223THE FIRST MONTH

struck between deaths and replacements will putFrance into the low stationary phase, where, as inthe United States, most of Western Europe, andthe British Dominions, low ’birth-rates are matchedby low death-rates to keep the population stable innumbers.Preoccupation with the immediate difficulties of

replacement in Western Europe should not blind usto the broader picture of the movements and pressuresof population in the world at large. BLACKER 18

describes how, in the last thousand years, the smallEuropean centre outstripped the rest of the world intechnical achievement. Exploration and colonisationspread the European stock over the Americas, Africa,and the East: indeed in North America whatWOODROW WILSON called the " swarming of the

English " resulted in an eleven-fold increase inthe population.. A high birth-rate combined withfalling death-rates to produce in both colonisersand subject peoples the early expansive phase ofpopulation growth. The checks and balances of

epidemic and famine, operating as in modern Chinawith its equally high birth and death rates and stablepopulation, were obliterated by advances in agricul-tural and sanitary science. These effects persist amongthe peoples of India and Indonesia ; but a new

demographic stage appeared in the centres fromwhich these colonising influences came. Industrialisa-tion and urbanisation in the " advanced " countriesof Western Europe were accompanied by closing ofthe gap between birth and death rates, and even,in the middle 1930s, by the stage of declining numbers.Areas of low fertility formed and grew steadilywider until, just before the second world war, thetrend altered and an increase in the birth-rate set in.The late war certainly did not arrest this reversal,and most Western European countries now have

higher hopes of demographic stability. In Eastern

Europe, particularly in the Soviet Union and in Japan,there exists a different state-one of late expansion,where the death-rates are declining more quickly thanthe birth-rates and population increase continues.In the Mohammedan world, breeding to capacitycontinues but the high death-rates hamper numericalincrease. Vital statistics in the Middle East, as inIndia and Indonesia, are rather unreliable ; in India,for example, the village chowkidar is notoriouslyselective in recording births and deaths. Yet it seemsclear that among the mixed blessings derived from acontact with Western civilisation has been a decreasein death-rates and a resultant expansion of the alreadyteeming millions of South-East Asia.These facts raise questions of material and moral

importance. The pressure of population and thedemand for Lebensraum has long been held to be apotential cause of war ; and in war the position ofthe relatively infertile Western European appendageto the great land, mass of Eurasia is unenviable.Again, the new food morality preached by Sir JOHNBOYD ORR, whereby each country receives a slice ofworld’s food cake in proportion to its human needsrather than to its economic purchasing-power,may have serious repercussions in this country.Even our present dietetic standards are princelycompared with the bare subsistence of the Indian

18. Blacker, C. P. Eugen. Rev. 1947, 39, 88.

peasarit,’and any strict egalitarianism would, BLACKERsuggests " keep our wives and perhaps our daughtersstanding in queues for many years to come." But,as ORR would no doubt point out, we have defiedMalthusian prophecies thus far, and the science offood production and distribution is still in its infancy.Beyond a certain point too, demography ceases tobe an exact science. Long-term population forecastswhich (said STOWMAN) " are made with impunity onlybecause no-one reads them ten years after they arepublished," are often little better than educated

guesses. All turns on the emancipation and educationof women in countries where over-population may bethe prelude to war. Through them, the contraceptivelimitation of families may balance the death-diminish-ing powers of sanitary progress, and relieve both theirown arduous lives and the pressing demands of toomany hungry mouths.

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Annotations

THE FIRST MONTH

DOCTORS and patients have now had a whole month inwhich to sample the advantages, disadvantages, andshortcomings of the National Health Service. Most

practitioners would agree, we believe, that the monthhas brought fewer changes than they feared. It is truethat, for many of them, surgeries have been unusuallyheavy ; but some of the extra work will not have to be

repeated. Patients uncertain of their rights, or how toobtain them, have come to ask questions, or to handin forms. Others have waited for July 5 before presentingthemselves to have their eyes tested, or their minor

operations arranged. Private patients who formerlyhad repeat prescriptions filled by pharinacists now cometo have each prescription written on to the official form ;but in course of time this additional labour will bereducible by prescribing, in some of the cases, medicineof a type or quantity that will demand less frequentrepetition. ,

Administratively the initial stages proceed steadily andwith surprisingly few hitches. The final count of doctorsjoining the service will not be known until allowancecan be made for those whose names now appear on thelists- of more than one executive council, and for thosewho have joined the .service to secure their right tocompensation, but who for reasons of age or infirmity,or because they now intend to specialise, will soon beretiring from general practice.. Even now, however, itis safe to say that enough doctors have joined to providein all areas an adequate service. The patients have notbeen backward in completing their application forms,and the number of patients on doctors’ lists is alreadysaid to approach 90% of the population. The cardshave come in quickly and many an executive counciloffice has found it hard to keep pace with its inordinatelyheavy daily intake. Some delay is inevitable while

patients’ cards are sorted, counted, and recorded, andone cannot expect the, new record cards to arrive

immediately after dispatch of the application forms.What is less excusable is that stocks of prescription andcertificate forms received by executive councils beforethe appointed day have sometimes been insufficient tomeet the practitioners’ needs, and that schemes are

announced for opting out of superannuation, and forclaiming compensation, before executive councils possessthe memoranda and application forms that will enablepractitioners to make their claims.The rapid enrolment of so high a proportion of the

public has only too quickly revealed the uneven distri-bution of doctors. Reports from some under-doctored

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areas tell of doctors with lists already more - thansaturated, -while from others come reports of groups ofdoctors faced with unexpectedly small lists, and shrinkingincomes, spontaneously approaching the. newly formedMedical Practices Committee with requests that theirparticular area shall be declared over-doctored, andclosed to the entry of. further practitioners.- Evidentlythe committee’s. purpose, as. well as its personnel, hasbeen tacitly accepted, and it has quietly embarked enits tasks. It, has delegated considerable power to theexecutive councils over such matters as the sanctioningof the employment of assistants, and the admission ofnew principals, only asking to be specifically consultedin a short schedule - of cases where., permission might- well,need to be withheld, ,

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The local obstetric committees, too, have begun workin most areas. For the most part they are interpretingtheir, mandate leniently, and refusing permission to fewdoctors who have signified their willingness to acceptmidwifery -responsibilities. Allocation committees haveso far had very -few cases, to - deal with-surprisinglyfew when --one considers the very large numbers of

patients (over 18 million) who have sought to be freshlyincluded in doctors’ lists in these -few short weeks.The fact that these cases have been so few goes farto show that the complaints of doctors refusing for allmanner -of reasons to accept certain patients, to whichso much prominence has been given in the press and inParliament, cannot concern more than a small minorityof doctors.

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Patients have: been confused. In particular, the

simultaneous launching of a National Health Service,participation in which is optional, and a NationalInsurance scheme, compulsory under penalty for mostfamilies, has led to every permutation of misunderstand-ing. But it does now seem that the relatively highrate of weekly insurance contribution which has becomepayable has been the determining factor which hasdecided - so many -to enter so quickly. Conversely, aremarkably high proportion of elderly- people have saidthat, as no direct weekly contribution is being asked ofthem, they feel it unfair to avail themselves of thebenefits to which they are entitled. It is probable thatmany who. so far have not signed cards will do so if inthe ensuing months they need medical care. The factthat - medicines cannot be supplied at the expense ofthe service to any but enrolled patients has broughtmany, and will continue to bring others, into the service.It will be surprising if the estimated 98% of acceptancesin the first two years is not reached long before this termis up. ..

July began with very unseasonable weather which didnothing to improve the health or the temper of theBritish public. The incidence of infectious illnesses,too,’ seemed somehow to linger on this year. and theload of measles, mumps, and chickenpox remained

greater than usual.. Nevertheless, we have got through thefirst month without undue disturbance, and the monthsthat follow should allow the new service to get well intoits stride before it has to bear the burdens of winter.

A SCRUTINY OF MENTAL HEALTH PROBLEMS

AGGRESSION, world citizenship, and guilt are thethemes of the three international conferences embodiedin the International Congress on Mental Health, to beheld from Aug. 11 to 21 at the Central Hall, Westminster.For this congress, organised by the National Associationfor Mental Health at the request of the InternationalCommittees on Child Psychiatry and Mental Hygiene,and the International Federation for Medical Psycho-therapy, some 2000 delegates, drawn from nearly50 countries, have registered. About 900 delegates arecoming from abroad, and only Soviet Russia, amongthe great powers, has failed to send any.

,.An. unusual plan of preparation has been followed:for some months past nearly 300 groups of people,including psychiatrists, doctors, psychologists, socialworkers, clergy, ,lawyers, -and others have been at workin more than 20 countries examining questions whichare to be considered at the congress. Reports of theirinvestigations have been sent to the organising committeein London, where they have been edited for considerationby an international preparatory commission. Thiscommission, composed of 30 leading people in the mentalhealth field from various countries, will meet at RoffeyPark, Sussex, for a fortnight before the opening of thecongress, to read the reports and decide- which aspectsof them should be-considered further at the congress.The main purpose of the three conferences is to study

group relations in the community, in industry, andbetween nations. It is, perhaps, from such studies thatwe shall at last achieve the ability to live at peace in asmall and crowded world.

GERMANY’S FOOD

How much food are the Germans eating today ? This

question has had the attention of many trained observers,but their answers are no more than conjectures since thescale of rations bears little relation to the amount offood consumed. Some months, ago Dr. Aschoff,l a Germannutritionist, told us that between last November andFebruary the rations might yield as little as 866-1-135calories a day. But these figures take no account ofunrationed food or of rationed foods from the blackmarket, which in Germany is many times more activethan any we have known in Britain. By some this blackmarket has been actually defended ; for the time being,it is argued, there is not enough productive work forthe population, and the two or three days spent eachweek in foraging for supplies averts the trouble usuallysaid to come from idle hands and brains. Nevertheless,there are ample reasons for .not -regarding such a situationas satisfactory. Any -black market is acutely competitive:without money to buy or goods to barter the customergoes without, and many city-dwellers are physicallyincapable of getting to the farms where the marketchiefly thrives. Moreover, the effect on the German mindof the present slender official rations must also be con-sidered. Naturally the Germans are preoccupied with therationing restrictions because of their comparativenovelty and their severity ; and naturally, too, as a

defeated people, they seek to circumvent a systemwhich may seem to be imposed by their conquerors.The danger now is that isolation, frustration, intro-version, and self-pity, reinforced by the meagreness ofthe official rations, by rumour, and by false propaganda,will establish a myth that the population was deliberatelystarved after the second world war. One example of thispropaganda is to be found in German reports of grossincrease in the incidence of tuberculosis-an increase notsubstantiated by competent outside observers.2 Howrumour may take root is shown again in Dr. Wolff-Eisner’s recent book, of which an account is given onp. 228. His integrity in describing the conditions ofstarvation and neglect which. he saw and suffered atTheresienstadt concentration camp is beyond dispute;and no doubt he brings the same honest intention tobear on his later passages where he suggests that condi-tions in Germany today are not much better than in thecamp. This contention, however, is supported only by-reference to the publications -of other German doctorsin which the possible effects of inadequate nutrition aredescribed in general terms, and by rumours of conditionsin Hamburg and Dusseldorf. Unlike most Germans,Wolff-Eisner shows awareness of the post-war plight of1. Aschoff, J. Lancet, 1948, i, 423.2. Tuberculosis in the British Zone of Germany. By MARC DANIELS,

M.D., and P. D’ARCY HART, P.R.C.P. H.M. Stationery Office,1948. See Lancet, 1948, i, 415.