§ 3.3 p.m.
§ LORD COHEN OF BIRKENHEAD rose to call attention to the Report of the Joint Committee on Health Education; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. In doing so, may I first remind your Lordships what was said by a very distinguished Member of this House and the Prime Minister of his country almost exactly a century ago: the health of the people is the surest foundation upon which the happiness and prosperity of the State depends. By "health" I do not mean simply the absence of disease; I mean a state of complete physical, mental and social wellbeing. To-day, however, it is not the promotion of health that captures the public imagination, but rather the dramatic triumphs of curative medicine. One has simply to bring in witness the newspapers during the past fortnight relating to the transplantation of a human heart. I yield to no one in my admiration for that stupendous achievement, but I would remind your Lordships that in the field of preventive medicine and the promotion of health there are triumphs even more important and more significant for the health of mankind, and its potentialities are even greater.1447
§ Let me remind your Lordships of two instances in which, during the lifetime of the youngest Member of your Lordships' House, the course of disease has been completely changed. In the decade 1933 to 1942 there were annually in this country over 55,000 notifications of diphtheria and 2,800 deaths. In 1942, the then Chief Medical Officer of Health, Sir Wilson Jameson, started a campaign for immunisation against diphtheria. Almost immediately there was a fall in the incidence of the disease, and in 1966 there were twenty notifications and five deaths—four of them in non-immunised children and the fifth is a man aged forty who was almost certainly not immunised. Take poliomyelitis. In 1957, when the Committee which I chaired recommended polio vaccination, there were 5,000 notifications of poliomyelitis in this country, of which some 3,200 were paralytic cases, and there were over 220 acute deaths. Last year there were 19 cases of paralytic poliomyelitis in this country with only one acute death.
My Lords, these are remarkable instances in which health education, in a way in which I shall illustrate a little later, has played a very significant part. I spoke of the potentialities of health education, and I cannot do better than to quote in witness what the Chief Medical Officer of the Ministry of Health wrote in his 1966 Report:
The number of deaths from cancer, bronchitis and heart disease which can be fairly attributed to smoking must have exceeded 50,000 in England and Wales (i.e., 10 per cent. of all deaths). The years of invalidism and ill-health must be added to the years of life lost.
Many critics of our health services to-day have urged that we should change the name of the National Health Service to National Hospital Service, because the Service is dominantly concerned with the cure of disease. I believe this criticism to be unfair, because I have known all the Ministers who have been concerned with the National Health Service since its inception in 1948, and none of them has lost sight of the importance of prevention of disease and the promotion of health.
§ It was in December, 1959, on the initiative of the then Minister of Health, that a Joint Committee of the Central Health Services Council and its Scottish counterpart was set up to inquire into 1448 health education. I had the honour of being chairman of that Committee. Its terms of reference were relatively simple, and I will refer to them quite briefly. They were: first, whether in the light of recent developments in medicine there are fresh fields in which health education might be expected to benefit the public; secondly, how far the result of past efforts in the health education field can be assessed; and, thirdly, what methods are likely to be most effective in the future.
§ My Lords, the Committee began its work in 1960. It took evidence from 89 bodies or individuals, written or oral or both, in England, and it took evidence in Scotland. One of its secretaries visited the United States and many of us were of course familiar with the efforts which are being made in the United States. We studied thousands of pages of published works, and we reported over the whole field on what had been done; by whom it was being done; on the results so far achieved by health education; the need for further studies; research on the techniques of health education; health education in schools and the future organisation which is necessary for health education.
This Report was in the hands of the Minister, having been approved by both Health Service Councils, in December 1963, and it was published in May, 1964. Clearly, consultations were going on for some period. The Times became a little impatient on December 10, 1965—that was over eighteen months after the publication of the Report—and in an article on the duty of preserving health it commented on the delay, saying that no action had been taken on the Report and Parliament had expressed no interest in it. The article continued:
The Cohen Committee, it should be noted, before their Report slides entirely into obscurity, made 43 recommendations on health education.
After these had been discussed, the article concluded, "A lot remains to be done."
§ Two months later the Government had announced their acceptance of the main conclusions of the Report, namely, that increased effort was needed in health education and that the first priority was a new and stronger central organisation; and the Government proposed, 1449 therefore, to establish a Health Education Council for England and Wales and Northern Ireland on the lines which the Committee had suggested and with functions broadly those proposed by the Committee. After that, consultations were evidently further prolonged, for it was not until eighteen months or so later—indeed, last August—that the name of the Chairman was announced. It gave many of us both pleasure and some confidence in the future of the Health Education Council that the Chairman was to be the noble Baroness, Lady Serota—a happy augury for the success of the new Council. But we still await its membership, its constitution, its terms of reference, the financing of the Council and so forth.
§ In these opening remarks, my Lords, I can refer only generally to the Report and what it conveys. May I say how delighted I am to see that so many Members of your Lordships' House are to take part in this debate, which I think is of prime importance?
§ The aims of health education have been defined many times, perhaps most simply by the World Health Organisation Committee who, in 1954, said that these are, first, to make health a valued community asset; secondly, to equip people with the knowledge necessary to promote health and to understand their health problems; and thirdly, to press for all necessary health services. The Ministry of Health and the Scottish Home and Health Department have of course acted in this direction for many years. They have a central organisation which is part of the Ministry. They spend somewhere in the neighbourhood—certainly this was so in 1963—of £125,000 a year on central planning and the provision of material for health education. The Central Council for Health Education, which was established in 1927, and its Scottish counterpart have also done valuable work in this field. They publish an excellent health education journal and have provided posters and other material for health education for local authorities. They promote lectures and conferences and so forth. Among other organisations, the B.M.A. published the Family Doctor, a very valuable contribution to health generally; the Royal Society of Health has its Health Education Group; the Royal College of General Practitioners has its Working Party on Health. There is an 1450 Institute of Health Education, and many of the special organisations which deal with mental health, epilepsy, diabetes, multiple sclerosis, and so forth, take some part in the promotion of health in their own special field. But, alas! all of them are far too small. There is no co-ordination of the work which they do. They lack the organisation and the finance to undertake the studies which are necessary in this field, and particularly research into the techniques and the assessment of health education. May I say, my Lords, that the money which is spent by the Health Departments does not, of course, include the work done by doctors, nurses, health visitors, midwives, pharmacists, dentists and many others who, as part of their professional duties, are in fact undertaking health education.
§ Perhaps your Lordships will permit me, quire briefly, to illustrate some of the fields in which health education plays a responsible and profitable role. Some of the most striking results have been obtained in maternity cases and child welfare. Here about 80 per cent. of the total amount spent on health education is expended, not without extremely valuable results. I need but remind your Lordships that the infant mortality rate in this country has halved during the past twenty years. It is now 19 per 1,000 as compared with 38 per 1,000 twenty years ago, and 138 per 1,000 at the beginning of this century. I am not suggesting that health education alone has brought about this result. Better housing, better nutrition, better ventilation, better facilities for clean water, sanitation and toilets, and so forth—all these have made a contribution. But certainly health education has played a very important part. I think of the days only thirty years ago when one saw running about the streets of this country children who were obviously deformed by rickets, suffering from bovine tuberculosis and from scurvy. To-day these things have virtually disappeared, owing to the better nutrition and the cleaner food which is provided for children.
§ Of course, it is in the schools that the foundations of health education should be laid; and, alas! we did not have the co-operation (I am not saying that we were denied it; it was not within the constitution of our Committee) of the 1451 Department of Education and Science. But it is the schools, I would emphasise—and it must be emphasised—where standards of cleanliness and hygiene should be taught and demonstrated, although it is true that it is fairly difficult to do so in some of the old schools at present in existence. Also—and I think this is of great importance—you may remember that Bernard Shaw said of the motto, "Mens sana in corpore sano" that it is not "A sound mind in a sound body", but "A healthy body which is the outcome of a healthy mind".
§ It is in schools that that healthy mind has to be taught. I feel strongly that we need to have some form of training in schools, so that the child has some knowledge of the structure and functions of his body. The form of training will depend on age and will increase in detail with age. In later forms and standards it may lead to biology courses and sex education, and we can continue with that type of health education in youth clubs, when marriage and parenthood can be investigated and discussed.
§ I think that one of the most valuable fields of education in schools is dental health education. I am a strong advocate of adjusting fluoride levels in water, but I have already stressed in an earlier debate the value to dental health and the prevention of caries of looking to tooth brushing and limiting the eating of sweets. I would remind your Lordships that the number of tooth brushes manufactured and sold in this country amounts to one per person per annum.
§ May I say a word about the control of infections? It is true that the major plagues and pestilences of earlier centuries—cholera, typhoid and typhus—have now been controlled by proper food hygiene, clean water supplies and the like. These did not require any contribution from the beneficiaries, but other infections do. Health education plays a major part in ensuring a maximum response to immunisation. It may be that in a short time there will be another major campaign. In the autumn of 1968 we are expecting the biennial epidemic of measles, which will affect perhaps a half to three-quarters of a million of the children of this country. We now have a vaccine which is effective and to which the reac- 1452 tions are minimal, and by means of which we hope to control the epidemic. But we have to start fairly soon. We have to use the methods of health education to persuade parents that their children should be vaccinated against measles as against other diseases.
§ Then there is mass radiology, which enables us to find sources of tuberculosis in the community. There is screening, such as exfoliative cytology. There are other cancer campaigns now going on. All these demand a contribution by their beneficiaries. We know many of the principles which govern a successful campaign for mass radiology, for example, but we know very little of the principles which govern a successful campaign in cancer education.
§ The most difficult tasks which confront health education are those which apply to adults in middle age, when the aim of health education is to modify deleterious habits—cigarette smoking, overindulgence in alcohol, over-eating, lack of exercise and the like. Women are by no means immune, because their footwear and clothing sometimes demand that they should be the subject of health education. Perhaps I can illustrate the need best by giving one statistic. Since the beginning of this century the expectation of life in men has increased by about 23 years and in women by rather more. But once you reach the age of 55 your expectation of life has increased since the beginning of the century by not more than a year or two. That is because of habits which we have indulged in during our younger days. There is always a reluctance to sacrifice present pleasures for future health. Many men know less about and pay less attention to the maintenance of their health than they do to the maintenance of their motor cars. It is often said that health education is a result of a few "do-goodies" and kill-joys getting together. Let me assure your Lordships that this is not so. Health education is intended to lead to a fuller enjoyment of life, and those who are prepared to listen and to act do have a fuller enjoyment of life.
§ If your Lordships have any doubt about whether health education has an effect in this field, I would give two interesting facts from America. First, insurance companies in America contribute to health education. The Metropolitan 1453 Life Insurance Company, for instance, has a budget of over £1 million a year for health education in order that life may be prolonged, and, secondly, many industrial concerns in America furnish time during a man's working hours to try to ensure that he is better educated in the health field so that there is less time lost from work through ill-health and that work-related injuries will diminish.
Much is going on now in the field of health education in preparation for retirement and old age. I trust that the noble Lord, Lord Amulree, may refer to that. I have referred to only a few of the ways by which through health education man can benefit himself, but in my view not the least important role is that it should produce an informed and educated public in the field of health. If this is so, then I believe that the public will press for the provision of more community health measures—playing fieds, clean air, and the like. Secondly, the public will be able to detect the fallacies of counter-health propaganda and the invitations to self-medication by misleading and often meretricious advertisements. Last year, the Chief Medical Officer wrote this in his Report:
For commercial advantage, cigarette smoking is constantly presented to the young as a glamorous, rewarding activity rather than the costly, dirty, damaging habit it is.
§ Thirdly, the public will then be informed of the available health services and how they can best use them. The amount of ignorance in this field has only to be known to be worried about. Finally, perhaps the public will be better able to understand the unfortunate lot of some citizens who, through misrepresentation, are wrongly regarded as having an illness—such as mental disease—which represents a stigma. Epileptics, for example, suffer from the fact that employers will not employ them because they believe that all epileptics are dangerous, whereas we know that there is a vast spectrum of epileptics, 80 per cent. of whom can be educated in normal schools and can undertake normal employment. But in all the things to which I have drawn attention one point must be stressed. It is that it is not enough simply to inform the public about health: they must be persuaded about health. Your Lordships will recall that Ruskin observed that education is not merely that one 1454 knows more, but that one behaves differently.
§ May I now, briefly, return to the Report? It discusses in detail who shall be health educators and the role of doctors—not simply medical officers of health, who have had this responsibility for many years, but all doctors, and especially general practitioners, who come into contact with their patients and have the opportunity of heart-to-heart talks about health education—dentists, pharmacists, nurses, health visitors and midwives; also school teachers, clergy and others who undertake health education.
§ But the Report stresses the essential role of a young and new profession namely, the profession of the health education officer, who is well-known in the United States, and whose work, I am delighted to say, is gaining wider acceptance in this country, despite initial opposition. Only this morning I had a letter from the Chief Education Officer at Southampton telling me that Southampton had appointed a health education officer. The Committee had no doubt that there should be a gradual recruitment of health education officers by local authorities, and that they should be backed by the appropriate staff, serving under the medical officer of health. The Report also deals with the training of health educators. I need not enter into detail about that or the background from which they come. It is varied: sometimes doctors, sometimes health visitors, sometimes school teachers, sometimes sociologists and so on.
§ The Report also discussed the various methods and techniques, and the materials available for health education, their relative cost and how effective they are. Alas! the results in many cases are not in the least encouraging. The Minister reported in his Annual Report, The Health of the Nation that in the Autumn of 1966 a national poster 16-sheet campaign ran for three months pointing out the hazards of cigarette smoking. Earlier campaigns had appeared to have had an effect, because the proportion of nonsmokers in the community had between 1961 and 1965 risen in men from 28 per cent. to 34 per cent., and in women from 56 per cent. to 58 per cent.—not, I think statistically significant. Yet, despite this recent campaign, three 1455 months' national campaign, the number of non-smokers did not rise but fell in 1966 to 32 per cent., for men, and 55 per cent., for women—that is, below the 1961 figure. In the 16 to 19 age group the results are even more disappointing.
§ Clearly, there is a great deal to be learned about the efficacy of posters and other form of health education advertising. Perhaps I should add that the one group that has responded to health education in the field of smoking is the doctor, because he knows and sees the effects. Although I cannot give the exact figure now, the number of doctors who smoke is certainly 50 per cent. less than it was before 1960.
§ Now I turn to the Committee's major recommendation, which has, I am delighted to say, been accepted by the Health Minister. I refer to the creation of a Health Education Council. I might add that it arose out of the Committee's conviction that there is a need for stronger organisation at the centre, adequately financed, and one which would put fresh zest, energy and initiative into health education. This Health Education Council, we felt, should be autonomous; that is to say, not a department, not a division of the Ministry of Health. If it were, the staff might well be called upon in times of stress to divert their energies to other activities within the Ministry of Health; and certainly a Council which is autonomous has greater freedom to experiment.
§ We felt that the Council should embrace all the health education functions of the Health Department. With one exception we also felt that the Health Education Council must be a new body, and not grafted on to any existing bodies dealing with health education. These were too small; the membership was not geared to the functions which the new Council should undertake, and they would be less competent to demand the support of, and to integrate, all the interests concerned with health education both within and without the health services. And this is the proposed territory of the new Council's remit. A Council of that type, it was felt, would attract support not only from Government, but also from local authorities and, when they realised the benefits it might convey, 1456 from voluntary organisations and business—insurance, industry and the like.
§ My Lords, may I say just a word about finance? For reasons which are fully detailed in the Report (I have no time to enter into them now) it was suggested initially that in addition to the sum now spent by the Department of Health Education we should spend another £500,000 a year on the Health Education Council. But over 90 per cent. of this would be for research, for field investigation, and for health education officers.
§ The functions of the Council would be these. First, it would be for the Council to determine priorities for a national programme. It would be impossible to carry out all the necessary programmes at the same time. Some body must determine what in relation to current needs is the priority. That would be the first function of the Council. Its second function, having decided on this, would be to plan and make arrangements for carrying out the programmes; and this would include seeking to create a favourable climate of opinion for their reception. This involves not only medicals and para-medicals, but also publicity experts.
§ Thirdly, the Health Education Council would give advice about campaigns to be conducted locally by health authorities. These campaigns would be mainly for those areas in which there are black spots, where immunisation is low, where venereal disease, illegitimacy, juvenile delinquency, and so forth, are high. The Council should be the repository of the best available knowledge, the most modern material for health education, and it could assist local authorities by seconding some of its own health education officers to help them as consultants. The Council must be concerned with the training of health educators in association with other institutions.
§ Fifthly, and of the greatest importance, it must be responsible for the conduct of research in health education and its evaluation. In this field, the field of health education, there are, as the late President Kennedy observed, vast stretches of the unknown, the unanswered and the unfinished, and indeed there are many simple questions to which we have not yet the answer. What does exhortation do? What does fear do? We know that 1457 in Birmingham when the international footballer Jeff Hall died the polio immunisation went up by leaps and bounds. Again, we do not know the relative costs of our methods of health education. Is it better to print 100,000 posters or to have one two-minute spell on television? We do not know. As I mentioned earlier, it is to the research element that at least 45 per cent. of the finances of the Health Education Council should, in our view, be devoted. A large part of the residue would be devoted to the training of health education officers, and the remainder would be for administration and other staff.
§ I trust that worthwhile projects, which are certain to be long-term in the field of health education, will not be jeopardised because financial support is interrupted. Some may, of course, regard half-a-million pounds as a large sum of money, particularly at the present moment, but it is only 1/2,800ths of the amount of money now being spent on the National Health Service, which has reached the figure of £1,400 million per annum. And, as John Webster reminded us over three centuries ago, gold that brings health can never be ill spent.
§ May I conclude by giving, very briefly, my personal views about the membership and constitution of the Council? I am sure that the Council should be small, like the Research Councils. I hope the Minister will resist every effort to make the Council representative of existing institutions and health authorities. What must be done is to choose members for their individual suitability for the tasks of health education, because of their experience in health education and in related fields. Of course, it will not include all the expertise which is necessary, but it will have the power to form small committees, working parties, and so forth, to deal with specific problems—research projects, dental health education and the like. I trust that the noble Lord, Lord Shackleton, who I observe is to reply to this debate, will be able to tell the House what is in the Minister's mind on size, membership and terms of reference of the Health Education Council, and assure the House that the Council will be launched without further delay and that the Government are prepared to give it that support which is vital to its success.1458
I conclude, my Lords, by congratulating the noble Baroness, Lady Serota, on her appointment to the chair of the Council, warning her, from my own experience, that the Council will be confronted by many initial difficulties. But every difficulty yields to the enterprising. And if at times she is minded to despair of man's indifference to his own health, let her recall the rousing cry of Emerson, slightly paraphrased to meet a current situation:
Give me health and a day, and I will make the pomp of Presidents ridiculous".
My Lords, I beg to move for Papers.