatment centre, known as the " British Columbia Cancer Institute," and the nursing home, both located in Vancouver, and of the consultative and diagnostic clinics located throughout the Province. These consultative clinics now operate at ten centres in the Province. The diagnostic and treatment centre of the British Columbia Cancer Foundation at the Royal Jubilee Hospital in Victoria continues to provide for a needed and expanding service. Western Society for Rehabilitation This voluntary health organization in the field of rehabilitation continues to give leadership to all of Canada in this field. The increasing responsibilities of this agency have necessitated the assistant medical director appointed in 1952 being employed three- quarter time instead of half time, as well as the appointment of a second assistant medical director on a full-time basis. During the year a highly qualified person in the field of logopaedics was added to the staff of the Cerebral Palsy Association, which is housed in the Western Society for Rehabilitation, and his services are available to all agencies housed at the Western Society for Rehabilitation. Early in 1954 there will be an additional twenty beds and 15,062 square feet of diagnostic, treatment, and out-patient facilities completed at the Western Society for Rehabilitation. This will aid materially in increasing the services now available to the people of the Province of British Columbia through the Western Society for Rehabilitation, Canadian Arthritis and Rheumatism Society (British Columbia Division), and the Cerebral Palsy Association. Canadian Arthritis and Rheumatism Society (British Columbia Division) Further expansion has taken place during 1953 in this voluntary health agency. In addition to the main diagnostic clinics established in the large centres, a travelling consultant service is now extended to physicians outside Vancouver. Mobile physiotherapy service is given from the treatment centres listed in the 1952 Report as well as from new centres in Port Alberni, Courtenay, Abbotsford, Chilliwack, Langley, and Burnaby. At least seventy-three communities have the advantage of home care. In all areas medical and lay committees give practical and financial support. Intensive care by the team consisting of the doctor, physiotherapist, occupational therapist, social worker, and nurse is given to in-patients at the treatment centre operated by the Canadian Arthritis and Rheumatism Society and located in the Western Society for Rehabilitation Building in Vancouver. The Canadian Arthritis and Rheumatism Society is renting increased space in the addition to this building nearing completion in order to provide for the establishment of an occupational-therapy department as well as expansion of existing services. Patients from all over British Columbia are referred to this treatment centre. The staff now totals forty-three, including a medical director and three consultants, two nurses, one occupational therapist, twenty-two physiotherapists, one driver, and three J DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 87 research and records stenographers. A shortage of physiotherapists delays and increases the cost of the programme. Three research projects are being conducted under the auspices of the Canadian Arthritis and Rheumatism Society—one at the Department of Biochemistry at the University of British Columbia on the basic aspects of rheumatism and arthritis, one on rheumatic fever and heart-disease, and one on rheumatoid arthritis. Some assistance toward this research is being received from the National Public Health Research Grant. CIVIL DEFENCE Lectures to various groups, including schools of nursing, the Vancouver Civil Defence School, and other interested groups, still continue as a responsibility of this Bureau. GENERAL The regulations under the "Practical Nurses Act" passed in 1951 were finalized during the year, but up until the present time these regulations have not become law in this Province. Considerable time was spent in the development of a research programme related to narcotic addiction as mentioned in the 1952 Report. The fall of 1953 saw the culmination of these efforts with the appointment by the University of British Columbia of a highly qualified psychiatrist to head up this research programme. The Mental Health Services under the Provincial Secretary's Department, the Attorney-General's Department, and this Health Branch will continue to be closely associated with the University in the planning and completion of this research project. The research is being financed under the National health grants and the Attorney-General's Department, with technical and professional advice and guidance being supplied by the University of British Columbia. The year saw the birth of the Alcoholism Foundation. It does appear that finally the efforts of all those interested in the problem of alcohol have been co-ordinated, and progress in the solution of this problem can be hoped for as the Foundation develops its programme. The Attorney-General's Department, the Mental Health Services of the Provincial Secretary's Department, and both the Health Branch and Welfare Branch of the Department of Health and Welfare have representatives on the board of trustees of this Foundation. Poliomyelitis was once again a problem in this Province, and although it will be covered in greater detail elsewhere in this Annual Report, several facts are worthy of mention. The responsibility for the development of a more satisfactory method than that which has existed in previous years for reporting, possible transportation, and hospitalization, including treatment, was given this Bureau by the Deputy Minister of Health. The recommended procedure for management of cases of poliomyelitis was developed with the valuable assistance and guidance given by the Poliomyelitis Committee of the Vancouver General Hospital. As a result of these recommendations, a poliomyelitis treatment centre for more severe cases was established at the Vancouver General Hospital, and later at the Royal Jubilee Hospital, Victoria. Details of these procedures in the management of poliomyelitis in this Province are available if desired. The people of the Province of British Columbia, and in particular this Health Branch, are once again deeply indebted to the Royal Canadian Air Force for its splendid co-operation in carrying out mercy flights in the evacuation of poliomyelitis patients to Vancouver. In the first eleven months of this year the Royal Canadian Air Force has flown approximately 25,000 miles in carrying out some twenty-two mercy flights. It is not possible to express in writing what this has meant to the people of the Province of British Columbia, not only in dollars and cents, but above all in the safety factor due to the presence of trained and experienced medical and nursing personnel on these flights. Y 88 BRITISH COLUMBIA The British Columbia Poliomyelitis Foundation has also given yeoman service in the management of poliomyelitis in this Province this year. Its funds have matched Government funds in the purchase of equipment, and over $100,000 has been spent on equipment alone in 1953. The British Columbia Poliomyelitis Foundation also assisted greatly in expediting the delivery of respirators to this Province when urgently required. Funds from this voluntary health agency have also assisted greatly in those fields for which the Health Branch has no funds. These include payment of special nurses, housekeeper services, and transportation, to mention a few. Gamma globulin was made available to this Province during the summer and is distributed through this Bureau to local health services for use on a restricted formula due to the shortage of supply of this product. It is distributed free, to be administered by the family physician to those contacts who meet the criteria as laid down by the Poliomyelitis Committee of the Vancouver General Hospital. During the year a consultant in nutrition from the Bureau of Local Health Services was attached to this office. This has been a most useful development, and her advice and guidance in the field of nutrition to the Division of Tuberculosis Control and voluntary health agencies related to this Bureau have been most valuable. NATIONAL HEALTH GRANTS General The total amount of funds available to British Columbia for the fiscal year 1953-54 is $3,849,447, excluding the Public Health Research Grant, which is allocated in Ottawa. The decrease of approximately $600,000 from the previous year is due to a decrease in the Hospital Construction Grant of approximately $1,000,000, which is only partially offset by the amount of $437,126 allocated to this Province in the three new grants introduced this year for laboratory and radiological services, medical rehabilitation, and child and maternal health. The amounts of the other grants remain essentially unchanged. The Health Survey Grant was discontinued this year, as the survey and report, for which this grant was provided, were completed in 1952. Four transfers of funds were made in order to meet the need for additional funds. From the Cancer Control Grant, $29,000 was transferred to the Professional Training Grant and $60,000 to the General Public Health Grant. From the Tuberculosis Control Grant, $20,000 was transferred to the General Public Health Grant, and from the Laboratory and Radiological Services Grant $20,000 was also transferred to the General Public Health Grant. Administration The administration of the National health-grants programme has continued to be quite satisfactory, and is no doubt due in large part to personal discussion of problems, the opportunity for which was provided by the visit of officials from the Department of National Health and Welfare and the Treasury Department to this Province in September. The policy of having the Assistant Provincial Health Officer in Ottawa at the time consideration is given to continuing projects has been accepted. As a result, approval of the majority of these submissions was received this year from the Department of National Health and Welfare before April 1st, 1953. This was of assistance, particularly to the non-government agencies, as it was then possible to inform them of the funds available for their services before the new fiscal year actually began. Grants Received for the Year Ended March 31st, 1953 Total expenditures for the year ended March 31st, 1953, were $1,986,279 or 45 per cent of the total available, as compared with $2,481,398, or 85 per cent of the total grants available, in the year ended March 31st, 1952. The decrease in total expenditures DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 89 is due primarily to the decrease in expenditures under the Hospital Construction Grant. These expenditures may be expected to fluctuate considerably due to the delays which occur in the construction of hospitals and health centres. The total amounts approved under the Mental Health and Tuberculosis Control Grants were less than in the previous year, when large amounts were used for furnishings for newly completed buildings. As a result, the total expenditures under these two grants also decreased. Detailed figures are given in the following table:— Comparison of Amounts Approved and Actual Expenditures with Total Grants for the Year Ended March 31st, 1953 Grant Total Grant Approved Actual Expenditures Amount Per Cent Amount Per Cent $43,599 48,599 2,478,153 43,599 518,616 370,329 17,585 33,320 588,060 293,682 $18,125 47,665 1,576,561 43,599 394,252 301,090 17,585 800 571,199 195,324 42 98 64 100 76 81 100 2 97 67 $15,990 44,587 598,751 43,599 357,339 239,438 13,381 680 494,355 178,159 37 92 24 100 Mental Health 69 65 76 2 84 61 Totals $4,435,542 $3,166,200 71 $1,986,279 45 The decrease in amounts approved and expended, as previously noted, also affected the position of British Columbia in relation to all Provinces. Excluding the Public Health Research and Health Survey Grants, the percentage of funds allocated was 72 per cent in British Columbia, as compared with 75 per cent for all Provinces. Similarly, the amount expended in British Columbia was 45 per cent of the total available, as compared with 51 per cent for all Provinces. Crippled Children's Grant A new development under this grant is assistance to the Cerebral Palsy Association of British Columbia. This made possible in October the appointment of a person well qualified in the field of logopaedics. As a result, an expert speech-therapy programme is being developed for children in the Lower Mainland area, and consideration is being given to the establishment of a training programme in logopaedics at the University of British Columbia. A detailed outline of the Crippled Children's Registry, which is financed under this grant, is given in the report of the Division of Vital Statistics which appears earlier in this Health Branch Report. Professional Training Grant The number of persons completing training under all projects during the calendar year 1953 was thirty-nine, and total expenditures made in regard to this training were $69,672.99. In addition, fifty-eight persons have taken short courses, varying in length from a few days to two or three weeks. Funds for this training have been provided by other grants in addition to the Professional Training Grant. Included in the short-course group are five health-unit directors who attended a mental-health workshop arranged by Washington State Health Officers' Association and twenty-four public health nurses who attended a short course in mental health arranged by the University of Washington. Expenditures for these two courses were charged to the Mental Health Grant. Y 90 BRITISH COLUMBIA Assistance is being continued this year toward the training of public health staff and the staff of general hospitals, as well as training in specialized fields such as medical rehabilitation, tuberculosis, and mental health. Hospital Construction Grant The Hospital Construction Grant was reduced this year, and, in addition, a smaller proportion of the accumulated unexpended funds from previous years was revoted, so lhat the total amount available this year is approximately $1,000,000 less than ,in 1952-53. The reason for these reductions is that a large proportion of the hospital construction which had accumulated during the war years has been completed or is well under way, and, therefore, a smaller amount should be sufficient for current new projects and the completion of those under construction. The number of hospital-construction projects initiated during the current fiscal year is comparatively small, but there are still a large number of projects to be completed. Venereal Disease Control Grant This grant is on a matching basis, and the total amount is therefore paid to the Province, as expenditures by the Province on venereal-disease control are considerably in excess of the amount of the grant. The standard and extent of service given during the year 1948-49 is being maintained. As all services for the control of venereal disease in British Columbia are provided by the Provincial Government, the annual report of this Division, which appears in a later section of this Health Branch Report, constitutes the report made on the use of this grant. Mental Health Grant The Mental Health Grant is of benefit primarily to the British Columbia Mental Health Services, Department of the Provincial Secretary. The majority of projects are initiated under the Director of the Mental Health Services, who also reviews all proposed projects which will be administered by other departments or agencies. In general, all phases of the Provincial mental-health programme have improved through the additional staff and facilities provided under this grant, but reference is made here only to some of the newer developments. The Department of National Health and Welfare has agreed that the Homes for the Aged, which are under the jurisdiction of the Mental Health Services, may be classed as mental institutions for purposes of this grant. As a result, therefore, it has been possible to improve facilities for the care of these patients. A more active programme to combat tuberculosis in the patients of the Provincial Mental Hospitals is being developed, assisted by additional staff provided under this grant. Additional staff has also been provided to assist in the new formal reactivation programme, which has been introduced into the wards for regressed patients in the continued-treatment units and which is showing valuable results. Mentally defective children are now admitted directly to The Woodlands School, New Westminster, without the necessity of first passing through the Provincial Mental Hospital, Essondale. This advance has been made possible by the provision of proper admission facilities in one of the three new 100-bed units. The Mental Health Grant has been of great assistance in providing surgical, laboratory, and X-ray equipment for the admission unit. The additional staff which has also been provided has assisted in the improvement and expansion of the programme at this unit. Assistance is being continued to the University of British Columbia, the psychiatric services in the Vancouver General Hospital and Royal Jubilee Hospital, Victoria, and the mental-health programmes in the Cities of Victoria and Vancouver. In the latter area, a nursing consultant with postgraduate training in mental health has been appointed DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 91 to indoctrinate new staff members and to assist the present staff in relation to the mental- health programme. Tuberculosis Control Grant This grant is similar to those for mental health and venereal-disease control in that the majority of the tuberculosis services are provided by the Provincial Government, and the largest proportion of this grant, therefore, is used by this Government department. Detailed information regarding these services is given in the report of the Division of Tuberculosis Control, which appears in a later section of this Health Branch Report. Public Health Research Grant Four new research projects have been approved this year for assistance under this grant, in addition to the continuation of three projects from previous years. An analysis is to be made of all phases of hospitalized illness as shown by the records of the British Columbia Hospital Insurance Service and the relationship of hospitalized illness to certain other factors, such as prepaid medical plans and co-insurance, as well as studies of certain administrative problems in connection with hospital insurance which may have a bearing on the quality and quantity of health-care available to the population. The purpose of this research is to obtain information essential in planning for the most efficient programme of health-care and the optimum utilization of hospital facilities and other health resources. This project is under the supervision of the Director, Division of Environmental Management, Provincial Health Branch. In co-operation with the Vancouver Chapter, Multiple Sclerosis Society of Canada, research is being carried on in regard to the causation, prevention, and cure of multiple sclerosis. Two projects initiated by the Canadian Arthritis and Rheumatism Society (British Columbia Division) and approved are concerned with the assessment of cortisone in the prevention of permanent rheumatic heart-disease and with the determination of human blood patterns and levels of the adrenal steroid hormones. Health Survey Grant As noted in the Annual Report for 1952, the Survey of the Health Services and Facilities in British Columbia, December 31st, 1948, was tabled in the House of Commons on July 2nd, 1952. This report, early in 1953, became the subject of much discussion, particularly by the British Columbia Division of the Canadian Medical Association. These discussions were naturally focused on Section VII of this report, which dealt with suggestions relative to the introduction of health insurance in specific specialties in the practice of medicine. Committees have been set up by the British Columbia Division of the Canadian Medical Association to study these recommendations, and in particular that recommendation pertaining to the diagnostic services, since a National health grant for laboratory and radiological services was made by the Federal Government in May, 1953. Details of this grant are found later in this Report. General Public Health Grant All phases of the general public health programme carried on by the local health-unit staff continued to receive assistance from this grant. The additional staff required in the local areas to meet the demands for public health services was an important factor in the request, which was approved, that the Public Health Grant be increased by the transfer of $60,000 to this grant from the Cancer Control Grant. Detailed information in regard to these services is given earlier in this Report, in the report of the Bureau of Local Health Services. A new project approved this year provides for the establishment of an industrial nursing service which, besides providing actual health services to the 1,700 Provincial Y 92 BRITISH COLUMBIA Government employees in Victoria, will serve as a study project for the promotion and development of this type of service in industry. The service is under the direction of the Director, Provincial Division of Environmental Management. A second new development made possible through an approved project was the employment during the summer months this year of three third-year medical students in health units, where they were given specific responsibilities. This plan has been most successful, with advantages to both the students and the health units. Approximately $40,000 from this grant is being expended this year for the purchase of equipment for the care and treatment of poliomyelitis. While the larger proportion of funds has been allocated toward the purchase of respirators, other equipment, such as rocking-beds, polio pack machines, and positive-pressure apparatus, has also been purchased. Funds for the above purchases were transferred to this grant from the Radiological Services Grant and the Tuberculosis Control Grant. This equipment is located almost entirely in the Vancouver General Hospital and the Royal Jubilee Hospital, Victoria, with the larger share being in the former. Treatment centres have been established at these two hospitals, and patients requiring specialized care are brought in from other areas of the Province. Cancer Control Grant The operations of the British Columbia Cancer Foundation, which are financed under this grant, are outlined earlier in this report in the section " Voluntary Health Agencies." The number of examinations done under the Provincial Biopsy Service has steadily increased since the inception of the service. The average number of tissue examinations per quarter referred under the Biopsy Request Form was 2,792 in 1951, 3,265 in 1952, and 3,995 each quarter in the first nine months of 1953. These figures do not include biopsy examinations originating in the hospitals having pathologists on their staff, but the number of these examinations has also increased. The quarterly average number of all biopsy examinations was 8,968 in 1952 and 9,633 in the first nine months of 1953. Laboratory and Radiological Services Grant The Laboratory and Radiological Services Grant is one of the three grants made available for the first time in 1953. The purpose of this grant is threefold—the improvement of the quality and the extension of diagnostic services and thus the improvement of medical care in general, the better distribution of medical man-power by providing diagnostic facilities to areas not already served and thus encouraging physicians to practise in these areas, and the reduction of personal expenditures for diagnostic services. The grant is distributed on the basis of 30 cents per capita of population and increases 5 cents per capita annually until a maximum of 50 cents per capita is reached. British Columbia's share this year is $359,400. Expenditures for equipment and professional training may be charged entirely to this grant, but expenditures for services must be matched by Provincial expenditures on such services of at least an equal amount. This provision should not delay expenditures for services under this grant, as it is expected the Department of National Health and Welfare will accept as matching funds the cost of such services provided under the British Columbia Hospital Insurance Service and a large proportion of the cost of the Provincial Division of Laboratories. The total of these two items is considerably in excess of the amount required. A Provincial programme for the utilization of these funds is now under consideration, and in this connection liaison is being maintained with the British Columbia Division of the Canadian Medical Association. In the meantime it has been agreed that, providing the need is established, funds for the purchase of radiological equipment will be DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 93 provided on the basis of 40 per cent from this grant, 20 per cent from the British Columbia Hospital Insurance Service, and the remaining 40 per cent from the local area; funds for the purchase of laboratory equipment will be provided entirely from this grant. A survey has been made of all laboratory and radiological facilities in general hospitals, but it is not expected that plans will be sufficiently far advanced to enable very large expenditures to be made this year. Medical Rehabilitation Grant This grant, which is available for the first time this year, is to make funds available to the Provinces for those areas of rehabilitation and for those groups of disabled persons with respect to which no grant funds have been available hitherto. Rehabilitation projects which relate to tuberculosis, mental health, and crippled children programmes will continue to be dealt with under existing relevant grants. Distribution of the grant is on the basis of $ 10,000 to each Province and the balance according to population. The amount allocated to British Columbia this year is $42,877. This grant is also partially a matching one; expenditures for equipment and professional training may be charged in full, but expenditures for services are on a matching basis. No difficulty is expected in regard to the provision of matching funds, as it is understood Provincial Government grants now being made to the Western Society for Rehabilitation and the Canadian Arthritis and Rheumatism Society (British Columbia Division) will be accepted by the Department of National Health and Welfare for this purpose. Rehabilitation is a problem which concerns several Government departments and voluntary agencies. Funds for rehabilitation are also available from various Government and private sources. Close co-operation is being maintained with all agencies concerned in order that a well-co-ordinated Provincial programme may be developed. Under these circumstances it is likely that projects submitted this year will be limited almost entirely to additional equipment for established services, while those to initiate or expand services are delayed until the Provincial programme is finalized. Child and Maternal Health Grant The purpose of the Child and Maternal Health Grant, which is the third new grant this year, is to assist in an accelerated and intensified programme for the improvement of maternity, infant, and child care. The grant is distributed on the basis of $10,000 to each Province, 50 per cent of the balance on the basis of the average number of births over the previous five years and the other 50 per cent on the basis of the average number of infant deaths over the previous five years. Total expenditures for approved services, equipment, or professional training may be charged to this grant. The amount available to British Columbia this year is $34,849. The child and maternal health services in this Province are an integral and important part of the general public health programme carried on by the staff of the local health departments, and it is planned to use this grant to strengthen and expand this phase of the general programme. ACKNOWLEDGMENT Valuable assistance and co-operation have been received from officials of the Department of National Health and Welfare, the Provincial Health Branch, the Department of the Provincial Secretary, particularly the Provincial Mental Hospitals staff, and the Commissioner and staff of the British Columbia Hospital Insurance Service. Harmonious working relationships exist with the city health departments of Vancouver and Victoria, the voluntary health organizations, and general and specialized hospitals, with all of whom this office has been in contact during the year. Y 94 BRITISH COLUMBIA REPORT OF THE DIVISION OF LABORATORIES C. E. Dolman, Director The year under review has been no less difficult than its predecessors. Staffing problems, which tend to become more acute as the number employed and the work-load increase, have been aggravated by these inefficient quarters, which discourage even the keenest new-comers. Such circumstances have made it virtually impossible to build up any reserves of trained staff, so that a few seniors find themselves continually training fresh recruits. Fortunately, some respite is in sight. In the autumn the contract was let for construction of the Provincial Health Building. It is hoped that the three floors assigned to the Division of Laboratories in this modern fire-proof structure will be ready for occupancy by the early summer of 1955. Table I. -Statistical Report of Examinations Done during the Year 1953, Main Laboratory Out of Town Metropolitan Health Area Total in 1953 Total in 1952 208 4,590 1,812 1,040 53 8,097 3,470 1,133 786 256 6,622 5,259 1,897 35 9,379 6,338 13,784 2,225 6,516 1,457 20,719 6,858 3,362 204 175 796 1,178 103,157 15,069 1,507 18,346 21,644 1,821 68 360 1,319 1,853 1,684 1,662 1,311 918 1,684 140 140 124 72 85 464 11,212 7,071 2,937 88 17,476 9,808 14,917 3,011 6,516 2,350 25,221 15,765 4,912 234 225 978 1,867 139,947 21,868 2,057 26,734 27,938 2,727 87 710 2,063 2,775 3,732 3,707 2,568 931 7,168 140 140 124 72 210 284 Blood serum agglutination tests— 12,124 Brucella group -— — 6,621 2,511 Miscellaneous Cultures— M. tuberculosis 120 15,919 8,026 C. diphtheria; - - 17,793 3,517 N. gonorrhoea; 6,054 1,959 893 4,502 8,907 1,550 30 50 182 689 36,790 6,799 550 8,388 6,294 906 19 350 744 922 2,048 2,045 1,257 13 5,484 Direct microscopic examination— 26,758 12,993 4,288 Treponema pallidum. — - 278 225 757 Miscellaneous — - Serological tests for syphilis— Blood- 1,740 142,071 25,324 2,842 Complement fixation, __ v.d.r.l 26,368 188 Cerebrospinal fluid— 2,845 131 Cerebrospinal fluid— 827 Protein 2,171 2,936 Milk— 3,225 Coli-aerogenes — Phosphatase... Water— 3,225 2,394 857 Coli-aerogenes Ice-cream— 7,015 152 152 152 63 125 117 110,726 260,024 370,750 345,022 DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 95 At the central laboratories the total number of tests performed and the actual work-load in terms of " unit values " showed an increase of about 8 per cent. The fairest way of computing and comparing laboratory work-loads appears to involve the " unit value " system rather than totals of " specimens received " or " tests performed." Under this system, each type of test is assigned a specific unit value, ranging from 1 to 10, based on the estimated comparative time taken to perform the test. Thus an agglutination test using a single antigen rates 1 unit, whereas a guinea-pig inoculation for tuberculosis rates 10 units. In a later section of this report, further reference will be made to work-loads and unit values. For present purposes, the work of the central laboratories in 1953 is shown in Table I under the customary headings, the corresponding figures for 1952 being also given. The branch laboratories at Victoria and Prince George showed increased activity during the year, while the number of specimens received at Nelson declined. Examinations made at these three laboratories in 1953 have been set forth in Table II. Addition of the nearly 70,000 tests carried out in the branch laboratories to the corresponding figure of 370,000 for the main laboratories gives the impressive total of 440,000 tests relating to communicable-disease control in British Columbia. This represents an increase of about 30,000 tests, or roughly 7 per cent, over the Division's 1952 total—the largest annual increment for several years. Table II.—Statistical Report of Examinations Done during the Year 1953, Branch Laboratories Nelson Prince George Victoria 48 Blood agglutination— 420 87 596 95 63 Cultures— 2,711 537 32 135 169 1,784 1,784 564 133 258 667 2 Direct microscopic examination— 1,132 738 6,143 111 23 5 39 69 271 Serological tests for syphilis— Blood— 21,489 1,564 2,205 6,367 58 18 82 84 1,128 1,107 408 56 977 231 484 Cerebrospinal fluid— 494 486 543 Milk- 642 642 259 573 823 1,341 1,341 1,341 1,359 1,359 Water— 718 Totals 12,232 4,071 50,492 Grand total, 66,795. Y 96 BRITISH COLUMBIA TESTS FOR DIAGNOSIS AND CONTROL OF VENEREAL DISEASES The continuing fall in the incidence of syphilis is reflected in a small reduction in the number of blood specimens received for sero-diagnostic tests. Cerebrospinal-fluid specimens also slightly declined. However, this trend was more than counterbalanced by a comparison, involving some 30,000 blood specimens, of the sensitivity and specificity of the so-called V.D.R.L. slide test and the presumptive Kahn test. This commitment arose out of the increasing concern about the accuracy of the latter test expressed at the last few annual meetings in Ottawa of the Technical Advisory Committee on Public Health Laboratory Services. In addition, several thousand blood and cerebrospinal-fluid specimens were subjected to complement-fixation tests, using lipoidal and the newer cardiolipin antigens in parallel. The senior bacteriologist in charge of the syphilis serology section carefully supervised these surveys and analysed the findings. The results, which were presented by the Director to the Technical Advisory Committee meeting early in December, seemed to indicate that V.D.R.L. slide test would be an efficient and desirable substitute for the presumptive Kahn test, and that the cardiolipin antigen was somewhat superior in the complement-fixation test. During the year the main laboratories participated, with very satisfactory results, in the sixth sero-diagnostic survey arranged by the Laboratory of Hygiene, Department of National Health and Welfare. Each of the Provincial laboratories in Canada examined portions of the same group of about 100 selected blood specimens, their respective findings being tabulated and compared. Unfortunately, the available amounts of these specimens were insufficient to permit inclusion of our branch laboratories in this survey. Mistakes in the performance of these sero-diagnostic tests are, on the whole, more liable to occur when the turnover of specimens is small. However, every effort has been made, by supplying standardized reagents, by refresher courses, and by personal visits, to ensure high standards of accuracy in our branch laboratories. Although the incidence of gonorrhoea has not declined to the same degree as that of syphilis, current methods of treatment often add to diagnostic difficulties, and consequently to increased dependence upon laboratory findings. Hence, perhaps the small reduction in the number of smears examined microscopically for N. gonorrhoea; and the increased requests from the Division of Venereal Disease Control for cultural examinations. In an effort to improve and simplify the procedures used in gonococcus culture work, a senior bacteriologist conducted an investigation into a new method, involving the so-called " transport medium " technique, developed by Dr. R. D. Stuart, Director of the Provincial Laboratory, Department of Health of Alberta. The established practice necessitated our maintaining at the V.D. clinic a supply of freshly made plates of special nutrient medium, the streaking of specimen swabs on to these plates, and the prompt shipping of the inoculated plates to the laboratories. The method under trial was based on the fact that gonococci (which soon die when exposed to oxygen and drying) will survive for several hours on carbon-impregnated swabs held in a buffered, semi-solid agar containing a reducing agent, thus permitting these swabs to be returned to the laboratories for plating on to nutrient media. A substantial number of specimens from the Division of Venereal Disease Control, subjected to both methods of culture, showed a distinctly higher gonococcus recovery rate from the transport medium, even when plating of the swabs was delayed for twenty-four hours. In October it was therefore agreed by the two Divisions concerned that the new method should be at once adopted. Apart from an immediate improvement in efficiency, it is now possible to envisage extension of this facility (when our staff and accommodation permit) to private physicians and health units operating within a twenty-four-hour delivery radius of the central laboratories. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 97 TESTS RELATING TO TUBERCULOSIS CONTROL All types of tests for M. tuberculosis increased during the year. Direct microscopic examinations of sputum and other specimens increased by roughly 20 per cent, reversing last year's trend, and presumably reflecting in part greater case-finding and follow-up activity on the part of the Division of Tuberculosis Control. Another contributory factor is that rapid changes may be induced in patients by modern methods of treatment of tuberculosis (as also of syphilis), which entail more frequent laboratory checks. An increase of about 6 per cent in the complex and time-consuming cultural examinations would have been considerably greater if the Division had not found itself compelled to impose some restraint on requisitions of this type. This section of the Division is especially under pressure to enlarge its services, and is the least able to respond because of the difficulties and dangers inherent in such work carried out in overcrowded quarters. For many years a warning has been sounded in these annual reports about hazards of accidental infection faced by the staff, particularly by those engaged in handling tuberculous material. In March a laboratory assistant accidentally inoculated the palm of her hand while injecting a guinea-pig with a culture for virulence test. Prompt first-aid measures failed to prevent development of a palpable local lesion. This was excised, and an intensive course of streptomycin and P.A.S. instituted under the supervision of the Division of Tuberculosis Control, whose co-operative interest in this episode is appreciated. The patient developed no further evidence of tuberculosis, though the outcome might have been otherwise before the era of specific therapy. The fortunate infrequency of such accidents is largely due to the extreme vigilance and careful technique displayed and enforced by the senior bacteriologist in charge of this section. Animal inoculations for tuberculosis increased from 284 in 1951 to around 500. We are indebted to Dr. F. O. R. Garner and Dr. Evelyn M. Gee at Tranquille for keeping us regularly supplied with healthy guinea-pigs throughout the first ten months of the year. Signs of incipient trouble (possibly pseudo-tuberculosis) showed in shipments received throughout the year. Trouble due to pseudo-tuberculosis developed in the animal colony toward the year's end. The supply and care of guinea-pigs entails perennial problems, even when the best of accommodation is available. In our parlous circumstances, it is indeed regrettable that these animals cannot be dispensed with altogether for diagnostic and virulence tests in tuberculosis-control. SALMONELLA-SHIGELLA INFECTIONS The section concerned with specimens relating to excreta-borne infections was again very, overworked, especially since early October, when the senior bacteriologist in charge broke her leg and was off duty for many weeks. Agglutination tests for organisms of the typhoid-paratyphoid group underwent a slight decline, possibly reflecting the lowered incidence of S. typhi and S. paratyphi B infections, which was unusually high in 1952. The much more exacting but more conclusive cultural examinations of faeces increased by over 20 per cent, to a total approaching 10,000. The actual number of Salmonella organisms isolated from individual patients or carriers was 131, the lowest total since 1948. On the other hand, this year yielded a large number of Salmonella types hitherto unknown in British Columbia, including S. bovismorbificans (the first isolation from human sources in Canada), 5". wichita, S. javiana, S. enteritidis, and S. brandenburg. This Province has the dubious distinction of apparently harbouring the widest range of Salmonella types in Canada, no fewer than thirty-eight types having been identified from human sources during the last decade. A rather surprising feature of this situation is that although many of these types are known to be potentially associated with animal reservoirs, no actual instance of animal-to-man conveyance has locally come to light. Y 98 BRITISH COLUMBIA Another single intsance of a Canadian rarity, S. paratyphi A, was encountered. S. kentucky, which was isolated once in each of the years 1949, 1950, and 1952, was isolated from six persons in 1953. Again, S. heidelberg, which made its first appearance in this Province last year, with seven persons infected, was identified in eleven individuals this year. Our bacteriological and epidemiological records suggest that these two Salmonella types are likely to have joined the ranks of some eight to twelve strains which must be regarded as more or less indigenous to British Columbia. The lower than average incidence of salmonellosis was unhappily overshadowed by extremely widespread and persistent outbreaks of shigellosis due to Shigella sonnei. In last year's Report it was stated that " the reservoir of unidentified carriers of Sh. sonnei may well have been enlarged " as a result of outbreaks of bacillary dysentery at girls' camps in Howe Sound, in the summers of 1950 and 1952. This prophecy has been rather strikingly borne out during 1953 by the total of 638 different persons yielding Sh. sonnei by stool culture. The lowest monthly number of persons infected was fifteen in October, and the highest was 129 in March, a month not generally associated with a heavy incidence of excreta-borne infection. OTHER TYPES OF TESTS Bacteriological Analyses of Foodstuffs, Milk and Milk Products, and Water The Division's responsibility for the bacteriological examination of foodstuffs has been restricted to materials which have either been implicated in outbreaks of suspected bacterial food poisoning or are deemed dangerous to public health because of faulty methods of manufacture, preparation, or storage. Problems of quality and adulteration fall within the purview of the Federal "Food and Drugs Act," and are dealt with by the Food and Drug Laboratory, Department of National Health and Welfare. Suspected food-borne chemical poisoning and kindred toxicological problems are referred to the Provincial Analyst, Department of Mines, or to the City of Vancouver analyst. Sometimes the dividing lines have to be rather arbitrarily drawn, but obviously the Division could not follow a policy of having to determine the edibility of any sample foodstuff, whether submitted by professional or lay persons. A few minor gaps in the services offered in this field seem a preferable alternative, in present circumstances, to a swamping of the Division by irrelevant demands for tests which would be neither conclusive nor scientific. The usual numbers and types of staphylococcal food-poisoning episodes were investigated during the year. No case of botulism was encountered. Bacteriological tests of milk and phosphatase tests for proper pasteurization increased by over 10 per cent. The senior bacteriologist in charge of milk and water testing arranges shipping-days with the Sanitary Inspectors, who collect the samples in the various health units, and the schedule is, on the whole, adhered to co-operatively. A special series of tests was conducted in the last quarter of the year, at the request of Dr. J. L. Gayton, Medical Health Officer for the City of Victoria, on raw-milk samples shipped in bulk from Vancouver to Victoria. Remarkably wide fluctuations in bacterial counts were noted. The Division continued to examine ice-cream and cottage-cheese samples collected from the Greater Vancouver area. Bacterial counts and coli-aerogenes tests on water samples increased slightly in number. Although some of these samples reach us after undue delay, so that results are not very reliable, there seems little doubt that water-supplies of dubious quality are being consumed in many parts of the Province. The Division adhered as firmly as possible to the agreed policy of referring to the local health unit all requests from private parties for examinations of well or spring water. The Sechelt Peninsula area presented some difficulties in this connection, since it is not yet organized under a health unit, while a high proportion of its permanent and temporary residents seem to depend on private sources of water-supply. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 99 Diphtheria Cultural examinations for C. diphtheria; again dropped considerably. However, the Division's findings indicate that the carrier incidence in this Province is too high to justify any complacency, a belief borne out by the occurrence of several cases of diphtheria during the year. Intestinal Parasites Microscopic examinations for intestinal parasites increased by over 20 per cent, and revealed an unusually high incidence and wide range of infestations. By arrangement with the Laboratory of Hygiene, Department of National Health and Welfare, a series of specimens was forwarded to all Provincial Laboratories by Mr. J. B. Poole from the Institute of Parasitology at Macdonald College, Quebec. Our findings were listed, and in due course the control laboratory's version was returned for comparison. The results were satisfactory enough to inspire reasonable confidence, and though the survey was unfortunately timed to coincide with some of the busiest months of the year, it certainly provided a helpful training opportunity. BRANCH LABORATORIES An increase of about 10 per cent in tests done at the Victoria branch laboratory was largely due to heavy demands for cultural and microscopic examinations for M. tuberculosis, stemming from the Victoria clinic of the Division of Tuberculosis Control. Sero- diagnostic tests for syphilis also increased, and would have mounted further had not some requested surveys of naval personnel been diverted to the central laboratories. A sizable expansion is also evident in the milk- and water-testing programme. Certain items of equipment being procured under a National health grant will relieve some bottle-necks. We are glad to acknowledge the cheerful and co-operative manner in which Dr. R. G. D. McNeely, director of pathology at the Royal Jubilee Hospital, and his staff have met the staffing and financial problems involved in the added work. The decline of about 16 per cent apparent in the Nelson branch laboratory is believed only temporary. The reduced number of Kahn tests, for instance, is partly due to a lowered employment rate at the Trail smelter, where new employees are routinely tested. Again, the smaller number of milk samples has resulted from Sanitary Inspector's illness or from poor coverage during vacation periods. When industrial activity in the Kootenay area is restored, the Nelson branch turnover of specimens will undoubtedly expand. The staff comprised an assistant bacteriologist in charge, a laboratory assistant, and a part- time cleaner, whose salaries have been covered by a National health grant. The success of this project has been due mainly to the fine qualities of the successive staff members posted to Nelson from the central laboratories, but owes much also to the generous co-operation of the Kootenay Lake General Hospital authorities in supplying accommodation. The Prince George branch laboratory, housed in the Cariboo Health Unit headquarters, has experienced many difficulties, which seem inseparable from operation on a one-person basis. The assistant bacteriologist has done her best to cope with store- keeping, media-making, cleaning glassware, and typing reports, in addition to actual technical procedures. She has conscientiously tried to overcome certain difficulties by adjusting her own programme of work. Although total tests increased by about 30 per cent, and notwithstanding the considerable benefits which have accrued to the sanitation of the area served, it seems that equally good services could be offered at less cost from the central laboratories, especially since there are now fast bus and aeroplane schedules between Prince George and Vancouver. Close contact was maintained with the branch laboratories by frequent correspondence, and by personal visits whenever opportunity permitted. In an attempt to bridge Y 100 BRITISH COLUMBIA distances and to stimulate our staff members in isolated areas, a laboratory bulletin was launched early in the year. Seven numbers were issued during 1953. At the Health Officers' meeting in April, distribution of the bulletin to all health units was advocated, and this practice has since been adopted. The Director is responsible for final editing. GENERAL COMMENTS The year was marked by greater than usual difficulty in recruiting staff with university training. Competition from local hospitals, university departments, and research organizations, as well as from the National Research Council, Defence Research Board, and the Laboratory of Hygiene, has become intense. Even if the salary ranges offered by our Civil Service Commission were higher than for corresponding positions elsewhere—and in some instances they are lower—this Division's working conditions would remain a serious deterrent. We have therefore been obliged to fill several vacancies for university graduates with matriculants, thus replacing a number of assistant bacteriologists with laboratory assistants. This step will result in a reduction of the average salary prevailing in the Division as a whole and in remarkably low operating costs. Figures compiled by a sub-committee of the Technical Advisory Committee on Public Health Laboratory Procedures showed that this Division's cost of performing 1 unit of communicable-diseases control work is the lowest in Canada. In 1952 our figure was 20.7 cents per unit, compared with 22.6 cents per unit in Quebec, our nearest competitor, where the prevailing salaries for non-professional staff averaged several hundred dollars less. In Ontario the per unit cost was 31.2 cents, or 50 per cent higher than our figure. Much of this disparity is due to our expenditures on supplies and equipment, and more particularly on housing and maintenance, being unduly low in relation to output. Apart from this, however, the work-load per staff member has been considerably higher than in other Provincial laboratories in Canada. For instance, the work-load per person in British Columbia in 1952 was 17,732 units against 10,609 units in Ontario; in other words, on the average each person on our establishment carries a 68-per-cent higher load than his or her counterpart in Ontario. A considerable increase in the size of the staff is obviously warranted, although we would have difficulty in recruiting suitable persons, even if we had room to accommodate them. This dilemma can only be solved when new quarters make a staff reorganization feasible. During August and part of September the Director had an opportunity, under a National health-grant project, to visit public health and research laboratories in the British Isles and certain countries of Western Europe. Some twenty-eight institutions were visited, and discussions held with a large number of laboratory and public health authorities. Data and impressions gathered during the seven weeks' trip confirm the heaviness of the work-load being borne in this Division. In one laboratory in England, for example, with a staff of about one-third our number (the majority being male) only about one-tenth our number of work units was done. It was also apparent that for a given population the number of specimens sent to public health laboratories in Canada, and especially in British Columbia, is very much greater than in the British Isles and Europe. The Director also attended the Sixth International Microbiological Congress, held in Rome early in September, where he served as a member of a committee on anaerobe classification, and presented a paper entitled " Clostridium botulinum type E." Miss D. E. Kerr, Assistant Director, managed the affairs of the Division with her customary competence during the Director's absence. Miss Kerr's efficiency and devotion to duty are well known to all who have occasion to deal with her, but it is none the less a pleasurable obligation to acknowledge these qualities once again. Under less conscientious leadership, the fine spirit animating the Division, which alone has enabled it to circumvent and endure so many handicaps, could not have been maintained. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 101 REPORT OF THE DIVISION OF VENEREAL DISEASE CONTROL A. John Nelson, Director During the year the number of venereal-disease cases reported in the Province was 3,671, which total includes 462 cases of non-specific urethritis, compared with 3,914 in 1952. Infectious syphilis has now become a clinical rarity; there were only twenty cases reported as of December 31st, 1953. Late syphilis and prenatal syphilis, as reported to this Division, have also shown a marked decline. TREATMENT This Division continued, as in the past, to overtreat gonorrhoea patients with massive doses of penicillin, and the results to date have shown that such treatment has been most successful in preventing concomitantly acquired syphilis. This overtreatment schedule, as developed within the Division, has now been accepted by other Provinces as routine therapy. We are pleased to report that this Division has continued to receive excellent co-operation from private physicians and other agencies within the Province in regard to the matter of reporting clinical cases of venereal disease. Prenatal syphilis has shown a notable decrease in the number of new cases reported—three new cases during 1953, as compared with eight new cases in 1952. This trend is indeed encouraging because prenatal syphilis for a number of years did not decrease with the same rapidity as did new cases of acquired syphilis as reported to this Division. Due to the decreasing patient case-load, it was deemed advisable during the course of the past year to avail ourselves of consultative service available from other agencies, and we thereby have been able to terminate two consultant appointments within the professional establishment of the Division. It should be emphasized that the calibre and availability of this consultative service to all physicians within the Province have been maintained at their usual high level. The treatment schedule was again completely revised by members of this Division and made available to all physicians practising in the Province. This new schedule was drawn up with the following intentions: To simplify and standardize treatment and follow-up procedures, and to present this material in a readily available manner. Free drugs were again made available to all private physicians for the treatment of patients with venereal disease. The newer types of antibiotics have also been made available for treatment of those patients who have demonstrated previous penicillin allergic manifestations. This Division has continued to supply all health units with the necessary drugs in order that they can be dispensed locally to the private physicians. Because of the increasing problem that non-specific urethritis presents, it was considered wise to retain the services of a genito-urinary consultant. During the forthcoming year it is hoped that the Division will be able to devise a more satisfactory schedule of diagnostic criteria" and treatment for the management of this troublesome condition. During the past year several new developments have taken place within this Division. A limited clinical assay was performed to determine whether or not the newer long-acting penicillins would be of assistance for the treatment of female repeaters who make up a goodly percentage of our problem. The consultant in epidemiology has advised that females be treated after one naming as a contact, in order that a modified type of speed- zone epidemiology could be instituted within this Division. The results of this change and of several others, although it is too early to report any accurate figures, have shown a very encouraging trend. 189399 Y 102 BRITISH COLUMBIA During the year, clinic and treatment facilities continued to operate at the following centres: Victoria clinic; Vancouver City Gaol; Prince Rupert and Prince George City Gaols; Greater Vancouver Metropolitan Health Committee, Health Unit No. 1; Male and Female Oakalla Prison Farm; Girls' Industrial School; Juvenile Detention Home; and New Westminster clinic. The Vancouver clinic no longer remains open on Saturday morning because of the marked decrease in clinic attendance. Other forms of venereal disease, such as chancroid and lymphogranuloma venoreum, encountered during the year were mainly found among mariners entering the port of Vancouver. There was no evidence of increased spread of these infections among the general population. EPIDEMIOLOGY It has continued to remain our belief that the key to the control of venereal disease lies in the vigorous and enthusiastic application of epidemiological methods. With our goal thus defined, it has been a constant and ever-increasing challenge to uncover new productive avenues of approach which might help us more rapidly to eradicate our reservoir of infection. During this past year special studies have brought to our attention the part played by the female in the transmission of gonorrhoea from the reservoir of infection to the fresh male host. In order to deal with this, we have adopted the policy that all female contacts to gonorrhoea be treated on their first visit to the clinic. The immediate problem of bringing the contact to treatment more rapidly has resulted in a modified programme of speed-zone epidemiology aimed at bringing a high percentage of our female contacts to treatment within twenty-four or seventy-two hours following receipt of information. The Vancouver City Gaol examination centre continued to function as a very important part of the epidemiology programme. The number of newly diagnosed gonorrhoea infections has decreased to an all-time low, and it is felt that this changing index accurately reflects the prevalence of gonorrhoea in Vancouver. Treatment in the centre is offered to all patients on epidemiological grounds or clinical evidence of infection. The clinic at Health Unit No. 1, Metropolitan Health Committee, now operates twice weekly, 11 a.m. to 1 p.m. A public health nurse is in attendance, 2 to 4 p.m. daily, to undertake serological testing for the U.S. Immigration, down-town cafes, and industries. Persons reporting here during the above hours may receive tests for gonorrhoea, and treatment if indicated. This year the Indian Health Services assumed almost full responsibility for the epidemiological follow-up of all Indians. Health units have established policy on a local level whereby the agency which is able to do the most rapid follow-up of the Indian handles the referred case. The epidemiological section continued to have a very satisfactory liaison with the private physicians throughout the Province. The adequacy of contact information obtained by the physician has improved so that we have been able to investigate many more of these contacts. New approaches to the suppression of facilitators and facilitating premises has required continuous study. Where misdemeanours occur, a greater effort has been made to pin-point responsibility on one individual. Three meetings were held during the year—one with other interested departments and agencies, and two meetings with the managers of hotels and rooming-houses which have been community trouble-spots over a period of several years. The American Social Hygiene Association again sent a representative to survey the facilitating processes operating in Vancouver City. These objective reports have proved helpful in giving us specific information regarding certain activities within the city. eeEeii DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 103 Senior members of the Division made a total of six visits to the field staff to discuss epidemiology techniques and assist with problem cases. This has been a year of changing emphasis for the epidemiological section of the Division. It is hoped a wise choice of activities on which to place emphasis will strengthen our programme and eliminate unproductive case-finding and case-holding effort. SOCIAL SERVICE For a three-month period during the year there was no case-worker at the Vancouver clinic, and service on a part-time basis was provided by Social Service staff from the Division of Tuberculosis Control. In spite of this staff difficulty, counselling service was continued for the patients reporting to the Vancouver clinic for treatment, and there were 805 patient-interviews carried out by the Social Service Section during the year. In addition, this Section participated in the educational programme for student- nurses, public health workers, and professional staff in allied fields undertaken by the Division of Venereal Disease Control. In our work with the patient-group, at the termination of each interview the clinic social worker recorded her assessment of the patient and his capacity to utilize this counselling service, and the following criteria were taken as a guide: — Group I. — This person is capable of taking responsibility for himself; he is functioning adequately in his life situation and his infection has been acquired as the result of an episode that is out of character with his behaviour pattern. Group II.—This person has capacity to take responsibility for himself but he needs help in defining this; he also lacks knowledge about the venereal diseases and about sexual behaviour in general. Group III.—This person manifests real conflict in some area of his life, and his promiscuous behaviour is symptomatic of this stress. The pressure may be external because of the life situation in which he finds himself, or it may be within the personality structure of the individual. Group IV.~In all of his personal relationships this individual functions on a casual level, and his sexual behaviour follows the same pattern. His roots are shallow, and he does not want to or is not capable of assuming personal responsibilities. His goal in life is ill-defined, but he is not in conflict about himself or his situation. Group V.—This is the chronic-problem person whose life is disordered and whose promiscuous behaviour is part of that way of living. He exists on the fringe of crime, and authority is his natural enemy. In the twelve-month period under review, out of the total 805 patient-interviews, rating of the patient by the social worker was recorded in 660 cases. Of the remainder, 70 had been rated in a previous interview, 42 required no service other than referral to some other medical resource, 14 were not venereal-disease patients, and 19 were not given a rating. Of the 660 who were rated, 104 were considered to come within Group I. For these patients the counselling interview was an opportunity for the patient to review his behaviour in the light of his goal in life, and thus the total treatment process became sex education with real meaning for the patient as a person. There were 163 patients classified as Group II, and here again the social worker's interview was geared to make the learning process a personal experience which would enhance the patient's capacity to meet future situations in his life. Among the 148 rated in Group III were most of the social ills, including marital conflict, personality disorders, alcoholism, adolescent revolt against parental authority, illegitimate pregnancy. With some, the basic problem was too deep-rooted for any Y 104 BRITISH COLUMBIA effective help to be given in one interview, but most of these people derived some comfort from sharing their problems with the case-worker. The interview was a sorting-out process, and the patient was encouraged to utilize the resources available in the community for meeting his particular kind of need. Some of these patients continued their relationship with the clinic social worker after medical treatment was completed. It is from this group of patients that most of the referrals were made from the Social Service Section to the psychiatric consultant. The 208 patients considered to come within the Group IV classification represented almost one-third of the total number rated. While these people represent a continuing problem in venereal-disease control because of their way of living, they can be helped to assume more responsibility in the epidemiological control of these diseases. For these patients the counselling interview was directed toward emphasizing the importance of the infected person in the control process, since he alone has the vital information about his sex partners that starts the epidemiological investigation. With this positive approach to the patient, the control programme became a combined operation of patient and staff, and this gave the patient some status. For many of them this is a rare and satisfying experience. There were thirty-seven patients considered to fall in Group V. This number was small because most of the chronic-problem patients report to the treatment centre at the city gaol rather than to the Vancouver clinic. There is very little that counselling can do for this group, except to give these people the experience of courtesy and acceptance. Like children, they respond to kindness by co-operating to the maximum of their limited ability. In summary, the twelve months' experience in the use of this rating scale indicates that about two-thirds of the patient-group derive benefit from the counselling service. The other one-third corresponds roughly to the proportion of the patient-group who have repeated venereal infection. EDUCATION The Division of Health Education is primarily responsible for the health-education programme to lay groups, while the Division of Venereal Disease Control has accepted the responsibility for professional and staff education. Lectures were given to student-nurses in all nursing-schools on the methods of control and the facilities available throughout the Province. The regular course of instruction was given to the students from the Vancouver General Hospital who come to the Division for a two-week period during their training. Besides lectures, they receive a thorough grounding in the clinical aspects of venereal-disease control and also take part in the epidemiology programme. Students taking their course in public health nursing at the University also came for a one-week period, to participate in all phases of our work. Lectures were given to the psychiatric nurses at Essondale, practical nurses at the Vocational School, second- and third-year medical students at the University of British Columbia, and to various other groups. Youth groups have requested speakers on several occasions. Fortnightly staff meetings were held at the Division headquarters. Lectures on various aspects of syphilis and gonorrhoea were given, also a very interesting panel discussion, with the consulting specialists giving interpretations from their special fields. These were attended by the consulting staff and members of the Division. An exhibit was again presented at the Kiwanis Annual Fair and Trade Exhibition in North Vancouver. " Corkie, the Killer " was the subject theme. Blood tests were offered to the public and literature distributed. At the annual meeting of the Health League of Canada a small display was put on to show professional groups the continued need of an active programme for venereal- disease control. Pamphlets were obtainable and much interest was shown. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 105 The manuals " Venereal Disease Information for Nurses " and " V.D. Control Program of the Health Branch " were revised and reprinted during the year. These manuals are widely distributed to student-nurses and other interested persons in the Province. A new pamphlet has been obtained which gives an excellent interpretation of the part played by the student-nurse in venereal-disease control during her hospital training. The following is a list of papers given or published by members of the Division in the course of the year:— (1) " Challenging Trends in V.D. Control," by Dr. A. John Nelson and Dr. Ben Kanee, presented before the American Academy of Dermatology and Syphilology in December, 1953. (2) " Police and Health Department Co-operation in V.D. Control," by A. John Nelson, M.D., D.P.H., was accepted for publication in the Journal of Social Hygiene. (3) In the January, 1953, issue of the Vancouver Medical Association bulletin a paper entitled " Prophylaxis of Ophthalmia Neonatorum," by G. R. F. Elliot, M.D.C.M., D.P.H., and A. John Nelson, M.D., D.P.H., was published. (4) " Recent Advances in Venereal Disease Control," by A. John Nelson, M.D., D.P.H., was accepted for publication in the Canadian Nurse. GENERAL National health grants continued to prove most useful in assisting the Division to maintain its ever-expanding services, as well as in affording opportunities for postgraduate training of medical and nursing personnel. Funds from these grants were made available to assist in the development and operation of the Bio-Medical Library, University of British Columbia. In the library, up-to-date literature on venereal diseases is maintained, and the senior consultant to the Division is an active member of the management committee. The Division is most appreciative of the co-operation and help extended by various other groups and agencies with an interest in the promotion of social hygiene and control of venereal disease. Special mention must be made of the Vancouver City Police, the Royal Canadian Mounted Police, the British Columbia Hotels' Association, the Liquor Control Board, the Indian Affairs Branch of the Department of Citizenship and Immigration, the Armed Forces Disciplinary Control Board of the United States 13th Naval District, and the American Social Hygiene Association. In addition, special appreciation is expressed to the Division of Laboratories, without whose ever-willing services and co-operation this Division would find it difficult to function, and also to the Division of Vital Statistics for its helpful advice and assistance so freely given at all times. Y 106 BRITISH COLUMBIA REPORT OF THE DIVISION OF TUBERCULOSIS CONTROL Dr. G. F. Kincade, Director In the following report an attempt will be made to analyse trends in the basic elements of tuberculosis-control and to emphasize those important changes which influence planning and indicate the lines of future development. There can be no doubt that with the important changes in treatment and case-finding that have occurred in recent years, the problem of tuberculosis-control has changed dramatically. We have now reached a critical stage in our development and must carefully analyse our position in an attempt to forecast the future. Experience in recent years, since the advent of antimicrobials and recent developments in chest surgery, has shown that tuberculosis can now be cured. Hence our whole concept in the approach to treatment has changed in that we now attempt to achieve a cure, whereas formerly we had to be satisfied to bring the disease under control with stabilization of the lesion, and through careful control of the patient to hope that the disease would remain arrested. Our present objective is the eradication of the lesion from the body. This has had many and varied effects on the programme of hospitalization, although the future bed utilization and needs are not too clearly indicated as the result of our changing treatment practices. Even though our practices have undoubtedly changed in the treatment of various types and stages of disease, the average length of treatment of the cases admitted to institutions over the past ten years has not varied greatly. The largest group of patients, according to length of stay, is the one treated four to eight months, representing 202 patients out of 890 discharges in 1952. Another 129 cases were treated one to four months, and 156 cases treated less than one month. All told, 666 cases, or 75 per cent of the total, were treated under one year. Actually it is surprising that the average length of treatment has not increased considerably. The death rates will show that many people with advanced disease are no longer dying of tuberculosis. These people are recovering through antimicrobials, but usually after prolonged hospitalization. Surgery has also increased markedly, in line with the present conception of removing dangerous foci which might later reactivate. This policy applies not only to the new cases who have an incomplete result from medical treatment and are left with a dangerous focus, which must be removed, but also to many other cases, of which there is a considerable backlog, who had their treatment in the pre-streptomycin era and pre-resection era and are now being readmitted for resectional surgery. These major chest surgical cases necessitate long periods of institutionalization. In view of the obvious increase in hospitalization of the above two groups, it must be indicated that medical cures through antibiotics in the less advanced cases must have been achieved in shorter periods of time. Moreover, those cases in which the definitive treatment is obviously surgical are more quickly brought into condition to undertake this surgery. One would therefore expect with fewer far-advanced cases being discovered and the backlog of surgical cases being gradually overcome that the periods of hospitalization should soon see a definite reduction. In this connection it is interesting to note that in 1952, 41.7 per cent of the first admissions to institutions were minimal, 33.2 per cent moderately advanced, and only 16.1 per cent were far advanced. Over the past ten years this has shown an encouraging trend, with the far-advanced first-admission cases reduced by almost 50 per cent while the minimals have increased by 50 per cent. BED SITUATION During recent months an unusual situation has been experienced in the Division of Tuberculosis Control in that there have been empty beds, and all cases, except for elective DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 107 surgical cases, could be admitted immediately. At the present time there are twenty-one empty beds and twenty-eight patients on the waiting-list. The waiting-list is composed of surgical cases or of those who will not go to institutions where beds are available. This enviable situation has been achieved mostly by the addition of new beds in the past year. At the present time there are approximately 925 beds within the units of the Division, as compared with 772 before the opening of Pearson Hospital. The number of applications for the first ten months of this year was 799, as compared with 804 in the first ten months of 1952, which would indicate that the reduction of the waiting-list is due to increased facilities and not to any reduction of persons needing treatment. Due to the nursing shortage there are forty beds in that complement at Tranquille which are not occupied. However, in view of the fact that there are fifteen empty beds at Tranquille in the limited complement now in use, the advisability of endeavouring to operate these extra forty beds under existing conditions is questionable. Notwithstanding the present favourable position, other factors which could affect the bed situation must be taken into account. It is well known that there are numerous cases needing treatment who refuse hospitalization. If these were forced into institutions, with effective legislation, a great many more beds would be needed. Similarly, if Provincial responsibility for chronic care is extended to non-pulmonary tuberculosis, present facilities could not meet these needs. A census of sanatorium patients taken on September 30th of this year indicates an increasing trend of occupancy of beds by male patients over 50 years of age. Out of a total occupancy of 843 beds, 562 were males, of whom 271 or 48.2 per cent were over 50 years of age. Out of 281 female patients, only 25 or 8.9 per cent were over 50 years of age. In all, 296 or 35.1 per cent of total beds were occupied by persons over 50 years of age. This has increased from 28.3 per cent a year ago. The ratio of male to female bed patients is at present exactly two to one, and in view of the fact that the distribution of males and females in the total population is almost equal, these figures would indicate that tuberculosis in the male is a much greater problem than tuberculosis in the female. Also the male over 50 years of age is one of our greatest institutional-care problems, and this appears to be definitely increasing rather than decreasing. MORTALITY The trends in mortality from tuberculosis are very well known and most striking. In 1946 there was a death rate in British Columbia of 57.4, with 576 deaths per annum. This year is chosen because it was about the beginning of the streptomycin era. The rate has declined steadily each year, until the present rate is less than one-quarter of that in 1946. In spite of an increasing population, only 214 deaths were recorded in 1952, giving a rate of 17.9. The preliminary figures for 1953 show 140 deaths, giving a rate of 11.4. Undoubtedly, most will agree that this dramatic decline in deaths has come about chiefly as a result of the antimicrobials. In the other-than-Indian group the proportion of deaths in age-groups 50 and over is very striking. The preliminary figures for 1953 indicate that only six deaths occurred in persons under 20 years of age, mainly in the 1-4 age-group. Eighty-three out of 123 deaths occurred in persons 50 and over, representing 67 per cent of all deaths from tuberculosis. The ratio of deaths in males to females in this group was five to one. MORBIDITY The reduction in morbidity from tuberculosis admittedly has not been so marked as in mortality, but, in spite of what is written elsewhere to trie contrary, there has been a striking decline in the number of new cases of tuberculosis discovered in recent years. This is of even greater significance in view of the increased tempo of our case-finding activities. Y 108 BRITISH COLUMBIA In 1943, at the beginning of community survey work, approximately 46,000 examinations were done, with 1,688 new cases being discovered. As this programme gained momentum, in 1947 approximately 180,000 examinations were done, and the peak in morbidity was reached with 2,616 new cases being reported. Since then case-finding efforts have been further expanded to include admission X-ray surveys and continuing community surveys, with 282,000 chest X-rays being taken in 1952. In spite of this there was a marked decline in new cases found to 1,383 for the year. In other words, while the case-finding effort increased over 50 per cent, the morbidity rate was reduced almost by the same degree. It is not suggested that present morbidity rates should give rise to complacency, nor should there be a reduction in efforts to seek out the undiagnosed case of tuberculosis, but it is felt that those engaged in the work should realize the true state of affairs and take satisfaction in the results achieved so far. An analysis of morbidity rates in the various age-groups over the past ten years proves interesting and shows that in all age-groups up to 14 years of age very little change has taken place. However, this group has had a low morbidity rate, now ranging from 25.5 to 34.0 per 100,000. In the age-groups above 20 years this rate ranged between 197.4 and 387.4 in the peak years of 1946 and 1947. In all groups over 15 years of age there has been a very decided decrease in the morbidity rates, now ranging between 100 and 150 per 100,000. Up to 39 years of age the female morbidity rate is slightly higher than the male, but over 50 years of age the male morbidity rate is twice as high as the female morbidity rate. Tuberculosis is truly becoming a disease of the male patient over 50 years of age. During 1953, 1,494 notifications of tuberculosis were received. MINIATURE X-RAY PROGRAMME For some time now every effort has been made toward getting a higher percentage of patients X-rayed on admission to hospital. During the year 1952 a marked improvement was obtained, and these percentages were raised from 35 per cent in the first quarter to approximately 50 per cent in the last quarter. On a yearly basis this represented 56,457 admission X-rays taken, which was approximately 40 per cent of all admissions in those hospitals where photoroentgen units were available. In the first quarter of 1953, 17,560 admission X-rays were taken, which represented a 50.10-per-cent average for hospitals having miniature X-ray equipment. However, in the second quarter of this year this fell very definitely, when out of 42,617 admissions only 17,314 persons were X-rayed, making a percentage of 40.6. This improved during the third quarter, and for the first nine months of 1953 the average was 47.78. During the year 1953, 68,198 miniature X-rays were taken in admission surveys. Although the total number is approximately 22,000 greater in 1953 than in the previous year, it does not represent a good effort in the over-all picture, although some hospitals are doing very well. Out of thirty-four hospitals operating miniature equipment at the present time, only nine or 26.4 per cent are averaging over 70 per cent of their admissions X-rayed, with only one over 90 per cent. Eleven other hospitals or 35.4 per cent are operating between 40 and 70 per cent, while ten hospitals or 29.4 per cent operate between 10 and 30 per cent. Four hospitals or 11.8 per cent operate below 10 per cent. It would therefore appear that twenty-five out of the thirty-four hospitals are not doing a satisfactory job, and obviously in a few hospitals only lip service is being given to the principles underlying this programme. However, in fairness to the hospitals it should be pointed out that through counting the over-all admissions to the hospitals, they were put in an unfavourable light because some of the buildings could not be serviced and in other instances some account should have been taken of those admissions that were covered by large X-rays. For this reason, the system of collecting figures has been changed, and it will now be done directly from the Division of Tuberculosis Control central office to the hospital concerned. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 109 We feel that this will show a truer picture and put the hospitals in a more favourable position. However, even when these corrections are made, it is obvious that constant supervision of the programme will be necessary to stimulate hospitals to achieve satisfactory results. It is pleasing that it was possible to extend the admission X-ray programme to the smaller hospitals at the beginning of this year, paying the hospital a per capita rate for X-rays taken on their own equipment. During the third quarter of this year 39.90 per cent of admissions to these hospitals had chest X-rays. During the twelve-month period 9,642 admission films were taken as part of this programme. When we consider that this is only in the organizing stage, the results look very encouraging. The over-all X-ray admission rate, including miniature and large plates, was 58.72 per cent for the first nine months, with 80,759 X-ray films being taken during the year. That a chest X-ray is now available to any person admitted to hospital in British Columbia is indeed a very satisfactory state of affairs, and has rounded out our case- finding programme in this Province. In assessing the value of the hospital installations throughout the Province, the principle of continuing community X-ray surveys, which has also been instituted through the use of these machines, must also be kept in mind. During the year 31,785 out-patients had chest X-rays taken on this equipment, which would indicate that this utilization was somewhat greater than in previous years. In some hospitals the number of out-patients X-rayed is greater than the number of in-patients. Thus, aside from their importance in the admission X-ray programme, these installations play an important role in the total case-finding programme. With the large amount of X-ray equipment committed to the case-finding programme, together with the large expense involved in conducting such a programme, it must be constantly considered how long this can be justified by case-finding results. It has long been recognized that this would be a case of diminishing returns, with fewer cases discovered as surveys were repeated throughout the Province. In 1944, when 40,441 patients were examined, 371 cases of pulmonary tuberculosis were diagnosed, making a case-finding rate of 9.2 per 1,000. This was only slightly lower in 1945, while in 1947, with 162,912 examinations, 699 cases of pulmonary tuberculosis were discovered, giving a rate of 4.2 per 1,000. In 1952, with 229,317 examinations, 802 cases of pulmonary tuberculosis were discovered, giving a rate of 3.5 per 1,000. It would therefore appear that after a drastic reduction in the first two years the case- finding rate since then has not fallen too markedly. In the matter of active pulmonary tuberculosis, the 93 cases discovered in 1944 represented a rate of 2.5 per 1,000, which fell to 0.55 per 1,000 in 1945, and in 1952, 155 active cases of tuberculosis represented a rate of 0.68 per 1,000. Again, this rate has not changed greatly over the past five years, and it would therefore seem that this is still an effective case-finding method. For some time now the examination of high-school students through X-rays on a mass X-ray survey basis has been discouraged. However, on occasions these surveys have been done. In 1952, 10,000 high-school students in Greater Vancouver were examined in this manner. An analysis of findings shows that only one case of tuberculosis was discovered. This definitely confirms the previous conviction that, as a case- finding method, results in this group are not fruitful, and it would indicate that the equipment can be used to better advantage in other age-groups. NATIONAL HEALTH GRANTS The total grant for tuberculosis-control for the present fiscal year is somewhat lower than previously. In 1952-53 it was $370,329. The original grant for 1953-54 was $367,585, and this has been reduced by $20,000 which was taken into another grant. Y 110 BRITISH COLUMBIA Of the $347,585 left, $338,431 has already been allocated for projects, most of which have been approved. Only $12,000 of this total has not yet been approved. For the first time since the grants were established, the Division was in a position to overexpend the amount allocated. In fact, to meet those projects at present proposed, it was necessary to delete projects already approved where it was obvious that the equipment could not be obtained nor the services utilized to the total extent of the money provided. It will be recalled that in the past the total amount of money available in the Tuberculosis Control Grant was not utilized, mostly as a result of non-delivery of equipment. The percentage utilization in previous years was as follows: 1948-49, 77 per cent; 1949-50, 77 per cent; 1950-51, 90 per cent; 1951-52, 76 per cent; 1952-53, 65 per cent. At the present time it looks as though the grant for this fiscal year will come much nearer total utilization. This, of course, depends on accounts being submitted in time and equipment now on order being delivered before the end of the fiscal year. However, there is not a great deal of equipment outstanding, and practically all the orders should be filled in time. A breakdown of the expenditures for tuberculosis under National health grants will show that $91,008, about 25 per cent of the total, is allocated to staff and equipment in the various units of the Division, which does not include a further $27,900 for a rehabilitation programme. This latter makes provision for extra rehabilitation services and the tripling of the existing staff. It is hoped that these new positions will be filled in the near future so that the rehabilitation programme may be properly developed in all of the institutions. At the present time there are twenty-four positions within the Division of Tuberculosis Control in which the salaries are provided through National health grants. Through these grants a considerable amount of money is spent on the case-finding programme. This represents over one-third of the total grant. The X-ray pool, which provides new photoroentgen units and replacements for the existing machines, is in the amount of $20,750. In this amount is provided new equipment for the Kimberley Hospital and the Salmon Arm General Hospital. For assistance in community survey work, $35,000 is allocated, while the payment for both miniature and large admission X-rays is in the amount of $75,000. Another large item in National health-grant expenditures is that for the antimicrobials, where $70,500 is allocated. Ten thousand five hundred dollars is spent for postgraduate training of doctors and nurses, while $8,500 of the National health-grant money is used in the educational programme for professional student-nurses and practical-nurse students. From these figures it will be seen that most of the money in this grant is committed to continuing projects. This amounts to over two-thirds of the total grant and leaves only about $100,000 a year for new projects and the purchasing of equipment. GENERAL No major changes have taken place in the planning and operation of the Division during the past year. Remodelling at Tranquille Sanatorium has continued and is nearing completion. The new laundry has been in operation since early in the year, and the conversion of the power plant from coal to oil, which took place last year, is now completed with the installation of storage-tanks and pumps. Conversion of the ground floor of the Infirmary Building to provide a library, central supply-room, pharmacy, dental offices, and X-ray department is just about finished. The last ward at Pearson Hospital was opened early in the year, and the institution has been running to capacity since then. The usual problems of setting up an institution have been encountered, but the hospital is operating very satisfactorily. The development of the grounds is well under way, with the planting of lawns and improvement of the lighting. DEPARTMENT OF HEALTH AND WELFARE, 1953 Y 111 Renovations in the Vancouver Island Chest Centre are about completed, to provide a separate X-ray survey clinic in this unit. The New Westminster Stationary Clinic is being provided with new and enlarged quarters in the Gyro Health Centre. This was made possible by the addition of a new wing to the building, financed in part by the British Columbia Tuberculosis Society. The tuberculosis-control programme in the Province involves many agencies whose close co-operation and sympathetic understanding are essential to successful operation. The harmonious relations and willing assistance from all departments of the Government—local, Provincial, and Federal—is sincerely appreciated. To the many voluntary agencies who assist in the programme, the Division is deeply indebted for the success of the work. The Vancouver Preventorium Board continues to provide facilities for the treatment of children with tuberculosis and is planning for an extension of their present facilities to accommodate a larger number of patients. As it has for almost fifty years, the British Columbia Tuberculosis Society continues to play a major role in the fight against tuberculosis. Always alert to the unmet needs in the fields of prevention, case-finding, and treatment, this group lends a great support to the public agencies. VICTORIA, B.C. Printed by Don McDmrmid, Printer to the Queen's Most Excellent Majesty 1954 635-154-7140
BC Sessional Papers
Eighth Report of the DEPARTMENT OF HEALTH AND WELFARE (HEALTH BRANCH) (Fifty-seventh Annual Report of… British Columbia. Legislative Assembly [1954]
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