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heavy new load of responsibility which properlybelongs to the management committees, whosemembers have been hand-picked for their sense of

public duty and knowledge of local affairs.A proper spirit of economy throughout the health

service must be based on mutual trust. There is noreason why a sense of trust and of service to thecommunity should not be infused down the line fromthe Minister to the ward-orderly, by personal contactand transference of a sense of individual responsibilityfrom the centre towards the periphery. The Ministry’saction, by checking this trend, will cause damage atall levels.

1. Public Health Lectures. By K. EVANG, J. E. GORDON, andR. G. TYLER. Boston, Mass. Unitarian Service CommitteeInc. 1952. Pp. 122. $1

Annotations

PREVENTION AND CURE

PREVENTIVE medicine in this country has alreadypassed through three phases, and the form that thefourth will take is in the balance. The fire and furyof Chadwick and his followers ecreated a new specialty- public health-from among the clinicians, and the

driving force of his " sanitary idea," the quality of themen it attracted, and the prosperity of the mid-19thcentury combined to give us world leadership in thenew ’science of prevention. At the beginning of the20th century the practitioners of this science were ableto extend their sway, first to a wide group of personalpreventive services, and after 1929, to a hospital servicewhich rapidly rivalled the old voluntary system. Thenin 1948, in the interests of a comprehensive and integratedhospital system, public health was shorn of its hospitals-even of the fever hospitals which it had controlledfor nearly a century-and of a number of its other func-tions, leaving many of its exponents confused and

frustrated, as they were for a time in 1854 whenChadwick’s Board of Health ceased to exist. Recentlythere have been signs of a new pattern evolving, and itis instructive to have the views of a distinguishedforeigner familiar with this problem in many parts ofthe world.

In the course of some lectures given during a medicalteaching mission to Israel,1 Dr. Karl Evang, director-general of the public-health service in Norway, distin-guished three basic systems of public health : (1) thecontinental European, originating in Germany and at itsinception a great advance, but now too legalistic andbureaucratic; (2) the Anglo-Saxon, more flexible, prag-matic, and crusading ; and (3) the Slav or Russian, whichhas attempted a more complete combination of curativeand preventive medicine but which, alas, can seldom bestudied except at second hand. The field he allots to

public health is comprehensive : it should, he thinks,not only be a specialty in its own right but also beresponsible for over-all planning and coordination of thewhole system, including curative medicine. In hisopinion neglect of curative medicine by the public-healthservices has been as unfortunate as the similar neglectby the clinicians of such preventive services as maternityand child welfare and tuberculosis. The central govern-ment should give centralised direction, but activityshould be decentralised : the division of health functionsbetween different government departments is largelyhistorical, and the trend is now towards concentration.On hospitals, Evang feels that the approach to efficient

administration must not be like the approach to a

mathematical problem—there are no " right answers."Nor should those who appropriate money for hospital

services demand the obvious advantages of " stabilisationof budgets," which inevitably leads to stagnation. Onthe open versus closed hospital, he favours the closed,with safeguards covering provision of diagnostic facilitiesfor surrounding practitioners and a system of efficientreporting on their patients ; selection of staff should beobviously impartial, and there must be flexibility in theallocation of beds. Rigid allocation of beds to specialtiesis on the way out, as are specialised hospitals-e.g., fortuberculosis and infectious disease. " The modern trendis away from very large hospitals " and a general teachinghospital, including psychiatric, tuberculosis, and infec-tious-disease departments, should not exceed 700-1200beds. An administrator with a medical degree, otherthings being equal, is to be preferred to a layman, andEvang quotes Goldwater as saying that " a stalwartmedical superintendent can protect his hospital from theexuberance of the reckless medical enthusiast more

effectively than can a non-medical superintendent," aswell as guarding clinical medicine from ill-informed laycontrol. While this does not imply that one of theclinicians at a large hospital should take full responsibilityfor the administration, he pleads for more clinicians tointerest themselves in administration.

" To my mind this is a vital point : when medical activitiesproliferate, as they do in modern society, medical men musttake administrative responsibility. If they do not, if theylimit themselves to clinical work, others, ignorant as to allthe medical factors involved, will organize the institutionsin which medical men will be invited to work. This appliesnot only to hospital medicine, but also to all other formsof medical activity. This calls for education in healthadministration, a field which has been neglected in mostcountries."

While rejecting the complete integration of hospitaland health services as being at present impossible andinadvisable in most countries, Evang emphasises the needfor " bringing the student and the teaching hospital outof their present clinical isolation,’ " quoting Newsholme’sdictum that " the treatment and prevention of diseasecannot administratively be separated without injuringthe possibilities of success of both." ,

1. Chu, C. M., Andrewes, C. H., Gledhill, A. W. Bull. World HlthOrg. 1950, 3, 187.

THE MASKS OF A VIRUS

THE influenza virus can assume a bewildering varietyof antigenic forms ; and, so far, the particular strainwhich causes an epidemic in any year has been recognis-ably different from all the strains found before. It hasbeen suggested that this continual antigenic novelty,allied to changes in virulence, is of great importance inthe annual renascence of the virus ; for if it returnedto us each year in the same form we would have builtup too strong a barrier of immunity to allow it to troubleus again. These are, at the moment, merely speculations,but it is fortunate that the techniques for studying theinfluenza virus have reached so sophisticated a stagethat it is possible to set about testing the truth of thisand other hypotheses.The World Influenza Centre of the World Health

Organisation has, since 1947, been making a special studyof the origin and spread of influenza epidemics. Althoughinformation is obtained from many parts of the world,attention is for the moment focused mainly on Europe.Here the work is grievously handicapped by the IronCurtain, which forms an effective barrier to the exchangeof news about the virus, though the virus itself brushesit aside easily enough. But despite the difficulties andthe fact that relatively few people are collecting strains,a brilliant start has been made and information of the

greatest interest is beginning to appear. The first report,on influenza in 1948 and 1949, was published two yearsago,l and now comes the report on the European epidemic