Public Health in the World Today [Reprint 2014 ed.] 9780674369191, 9780674369184

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Public Health in the World Today

London : Geoffrey

Cumberlege

Oxford University Press

PUBLIC HEALTH IN THE WORLD TODAY EDITED

BY

J A M E S STEVENS SIMMONS Brigadier General, U. S. Army, Retired; Dean, Harvard School oj Public Health A S S I S T A N T EDITOR · I R E N E M .

KINSEY

W I T H A FOREWORD BY

JAMES BRYANT CONANT President of Harvard

University

HARVARD UNIVERSITY PRESS Cambridge,

Massachusetts

• I 949·

Copyright, i)

2120

91.5

42.7

3250 6900

87.6 22.0

4.6

'4S-5

14.9

8600

8.5

6.8

•9.6 17.I

13.6

1.04

0.3

ζ-7

0.9

10350

Probable Total Activity (c)

69.3

Total (c) 67.8

... « 6.5

~9S

of discarding them than to pour them into the sink drain. When this is done a large fraction may remain in the sink traps, permitting dangerous fumes to enter the room. Moreover, in many cases the material plates out on the walls of the drainpipe where it may present a serious hazard to an unsuspecting plumber. Burial. — Most of the waste liquid containing alpha-emitting contamination and all the contaminated waste solid material are buried in 301

Public Health in a New Era deep trenches. These radioactive burial grounds are maintained in guarded areas to prevent persons from carrying off dangerously contaminated objects. The foregoing discussion has indicated some of the methods of radioactive waste disposal. T o these may be added methods used at other sites, such as underground discharge in deserts and burial at sea. Some of the radioactive products are long lived and will present health hazards for many thousands of years. Some of these materials are mixed into concrete blocks and buried at sea or placed in permanent storage. Perhaps none of the presently used methods of waste disposal is completely satisfactory for a large-scale operation or on a long-time basis. Although the radioactive contamination in the air and in the water in the neighborhood of Oak Ridge National Laboratory is far lower than the tolerance value, the problems are somewhat cumulative with time and eventually might lead to health and instrument difficulties. It is for this reason that studies of new methods of decontamination and waste disposal, now under way, are believed to be of considerable importance. Most of the health physicists seem to favor the use of some method of concentrating the radioactive waste products and placing them in permanent storage rather than seeking a maximum of dilution. Isotope dilution is the ideal solution for some of the radioisotopes, such as iodine, carbon, phosphorus, sodium, and hydrogen, but it cannot be used for the transuranic elements nor for some of the rare elements. Methods of Calculating Tolerance Levels for the Various Radioisotopes?· W e have already given (Table I) values of the ratio of the activities of certain radioisotopes present at any time to the tolerance concentrations. W e shall now indicate the methods used and the assumptions made in calculating the tolerance values. In general, there are two types of tolerance: (i) internal tolerance; and (ii) submersion tolerance. Internal tolerance. — The body organ that is found to sustain the maximum damage (or, in some cases, the earliest damage) is used in determining internal tolerance for each radioisotope. The various "This section is an extract from an article on the same subject published in the Journal of Fhysteal and Colloid Chemistry 51, 984 (1947). • 302 .

New Public Health Problems of the Atomic Era methods of body intake, such as ingestion, inhalation, skin absorption, and incision, must be considered for each compound encountered. T h e biologist determines the rate of body uptake by the various methods of intake and the fraction deposited in each organ of the body. In these calculations it is assumed that the coefficient of elimination λ is the sum of the biologic elimination factor Xe and the physical radioactive decay factor Xr\ that is, λ = λβ + λτ.

From the relation between λ and the half-life T , one can show that У ^

TeTr Te +

Tr'

T h e tolerance levels for the various types of radiation are given in Table III T h e radiation tolerance limit of each of the body organs is assumed to be loo mrem per day. T h e rem (roentgen equivalent man) is the amount of radiation that will produce the same damage to man as the roentgen. T h e rep (roentgen equivalent physical) is defined either (i) as that amount of radiation absorbed in tissue to the extent of 83 ergs per gram of tissue, or (ii) as that amount of radiation that is absorbed in a small air cavity in the tissue to the extent of 83 ergs TABLE III. Tolerance or maximum permissible exposure to radiation at Oak Ridge National Laboratory. T y p e of Radiation

(mr/day)

(mrep/day)

(mrem/day)**

X-ray Gamma Beta Fast Neutron Thermal Neutron Alpha *

100 100

100

100

100 100

20 5° 10

100

100 100 100

100

* This alpha tolerance level is considered only from the standpoint of internal irradiation effects. ·* As indicated by this table, the rem (roentgen equivalent man) is the amount of radiation that will produce the same damage to man as the roentgen. The rep and rem units were introduced into the project literature by H. M. Parker at Hanford, Washington. ' T h e present indication is that lower levels of permissible radiation exposure will be adopted early in 1949. Several national committees within the United States that are concerned with radiation protection have reached preliminary agreement to lower the permissible exposure to x- and gamma-radiation from :oo milliroentgens per day to 300 milliroentgens per week.

• 303 ·

60

90 IZO ISO 180 ZIO 240 270 300 DAYS AFTER SR®® DAIDT CONSUMPTION BEGINS

360

0.6

-ROENTGENS^ ABOVE TOLERANCE ROENTGENS BELOW TOLERANCE _L _L 60 90 120 150 ΙΘΟ 210 240 270 300 330 360 DAYS AFTER A SINGLE DOSE OF S R ® ' REACHES THE BONE. FIG. 4· (Upper) Daily exposure rates when Sr™ enters bone at a constant rate. Exposure: top curve, 36.5 r in i yr; bottom curve, o.i r on the 365th day. (Lower) Radiation (г/day) when a short-lived radioactive material is fixed in an organ of the body, on the assumption that 36.5 r of gamma-radiation will be received over the period of i yr. Note that the initial exposure rate exceeds O.I r/day and that the rate at the end of the year is less than this tolerance value. 30

New Public Health Problems of the Atomic Era per gram of air. The value obtained from definition (ii) is equal to that obtained from definition (i) multiplied by the relative stopping power of tissue and air. Figure 4 illustrates the three types of permissible tolerance exposure for simple radioisotopes (isotopes that do not produce a radioactive daughter). Figure 5 shows the exposure rate of a parent-daughter chain or the disintegration rate when the energies of the parent and daughter products are the same. In this case the parent and daughter exposure rates are equal when the daughter exposure rate is maximum, and transient equilibrium is reached at a time equal to twice the time

1.0

1.2 1.4 1.6 TIME ty ( Y R )

FIG. 5. Radiatíon rate f r o m a parent-daughter pair, on the assumption that the half-life of the parent is i y r and that of the daughter, 0.5 y r . T h e parent and daughter curves are parallel at 2 y r and the ratio of the daughter activity to the parent activity is 1.5 at this time.

305

90 120 150 180 210 240 270 DAYS AFTER S R ® ® REACHES THE BONE

300

ЭЭО 360

FIG. 6. Radiation (г/day) to the skeleton from the portion of a single dose of Sr®° that reaches the skeleton and produces an exposure of 36.5 r during the year. Curve A, total exposure rate; curve P, parent exposure rate; curve D, daughter exposure rate. 306

New Public Health Problems of the Atomic Era of the daughter maximum. The general case of exposure rate, when the energies of the parent and daughter are not equal, is illustrated by the Sr90-Yeo curves in Fig. 6.

.004 .006χ)0θ.01

.02

.04 .06 .08.1

EXPOSURE TIME t y (YEARS)

,Ζ

.6

.8 LO

FIG. 7· Curves showing how the tolerance rate of concentration of Sx®" in the body varies with exposure time, damage to the bone being due to S r " alone, Y " alone, and to S r " + Y " , respectively.

Of course, the maximum time that a person expects to be exposed to these radioisotopes determines the permissible exposure, and the effect of exposure time in the case of Sr®"-Y®® and Pu^^® is illustrated by Figs. 7 and 8, respectively. 307

Public Health in a New Era Sometimes it is difficult to determine the effective half-life accurately. Figure 9 illustrates the influence of this factor on the tolerance concentration in air for plutonium and radium. Submersion Tolerance. — Often the radiation from outside the body is greater than that from inside. This is especially true for the radioisotopes of the noble gases, such as argon and xenon. Submersion

.4

.β

I

г

4

6

10

20

«0

60

EXPOSURE TIME t y ( Y E A R S )

FIG. 8. Curves showing how the tolerance concentration of plutonium in the air varies with exposure time, for bone damage and for lung damage.

tolerance for beta-gamma activity in a large body of fluid may be determined by assuming that the energy absorbed per unit volume is equal to that emitted per unit volume. For the tolerance level of o.i r/day, when the radiation comes from the total solid angle of 4π steradians, the tolerance concentration in air is found to be =

(2.09 X

io-6)/£i^c/cm3,

=

(1.61 X

io-3)/E^c/cm3,

and that for water is 0 „

where E (Mev) is the effective energy of the radiation. Since the radiation to the human body, with a few exceptions such as the ear, would be from a solid angle of only zir steradians, the foregoing values • 308 .

New Public Health Problems of the Atomic Era could be doubled. Table I V summarizes some of the results for various radioactive materials. It should be pointed out here that it is the practice on the Plutonium Project to multiply the tolerance values given in this discussion by a factor of safety of ten (or more), and it is considered preferable to refer to "maximum permissible exposure" rather than to "tolerance exposure." 160

.04 .06.08.1

.2 .4 .6 .8 HALF UFE Ту (years)

FIG. 9. Curves showing how the tolerance concentration in air of radium and plutonium vary with the assumed effective half-life. T h e circles on the curves indicate the values of half-life that are assumed in this report.

Personnel Radiation Monitoring All persons entering the restricted area of Oak Ridge National Laboratory are required to wear a film badge; and those who work regularly in this area wear, in addition, two pocket meters. The film • 309 ·

Public Health in a New Era badge contains a regular-sized dental-film packet. This film packet, which is produced by the du Pont Company, contains two films; one a sensitive film with a useful range from about 20 mr to 20 r, the other with a useful range from about 1000 mr to 40 r. The film badge contains an open window and a cadmium screen which is i mm thick. After the film is developed, densitometer readings are taken of a portion of the film that was worn behind the cadmium and of a part that was TABLE I V . Computation Element

Sr» Sr" —Y«" Sr"

Y«

Y" Zr" —Cb" Zr» Cb« Ru*" Ru^'" — R h ^ "

Rtf" Rh™* Te"' Те"» те^

Absorption in Critical Tissues (per cent)

7-5

7-5 0.14 .14 .005 .2 .00015 .00015

1-5 1-5 1-5

of tolerance Critical Tissue

Bone Bone Bone Bone Bone Bone KidneyKidney Kidney Kidney Kidney

values for ingestion

T. Tr (days) (days) 200 200

S3 9125

41.8

'95

E (Mev) 0.5

•9

submersion.

Ingestion Submersion Tolerance Tolerance (дс/lit) (дс/lit) 4.8

3-2

0.57

.2

8.1

57 65

2-5 •7 51 •5 2.6 36

35

20

0.8

236

2.0

.8

11400

2.0

365

13 18

2.0

3200

500 500 80

50 20

20

τ

(days)

and

15 15 "5

90

32 3-2

2.1

3114 211

1640

0.77

O.OI 13 10 2.6

•23

14 1-7

0.31

2-3 3-2

161

4.0

7.0

0.84

1.2

2.6 5-2

• The half-life of is so short that this isotope has no effect except where it is in equilibrium with Ru™ behind the open window. In this way, it is possible to make an estimate of the energy of the radiation and form a better judgment of the roentgen exposure. The open-window reading furnishes some knowledge of the beta-particle exposure, but this reading is difficult to interpret when the exposure is due to soft gamma-rays or to a mixture of beta- and gamma-ray activity, since the film is about fifty times as sensitive to soft gamma- as to beta-radiation. Several series of calibration films are developed with each batch of badge films. These calibration films are made by exposing some of the films to different gamma-ray doses from a radium source and to betarays from and uranium. They are kept available in a refrigerator so that a calibration series can be included with each batch of films that is • 310·

New Public Health Problems of the Atomic Era developed. The density readings of these calibration films are plotted on a graph and this graph is used to determine the radiation exposures to the films from the film badges. Special precautions are used in developing the films, such as maintaining the proper temperatures and sufficient circulation of the developing fluids, and in this way reliable readings can be made for exposures as low as 7 mr. In practice, however, since the films are ordinarily developed only once a week, it is not necessary to attempt reading them to values lower than 30 mr. The films are marked by exposing the upper portion of the badge, which is perforated with the pay-roll number, to soft x-rays, the lower part of the film being shielded with lead during this marking operation. Table V indicates how various batches of film differ in radiation T A B L E V . Radiation

sensitivity

of four

batches

of

fihn.

Film Batch Number

Dose (mr)

S52-3

552-12

552-25

552-30

100

0.07

0.06

0.04

0.09

250

.16

.09

.21

500

.30

•15 .28

.20

750 1000

.42

.42

.30

•55

•54

41

•43 .64 .85

sensitivity and shows one reason why it is necessary to use calibration film. Careful tests and calibrations are made regularly of the film meters and pocket chambers, and therefore considerable reliance can be placed on the readings obtained. On some occasions the regular film has been darker behind the cadmium than behind the open window. Such cases have been traced to neutron exposures. When a person plans to work in the pile building or to do any work in which neutron exposures are possible, it is his responsibility (or that of his supervisor) to see that he is provided with the special neutron film. This film is purchased from the Eastman Kodak Company and is put up in the regular dental-film packets. The packets are placed in the film badges behind the regular films of persons who are known to work where neutron exposures are possible. This film has a 30-micron alpha-sensitive emulsion and is very insensitive to gamma-rays (so insensitive that it could serve as a "crash" badge to indicate a near-fatal dose in case of serious accident). The portion of the film behind the cadmium screen of the badge receives •

311

·

Public Health in a New Era tracks owing to the fast neutron-proton recoils from the reaction H(n,p), and the film that is behind the open window receives tracks owing to this reaction plus the thermal-neutron reaction After the films are developed, the tracks are counted with the aid of a dark-field microscope. The neutron tolerance for a two-week period is taken to be sixteen tracks for twelve fields of vision. This corresponds to a neutron flux of approximately 200 fast neutrons or 3000 thermal neutrons per square centimeter per second, with an exposure of eight hours per day. The field of vision of the microscope in this case is 2 X 1 0 - ^ cm^. When work is being done in which there is considerable radiation exposure of the hands, a special film ring is used. The rings were originally machined from aluminum. They had a thin aluminum window and a cadmium shield. At present, the rings are stamped from plastic material and cost only a few cents each, or a small fraction of the cost of the aluminum ring. They contain films that are cut in the shape of circular disks from the regular badge-meter film. These film rings are especially suited to beta-ray measurement and are calibrated with beta rays from P®^ and uranium. The films that are used are about twice as sensitive to hard gamma-rays as to beta-rays, as is shown by the graphs in Fig. 10. That is, i r of hard gamma-rays produces the same film darkening as 2 rep (roentgens equivalent physical) of betaradiation. The question is sometimes raised whether the film badges are worn on parts of the clothing such that they indicate a good average of the exposure received by each person. Of course, this factor may vary considerably with individuals and with the type of radiation exposure. Table V I gives the results of a series of experiments in which these TABLE VI. Efficiency of film badge in measuring average body exposure. Location of Film on Body

Film Meter Readings (per cent)

Regular Position Right Leg Left Leg Right Wrist Left Wrist Crotch Chest Back

100 78 80 105 97 73 88 59 • 312

·

New Public Health Problems of the Atomic Era badges were worn for a week on eight different parts of the body by a number of persons undergoing radiation exposure over an extended period of time. Only the meter worn on the right wrist indicated radiation exposures slightly higher than those registered by the film badges as regularly worn by the laboratory personnel. Figure 11 shows the various types of pocket meter employed at the Oak Ridge National Laboratory, those in general use being produced

.02

.04 .06 .0Θ J Λ А Л Я Х FILM DENSITY OF FINGER RING RLM

Ζ

4

β

8Ю

FIG. IO. Film density as a function of exposure to two types of radiation. T h e curves show that the films used are about twice as sensitive to hard gamma-rays as to beta-rays.

by the Victoreen Company. They are small, pencil-shaped condensers which are charged to a potential difference of 150 volts. Tests have shown that this potential difference is sufficient for voltage saturation and that ion recombination introduces no serious error unless the meters are worn in a radiation field exceeding 250 r/hr. (Persons in general are not permitted to enter radiation fields in excess of 5 r/hr, and then only during emergencies.) These meters have a useful range extending from about 10 mr to 280 mr. The discharge of the meter is proportional to the radiation exposure, except for false readings. These • 313 ·

Public Health in a New Era false readings are produced by electric discharge of the meter owing to leakage across the insulator when it collects dust particles or moisture or both, and by rough handling of the meter. A good meter will not discharge when it is dropped. The pocket meters formerly in use were defective in this respect, and for this reason two meters are worn side by side in the pocket; single readings are considered false and only the smaller of a double reading is considered to be due to radiation. However, the Victoreen Company has greatly improved their meter by the incorporation of some changes recommended by our laboratory and by their own engineers. Originally, one false double reading was obtained per I ООО pairs of readings, but the improved design gives only one false double reading per 400,000 pairs, so that it is no longer necessary to wear two meters if o. 16 per cent false readings can be permitted.

Building Surveys Limitations of space do not permit a detailed description of the survey instruments used at Oak Ridge National Laboratory. The most important of all the radiation detection instruments is the electrometer. This instrument has the necessary sensitivity and at the same time maintains an accurate calibration over a long period of time. The two best electrometers available are the Lauritsen and the LandsverkWollan (Fig. 12). Electrometers can be mounted as pen-sized dosimeters (Fig. 1 1 ) that are useful to wear in intense fields of radiation where it is necessary to follow the exposure as the experiment progresses. T w o of the favorite electronic instruments are called the Zeus and the Cutie-Pie (Fig. 13). These instruments can be used to measure alpha-, beta-, and gamma-radiation. The Zeus is adapted to measuring the contamination on flat surfaces, whereas the Cutie-Pie is especially suited to making measurements inside a hood or over the edge of a lead barricade. Figure 14 shows one of these Cutie-Pies in use. Here one of the health physics surveyors is measuring the level of radiation while an operator removes a sample of radioactive material from a lead coffin by means of a pneumatically controlled rod. This sample is then placed in one of the lead containers on the dolly. In the background the 6-foot shield of the pile is shown, and to the left is a monitron. • 3 4

·

New Public Health Problems of the Atomic Era ТЫз instrument sounds an alarm when the general radiation in the area exceeds a rate of o. i r per eight-hour day. The usefulness of the Geiger counter as a survey instrument has been grossly exaggerated in some of the recent publications. This instrument should be used only as an indicating device for making qualitative survey measurements. Once radiation is located, the quantitative measurements should be made with an electroscope. The Geiger counter has the advantages of high sensitivity and maximum simplicity of operation, but some of its disadvantages are that it changes calibration and plateau characteristics with use, it jams in an intense radiation field and probably reads zero instead of infinity, it has a limited lifetime, it is usually photosensitive and thermally sensitive, and it is energy dependent. An extremely useful application of the Geiger counter is made in the fourfold hand-and-foot counter shown in Fig. 15. Here the operator places both hands in the pockets of the instrument, thus setting it into operation; it cuts off automatically after 24 sec, indicating on mechanical registers the radiation level on both sides of the hands and on the feet. Counters are also used in the decontamination laundry for checking the activity of clothing after it has been washed. Fast neutrons are measured by means of a double ionization chamber. One of the best available instruments for measuring alpha activity is equipped with probes ranging in size from those small enough to be placed in the nostril to a large flat plate with a counting area of several square feet. Figure 16 shows one of the health physics surveyors dressed in protective clothing, wearing an all-service mask, and using a fish-pole electronic meter to locate areas of high activity following a spill of radioactive material. Figure 17 is included to indicate an important health physics effort to educate the laboratory personnel concerning the necessity for radiation protection. The instrument shown in the upper left-hand corner is an automatic hand-and-foot counter. Conclusion Regardless of other developments in the atomic age, there is a great opportunity for physicists, chemists, engineers, and junior personnel in health physics in the future. On the one hand, health • 315 ·

Public Health in a New Era physicists can be of great assistance in setting up a suitable, necessary, and sufficient inspection system for a world atomic development authority. If, on the other hand, an atomic war is to come, it is important to have a large force of health physicists to make measurements of air and water radioactivities, to recommend which areas should be evacuated, and to determine the best decontamination procedures. The availability of a sufficient number of health physicists should tend to remove some of the fear, and minimize the dangers of a panic in case of an atomic war. However, the immediate need, and the principal purpose of the foregoing discussion, is to call attention to some of the radiation hazards involved now and to acquaint interested persons with the tolerance levels and with the instruments that are available to assist in maintaining radiation-hazardous operations within safe limits. Experience has indicated that the best protection against radiation hazards is a clear understanding and a full appreciation of health physics problems by all who work with radioactive materials. The accomplishment in developing the proper respect for radiation among the laboratory personnel is considered the greatest single factor that has prevented any known radiation damage to persons working on the Plutonium Projects. This statement is made with the knowledge that an adverse change in this condition would probably soon lead to fatal consequences. Many of the answers are not known by us, but we will be glad to offer limited assistance on these health physics problems to anyone.

316

FIG. I I . Photograph of several types of pocket radiation meter.

FIG. 12. T w o Wollan.

types of

electrometer:

upper,

Lauritsen;

loiver,

Landsverk-

ζ

t:

U

s

^

^

~

^ ..

. .. .. .. ..

c U T i E P ; b

FIG. 13. T w o electronic radiation-detecting instruments.

FIG. 14. T h e Cutie-Pie in use. A health physics surveyor measures the level of radiation while an operator removes a sample of radioactive material f r o m a lead coffin by means of a pneumatically controlled rod.

FIG. 15. Fourfold hand-and-foot counter. T h e instrument indicates the radiation level from possible radioactive material on both sides of the hands and on the feet.

FIG. 16. A health physics surveyor equipped to locate areas of high activity following a spill of radioactive material.

Û Âmd cMitirlntíme^..,.,

штшм

ALTH pmsiß fbrljmrPnitecim FIG.

17.

personnel

A wall poster used in the safety education program for laboratory

NATIONS

UNITED FOR

HEALTH

JAMES A. DOULL AFTER

MONTHS

OF UNCERTAINTY

EARLY

FAVORABLE ACTION

BY

THE

Congress, authorizing participation by the United States in the World Health Organization, may now be predicted. This organization became a legal entity on April 7, 1948 when the twenty-sixth and twentyseventh members of the United Nations deposited their acceptances of the constitution with the Secretary General of the United Nations. The first World Health Assembly will convene at Geneva on June 24, 1948. This will be a meeting of great significance: An executive committee must be elected, a director general appointed, the headquarters of the organization designated, and the program and budget for the first year approved. The time has come to advance toward fulfillment the high purposes written into the constitution at the New York Health Conference. Earlier History. Modern international cooperation in the field of , health is usually regarded as having begun in 1851 when the government of France convened an international conference at Paris to formulate a plan of action against cholera. Representatives of twelve nations prepared a draft convention, but this never came into force because of failure to receive the necessary number of ratifications. During the succeeding forty years five similar conferences were held, but little of significance was accomplished; the fundamental knowledge was still lacking. The Venice Conference of 1892 produced the first of a long series of formal conventions or sanitary treaties. The discussions related almost entirely to vessels passing through the Suez Canal. At the Dresden Conference of 1893, the important principle was accepted that observation of a person from a suspected ship might be permitted at his own home instead of in a detention hospital. This was the first official recognition of "surveillance." The Paris Conference of 1894 • 317 ·

Public Health in a New Era was concerned only with sanitary rules for the Mecca pilgrimages. The Venice Conference of 1897 was called because of the appearance in Bombay, in 1896, of bubonic plague. The first of a series of conventions based upon correct epidemiologic principles resulted from the Paris Conference of 1903. The microbial origin of disease was no longer a theory, and transmission of yellow fever and malaria by mosquitoes had recently been demonstrated. A proposal for establishment of a permanent Bureau of Health was adopted. This action was implemented four years later by the Rome Arrangement which set up at Paris the International Office of Public Health. Under the aegis of the Office, international sanitary conventions were drafted in 1912, 1926, and 1933 (for aerial navigation). The Ofiice received and transmitted regularly notifications of the occurrence of cholera, plague, smallpox, typhus, and yellow fever. The Office has a permanent committee which meets annually and which includes a representative from each member country. Under the terms of a protocol signed on July 22, 1946, the Office has been practically liquidated. Except for a skeleton staff the personnel has been retired or turned over to the Interim Commission of the World Health Organization. The Health Organization of the League of Nations was established in 1923. It had, relatively, a small annual budget, the largest being $414,078 for 1931, including a generous supplement from The Rockefeller Foundation. As a part of the League, its budgets and policies were subject to the direct control of a political organization. It duplicated to some extent the work of the Office, but went far beyond epidemiologic reporting in the scope of its activities. In its early days it assisted in stamping out the epidemics which followed World W a r I. It rendered great service by establishing international standards for biologies, and it sponsored international studies on cancer, leprosy, malaria, nutrition, and rural hygiene. It entered the fields of social insurance and housing. Most important, it rendered effective service by assisting in reorganization of certain national health departments. The oldest of the international health organizations is the Pan American Sanitary Organization. This organization was established in 1902 by a treaty known as the Pan American Sanitary Code, to which all twenty-one American republics are parties. In January 1947, the .318.

Nations United for Health twelfth Pan American Sanitary Conference, which was held at Caracas, drafted a plan of reorganization and defined the Pan American Sanitary Organization as consisting of four parts: Conference, Directing Council, Executive Committee, and the Pan American Sanitary Bureau (the Secretariat). Under the Code the Bureau receives and disseminates epidemiologic information, sponsors fellowship programs, provides technical assistance on request, and promotes cooperation in research by different countries. The War Period. August 21, 1941, the date on which Mr. Roosevelt and Mr. Churchill signed the Atlantic Charter, may be regarded as the date of conception of the United Nations. On January i, 1942 twentythree allied powers, declaring their intention to act in unity and with their full resources to defeat the enemy, subscribed to the principles of the Charter. On October 7, 1944 the Dumbarton Oaks Proposals gave to the world a specific plan for an international organization to be known as the United Nations. The actual birth date was June 26, 1945 when, at the United Nations Conference for International Organization at San Francisco, fifty nations signed the Charter of the United Nations. All this occurred in wartime, when life and freedom were at stake. Consequently these international instruments were concerned primarily with security, with pacific settlements of disputes, and with methods of handling breaches of the peace. Nevertheless, even in the earliest, the Atlantic Charter, there is evidence of recognition of the fundamental causes which lie at the root of all serious social disturbances including war itself: "Fifth, they (United States and United Kingdom) desire to bring about the fullest collaboration between all nations in the economic field with the object of securing, for all, improved labor standards, economic advancement and social security." In the Dumbarton Oaks Proposals this sentiment is linked definitely with the attainment of peace: "With a view to the creation of conditions of stability and well-being which are necessary for peaceful and friendly relations among nations, the Organization should facilitate solutions of international economic, social and other humanitarian problems. . . ." In the Proposals, although an Economic and Social Council was in• 3'9 ·

Pubitc Health in a Neiv Era eluded, it was classed as a subsidiary organ. It remained for the San Francisco Conference, under pressure from certain smaller nations, to raise the Council to the dignity and importance of a principal organ of the United Nations. At San Francisco, also, chiefly owing to the insistence of Dr. G . H. de Paula Souza of Brazil, provisions were written into the charter specifying health as one of the fields in which the General Assembly "shall initiate studies and make recommendations . . . ," health problems among those for which the United Nations shall promote solutions, health as a field for a specialized agency to be brought into relationship with the United Nations, and international health matters among those on which the Economic and Social Council may make or initiate studies and reports. A further significant step was taken by the San Francisco Conference. Unanimous approval was given to a joint resolution introduced by Brazil and China calling for establishment of a single international health organization. Early in the war, leaders in public health in the United States and Great Britain, and doubtless those in other countries, began to think seriously of the postwar situation. In addition to political developments, two events greatly stimulated these thoughts. The first was the Conference on Food and Agriculture, held at Hot Springs, Virginia, in June 1943. This Conference declared that "the first cause of hunger and malnutrition is poverty. . . . It is useless to produce more food unless men and nations provide the markets to absorb it. . . . There must be an expansion of the whole world economy to provide the purchasing power sufficient to maintain an adequate diet for all," and that "the primary responsibility lies with each nation for seeing that its own people have the food needed for life and health." Out of this Conference came the Food and Agriculture Organization. This was the first of a series of new organizations which, together with their pioneer prewar prototype, the International Labor Organization, constitute the specialized agencies of the United Nations. T o qualify as a specialized agency, each must be established by intergovernmental agreement (treaty) and have wide international responsibilities. The second event was establishment of the United Nations Relief and Rehabilitation Administration by an Agreement signed in Wash• 320 ·

Nations United for Health ington on November 9, 1943 by representatives of forty-four nations. Among its functions was provision of basic medical services for victims of war. Its achievements in the health field have recently been reviewed by Dr. W . A. Sawyer. The estimated total expenditure for health work for a period of operation of about three years was close to $168,000,000. Of this, more than 80 per cent was expended for medical and sanitation supplies. More than eleven hundred international professional health personnel were employed. During and following World War I serious epidemics of typhus fever occurred in European countries. Following World W a r II, thanks to the availability of D D T (dichloro-diphenyl-trichloroethane) and to practical demonstration of its value by experimental and field trials, typhus was kept under control by the occupying armies aided by the United States Army Typhus Commission and the International Red Cross. "As soon as the shipping lanes were cleared, U N R R A despatched thousands of tons of D D T powder and many hundreds of dust pumps." U N R R A staff were sent to assist local health workers. Also, extensive and highly successful campaigns against malaria were carried out by U N R R A in Greece and Italy with the cooperation of national health authorities. Early in 1944, the writer was sent to London by U N R R A and assisted in the organization and work of two expert commissions of U N R R A ' s Standing Technical Subcommittee on Health for Europe. The first of these drew up a plan for medical supervision of displaced persons to be returned to their homes on cessation of hostilities. The second commission prepared draft revisions of the international sanitary conventions for maritime commerce and air navigation, respectively. The conventions were modernized, especially those provisions relating to yellow fever. Because of the virtual isolation of the International Office of Public Health, each draft provided that U N R R A should carry out the duties assigned to the Office by the earlier conventions. U N R R A continued to exercise these functions until they were transferred to the Interim Commission of the World Health Organization on December i, 1946. Flanning for the World Health Organization. It has been mentioned that, early in the war, health leaders in several countries had • 321

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Public Health in a New Era given thought to future international collaboration in health work. In October 1944 the American Public Health Association passed a resolution calling upon the Secretary of State to take leadership in the movement. In February 1945 Dr. L. L. Williams, Jr. and the writer were assigned to the Health Branch of the Division of International Labor, Social, and Health Affairs of the Department of State to develop plans for a postwar international health agency. In April 1945 the writer, as the representative of Dr. Thomas Parran, then Surgeon General, was sent to discuss the matter informally with Sir Wilson Jameson and Dr. Melville MacKenzie of the Ministry of Health of Great Britain. The opinion at that time was that a health commission should be established as a part of the Economic and Social Council; that is, its position should be somewhat similar to that of the Health Organization in the League. On return, the writer was detailed as an assistant to the United States Delegation at the San Francisco Conference. Following this Conference where, as has been said, it was decided that a specialized agency for health should be established, a draft constitution was drawn up by the Public Health Service and the Department of State. This draft was examined and amended in October 1945 by an advisory group of thirty, representing public health, labor, industry, and civic groups. It should be stated also that in December 1945 the Congress passed a joint resolution requesting the President to take immediate steps toward convening a health conference and formation of an international health agency. Although the resolution introduced at the San Francisco Conference by Brazil and China contemplated calling an international conference under the sponsorship of a small group of nations, it was decided that the initiative should come from the United Nations. In January 1946 the Economic and Social Council named a Technical Preparatory Committee from sixteen nations which met in Paris in April 1946. Dr. Parran was designated from the United States, with the writer as his alternate. The draft constitution submitted by Dr. Parran was adopted in large part. Plans were made for a full-scale international health conference to be called by the United Nations. This Conference was convened at N e w York on June 19, 1946. There were present representatives of the fifty-one members of the United Nations • 322 ·

Nations United for Health and, as observers, delegates of thirteen nations not members of the United Nations. T h e Conference lasted five weeks and was very successful. A constitution establishing the World Health Organization was agreed upon and signed on J u l y 22, 1946 b y representatives of fifty-one members of the United Nations and ten nonmembers. T h e principal organ of the World Health Organization was named the Assembly, to be composed of representatives of all member nations and to meet at least once a year. T h e constitution was to enter into legal force when acceptances by twenty-six members of the United Nations were deposited with the Secretary General of the United Nations. Among the difficult problems resolved were: ( i ) T h e admission to membership in the World Health Organization of nonmembers of the United Nations. Those invited to the International Health Conference were permitted to become members by accepting the constitution prior to the first meeting of the Assembly. Others may be admitted b y a majority vote of the Assembly. (2) T h e absorption b y the new organization of the functions of the International Office of Public Health and of the Health Organization of the League of Nations. (3) T h e question of the future relation of the Pan American Sanitary Bureau to the World Health Organization. Article 54 of the constitution of the W o r l d Health Organization defines its future relations to existing regional organizations as follows: " T h e Pan American Sanitary Organization represented b y the Pan American Sanitary Bureau and the Pan American Sanitary Conference and all other intergovernmental regional health organizations in existence prior to the date of signature of this Constitution, shall in due course be integrated with the Organization. This integration shall be effected as soon as practicable through common action based on mutual consent of the competent authorities expressed through the organizations concerned." Under a special arrangement signed at the same time as the constitution, an Interim Commission of eighteen nations was established to carry out certain essential duties and to make plans for the first meeting of the Assembly of the W o r l d Health Organization. This Commission has fulfilled the obligations placed upon it and will report to the Assembly at its first session. Ordinary operations of the Commission have • 323 ·

Public Health in a New Era been financed by loans from the United Nations. The continuation of the United Nations Relief and Rehabilitation Administration fellowship programs and of technical assistance to certain countries which had been receiving aid from U N R R A was made possible by a transfer to the Commission of $3,000,000 of residual U N R R A funds. About two hundred fifty fellowships have been granted. The countries receiving technical assistance are Austria, China, Ethiopia, Hungary, Italy, and Poland. The Interim Commission appointed expert committees on the following subjects: epidemic control, quarantine, tuberculosis, malaria, biologic standardization, pharmacopeia, habit-forming drugs, international lists of causes of death and morbidity, and venereal diseases. Included in the report of the Interim Commission are proposals as to program and budget for the first year of the organization. A budget of approximately $6,300,000 is proposed. The program suggests concentration of effort on the control of malaria, tuberculosis, venereal diseases, and on maternal and child health. Examination of the draft budget, however, shows a maximum of $322,000 devoted to any of these activities, although a share of the amount designated for fellowships should be added in each case and also some part of the overhead expenses of the organization. It is perhaps not a good omen to see a large proportion of the draft budget ($873,000) earmarked for "other activities," but this item indicates the difficulty of securing agreement on programs when many nations and cultures are involved. The Commission also will present to the Assembly a report on the site of the headquarters of the organization. Among the sites proposed are Geneva, London, New York, and Paris. A draft agreement with the United Nations has been prepared as required under Article 57 of the Charter of the United Nations. Similarly, draft agreements with the Pan American Sanitary Bureau and with certain specialized agencies in related fields have been drawn up. Related Work of the United Nations and Other Specialized Agencies. Although there has been a determined effort to free the World Health Organization so far as possible from direct political control, it is recognized that there must be a close operating relationship between all specialized organizations and the United Nations. • 324 ·

Nations United for Health The Economic and Social Council of the United Nations has established commissions in certain fields which are of interest to the World Health Organization. Chief among these are the Population, Statistical, Social, and Narcotic Drugs Commissions. The Statistical Commission is charged with the responsibility of coordinating the statistical work of all the specialized agencies, although the method of achieving this coordination is a matter of mutual agreement in each case. A central statistical unit has been organized within the secretariat of the United Nations. The Population Commission (formerly Demographic Commission) studies and advises the Council on population changes and trends, and the interrelations of economic and social conditions to population trends. The Social Commission advises the Council on social questions not covered by specialized agencies. This Commission is interested in child welfare, traffic in women, crime prevention, and other major social problems. The Commission on Narcotic Drugs advises the Council on all matters relating to the control of narcotics. In addition to these permanent commissions there should be mentioned the International Children's Emergency Fund of the United Nations. The Interim Commission of the World Health Organization is cooperating with the Fund in its campaign for BCG vaccination. Doubtless the World Health Organization will continue this policy of full cooperation with a view to assuming such medical activities of the Fund as are of a permanent or long-time nature when the Fund is liquidated. Four existing specialized agencies have activities in the health field: ( I ) The Food and Agriculture Organization. This organization is by its charter concerned with nutrition and rural hygiene. To utilize fully the facilities of the Food and Agriculture Organization and of the World Health Organization and to prevent overlapping of activities, joint committees of the two organizations will be necessary in these fields. (2) The International Labor Organization. At its twenty-ninth session, the governing board of the International Labor Organization noted with satisfaction the provisions contained in the constitution of • 325 ·

Public Health in a New Era the World Health Organization that the Health Organization would act in Cooperation with other specialized agencies in respect of a number of matters of interest to the International Labor Organization, notably prevention of accidental injury, improvement of nutrition, housing, sanitation, recreation, economic and working conditions and other aspects of environmental hygiene, and promotion of maternal health. (3) The International Civil Aviation Organization. Collaboration between the International Civil Aviation Organization and the World Health Organization is clearly desirable. In certain problems of common interest, especially in the revision of the international sanitary conventions, the World Health Organization will find it useful to call upon experts from the International Civil Aviation Organization for technical advice. Similarly, the International Civil Aviation Organization, which has an interest in aviation medicine, will require from time to time the technical assistance of the World Health Organization. (4) United Nations Educational, Scientific, and Cultural Organization. The responsibilities of the United Nations Educational, Scientific, and Cultural Organization as defined by its constitution include several fields of activity in common with the World Health Organization, especially in the basic sciences and education. The experience of the period of the Interim Commission has shown the practical need for mutual consultation and cooperation in various programs; for example, assistance to scientific institutions, improvement of scientific documentation, coordination of fellowships and grants-in-aid, health education as a part of fundamental education, the so-called basic sciences in medical education and research, nutritional science proposals, coordination of medical science congresses, and others. T o avoid differences of approach and duplication of work on problems of mutual concern, and to coordinate the efforts and increase their effectiveness a provisional arrangement has been made for cooperation between the World Health Organization Interim Commission and the United Nations Educational, Scientific, and Cultural Organization. International Nongovernmental Organizations. There are a large number of nongovernmental organizations with interests closely related to those of the World Health Organization. It will be necessary, .

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Nattons United for Health and mutually advantageous, for the World Health Organization to enter into cooperative relations with several of these, probably including the World Medical Association, the International Union Against Tuberculosis, the International Union Against Venereal Diseases, and the International Union Against Cancer. It is too early to speak of a future International Health Council grouped around the World Health Organization, but, without attempting to influence their policies, the World Health Organization could make available many of its facilities to these organizations. Since the World Health Organization and these various organizations will doubtless be utilizing the services of the same experts, cooperative arrangements would ensure economy of effort. Bilateral Efforts of the United States. For many reasons, political and other, not all international health activities are conducted through the United Nations. This situation is necessary, has advantages, and will probably continue until that remote date when a single world government is established. Nations, like individuals, have their particular friends and business acquaintances. In the health field the United States has many obligations, some having a treaty status, which are the basis for programs of exchange of students between the United States and other countries and for the loan to other countries of scientific and technical personnel. American Republics. Under Public Law 355 of the seventy-sixth Congress, training in the United States is offered to qualified individuals from the other American republics in a large number of fields, including public health. In some instances, all or part of the expenses are borne by the foreign country; in others, all the expenses are borne by the United States. In public health, the awards are made by the Surgeon General of the Public Health Service. Under this law also, scientific and technical personnel are assisting the other American republics. The most recent example in public health is the assignment of a scientist from the National Institute of Health to assist Peruvian workers in the investigation of the effects of the habitual chewing of coca leaves. The Institute of Inter-American Affairs, established during World War II, and now a part of the Department of State, has accomplished • 327 ·

Public Health in a New Era much of permanent value. Through cooperative programs with nearly all of the other American republics, the Institute has constructed health centers, hospitals, sewage and water plants, and has promoted general sanitation and health improvement. To implement its programs the Institute has granted a large number of fellowships. The Smith-Mundt Act. The recent passage of this Act by the eightieth Congress establishes a program for worldwide exchange of persons. The potentialities of this Act are great. A small appropriation was made by Congress for June 1948, but the amount to be made available for the fiscal year 1949 has not yet been determined. The Fulbright Act. The operation of this Act, passed by the seventy-ninth Congress, is slowly getting under way. A large number of countries owe the United States for surplus property, in some cases large sums. Those countries which agree to do so may pay off these debts in local currencies by supporting United States students studying in their universities. It will be possible for some foreign students wishing to study in the United States to receive travel assistance if transportation companies will accept the foreign currencies. Fulbright funds are not subject to annual appropriations and the program is being planned for a period of twenty years. Liberian Mission. As a war measure, the State Department, at the request of the government of Liberia, asked the Public Health Service to send a public health mission to Liberia. This mission, all Negro, is engaged in training Liberian personnel in nursing, sanitary inspection, technical laboratory work, and so forth, and in building up the Liberian Health Department. Philippine Mission. The Public Health Service has also a mission in the Philippines under the Philippine Rehabilitation Act passed by the seventy-ninth Congress. Under this Act, twenty-five Filipino physicians are now doing postgraduate work in public health methods and administration in this country, and some twenty-two others are expected to commence work during 1948. Greek Mission. The American Mission for Aid to Greece has a public health division from the Public Health Service. Approximately fifteen physicians, engineers, and nurses are in this division. It is anticipated that this division will be continued under the European Cooperation Act passed by the eightieth Congress. .328.

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Nongovernmental Agencies. Space does not permit discussion of the activities of United States voluntary agencies and foundations. The earliest endeavors were those of the various church missions, and medical missionaries from the United States are today to be found in the most distant and remote areas. Groups of specialists have been sent out to various European countries by the Unitarian Service Committee. Nonmissionary groups with health interests include the American Bureau for Aid to China, the Greek War Relief Association, the Near East Relief, and many others of importance. Many philanthropic foundations have international interests. The Rockefeller Foundation has engaged in health work in almost all countries of the world in the four decades of its existence. The Kellogg Foundation offers fellowships for Latin American physicians in certain fields. The Prospect. The World Health Organization commences activities under circumstances very different from those under which the Health Organization of the League of Nations began. There were political difficulties then; they are much more serious now. The failure of the United States to join the League resulted in the unnecessary continuation of the International Office of Public Health and in restriction of the development of the League's health activities. Today there is a single health organization, but the extent of cooperation, even in health affairs, between nations of fundamentally divergent ideologies remains to be determined. W e can only hope, with Mr. Raymond Fosdick, that health may be "a rallying point of unity" in this troubled world. It is necessary to broaden the horizons of public health in two directions. First, the objective of the World Health Organization, namely, the highest attainable standard of health for all peoples, is meaningless unless there is a common front against poverty and disease. The health status of a nation or of a community of nations depends upon capacity to pay for indispensable professional and technical services and facilities. The converse is also true. Adequate health personnel and facilities can raise the economic level of a nation and of the community of nations. Secondly, our concept of the scope of international health work • 329

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Public Health in a New Era must be broadened. Even to one untrained in the law it must be obvious that there has been in the past few years a gradual broadening of our ideas of international problems in general. Advancing social legislation on national levels has had its effect on international social thinking. In public health a generation ago, only the transmission of infectious disease from one country to another was thought of as a health matter of international concern. The constitution of the World Health Organization, on the other hand, throws into high relief the interdependence of nations and the need for cooperative efforts in practically every phase of disease prevention and health promotion. All progress in public health depends primarily upon research. In the medical field, and in the sciences underlying medicine, the fundamental discoveries have been truly international and there is no reason to suppose that any one nation will have a monopoly of the genius of the future. This surely establishes a sufficient case for the intention of the World Health Organization "to promote cooperation among scientific and professional groups which contribute to the advancement of health." There is a gigantic task awaiting the World Health Organization in the application of well-established measures. To paraphrase old Sir Thomas Browne: Asia, Africa, and America have brought in their List, Pandora's box has swollen, and there is a strange pathology. All three continents have, in greater or less degree, such preventable infectious diseases as smallpox, diphtheria, malaria, tuberculosis, the dysenteries, schistosomiasis, typhoid fever, and venereal diseases — to mention only a few of the more serious. Large sections of the population of all three continents suffer from malnutrition and from specific deficiency diseases. In even the most advanced areas the risks of death in childbirth and early infancy are far too high. How will the Health Organization function? The general health forum or Assembly will provide an opportunity for the health officers of the world to discuss and debate their problems and to determine how they must be solved. Secondly, some of the expert committees already established by the Interim Commission doubtless will be continued and new ones will • 330

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Nations United for Health be set up from time to time. These committees will assemble, refine, and pass on to the Assembly the scientific knowledge of the day. In the third place there will be a permanent secretariat. This body will be composed of as able health administrators as can be attracted by the unusually generous terms which an international organization can offer. Teams of experts, employed on a short-time basis, will supplement this staff. As confidence in the Health Organization grows, it will not lack for requests to assist national governments in developing their health services. This was the experience of the League; it is the experience of the Pan American Sanitary Bureau. T h e United States government is currently in receipt of requests from foreign governments for the loan of scientific personnel in the health field too numerous to meet. T h e World Health Organization will have to establish some type of world register of experts in all branches of public health and keep it up to date. A specific activity will be the preparation and adoption of regulations concerning nomenclature of diseases, and of standards of safety and potency for biologies and drugs moving in international commerce. A series of regulations to replace the sanitary conventions will also be necessary. These regulations will come into force upon notice to governments, which will of course have opportunity to make reservations or refuse to accept. T h e most important function of the World Health Organization is education. This organization will "promote improved standards of teaching and training in the health, medical and related professions." Professional education can be aided by making representations to governments and by such direct means as fellowships. T h e World Medical Association and the World Health Association working together should do much for medical education throughout the world. T h e World Health Organization "will assist in developing an informed public opinion among all peoples in matters of health." Such popular education, on which in the end the success of the health movement chiefly depends, will be promoted in cooperation with the United Nations Educational, Scientific, and Cultural Organization. Popular education will march also with specific phases of the World Health Organization program. T h e late Dr. William H. Welch used • 331

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Public Health in a New Era to emphasize that popular education relating to tuberculosis had had an effect far beyond its immediate objective. A similar effect will surely follow the necessary educational work which will be part of the World Health Organization's campaign against specific diseases. The peoples of the world have announced their intention to work together to the end that all may share in the benefits of medical and sanitary science. This announcement is a triumph for the public health movement, scarcely a century old. More significantly, it is a challenge to professional health workers to see to it that they are equal to the task of writing a new and wonderful chapter in the history of the human race.

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