82
National Health Service
the M.F.C.M.; and the need to provide increasing responsibility at a rate acceptable to the trainee and the trainers. In clinical specialties, the senior registrar will already have a higher qualification, and be able to take important
responsibility.
COMMUNITY MEDICINE: HAS IT A FUTURE? CONSIDERATIONS OF MANPOWER
PAUL J. HEATH
WILFRID H. PARRY
Sheffield Area Health Authority (Teaching) PATTERN OF TRAINING
COMMUNITY medicine represents a progressive combined development of medical administration and public health. As with any other discipline, the subject matter is continually changing, and important factors which have emerged from the reorganisation of community medicine are: (a) increased utilisation of techniques derived from many sources, in particular the behavioural sciences;’ (b) rationalisation of training; (c) founding of the Faculty of Community Medicine (referred to subsequently as the faculty); and (d) continuing change in the organisation of patient care. Comparisons are often drawn between the training of specialists in community medicine and in clinical subjects, but in practice there are many differences. The period up to and including general professional training, recommended in the report of the Royal Commission on Medical Education,2 is similar for all branches of medical practice. A doctor planning a career in community medicine should obtain a varied clinical experience, preferably in both hospital and general practice, before starting specific training. There are special posts in various parts of the country which attempt to combine clinical experience with an introduction to community medicine, thus retaining flexibility in early training in case trainees should feel that the specialty had less of an appeal than was felt initially. At the stage of registrar in community medicine, the individual is in a position not unlike that of the senior house officer in clinical specialties, in that he or she will be working for part I of the appropriate professional qualification (in this case Membership of the Faculty—M.F.c.M.), and most will be new to the specialty, their clinical training having provided no practical introduction. Thus they cannot be given satisfactory responsibility, and efforts should be directed towards grasping the essential principles of a very different type of specialty whilst covering the academic work for the first part of the M.F.C.M. The Royal Commission2 recommended that, to smooth the transition from clinical to social medicine, the third year of general professional training should be spent in a junior administrative appointment or a research or teaching post, a pattern since adopted by the faculty. As more recruits to the specialty enter by way of such training posts, the position of the community medicine registrar will become more like that of his clinical
colleague. During the early senior registrar period, unlike most clinical specialties, the full higher professional qualification will still not have been obtained, and this period may be regarded as a combination of the following: the development of an ability to think in terms of community health; work carried out under supervision and aimed at completion of the thesis for part u of
Numerically, the specialty of community medicine always remain small, representing approximately 6-5% of the total of consultants (including academics) in England and Wales. At present there are, in England and Wales, a disproportionate number of vacancies in all grades, together with doctors who, before reorganisation, were working in either medical administration or public health, and who are not in a substantive post (the "latched-on" medical staff). In addition, there are a few registrars and several senior registrars in post, but a major problem is the number of retirements expected within the next ten years (31% of those in post), reflecting the general age distribution of those appointed in
will
1974. In September, 1975, there were 119 vacancies in England and Wales, of which 40% were in health-care planning and information posts. The Working Party on Transferred Medical Officers in 19743 sent a questionary to all doctors working in either public health or medical administration before reorganisation, or in community medicine after that date. Of 366 questionaries distributed, 251 (68%) were returned, and of these, 94 respondents indicated that they wished to pursue a career in community medicine. There were also 27 who indicated an interest, but preferred to await the report of the Court Committee. Of the 94 doctors 51will retire within the next five to ten years (assuming normal retirement ages). Only 19 (20%) would be prepared to move house, whilst 57 (61%) would be prepared to commute to a new job; most need to find posts near to their homes (even allowing for commuting); therefore, many of those involved will be unlikely to take substantive posts and should be found posts either in a supernumerary grade or as defined in paragraph 8 of the Report on Doctors’ and Dentists’ Remuneration.4 TABLE I--COMMUNITY PHYSICIAN POSTS LIKELY TO BECOME VACANT DUE
TO RETIREMENT, BY YEAR AND TYPE OF POST
This table
that all doctors retire medical officer. medical officer.
assumes
at
65.
R.M.o.=regional A.M.o.=area
c.B.=capital building M.s.=medical staffing, R=region, A=area. H.c.p.=health-care planning; R=region; A=area. s.s.=social services. c.H.=chlld health. E.H.=environmental health. D.c.p.=distnct community physician. *General duues. tDlstnct support.
83 TABLE 11-PROGRESS OF TRAINEES THROUGH RECOMMENDED TRAINING
PROGRAMME, 1975-1984
At
a
generous
estimate, 25% of the 75 who would
not
prepared to move house (approximately 19 people) might be so placed that they could, after further training, take career posts within commuting distance. Thus 38 career posts might be filled from this source. The numbers of those expected to retire in the next
applied to the national picture to construct which III attempts to show the rate at which currently empty posts will be filled assuming the situation shown in table n obtains. Vacancies do not start to decline steadily until 1979/80. This date may vary slightly with the training time required for the 38 people included for the year 1977. In practice, recruitment may be at a rate well below 30 per annum, when stabilisation would take considerably longer. Similarly, there may be losses of personnel currently in post for reasons other than retirement, plus losses during training. Thus, for some considerable time community medicine, at the levels covered in this discussion will have a significant proportion of vacancies within the career grades.
table table
II were
be
years are shown in table i. The totals show three peak years: 1979, 1980, and 1982. As recruitment becomes more regular, losses from this cause will probably show less fluctuation. An important point when considering retirements is the rate at which the key posts of regional and area medical officers fall vacant and the likely field of recruitment for their successors. The importance of these vacancies is the potential of their new incumbents for influencing the development of the specialty. At present there are 44 registrars and 10 senior registrars in post, and the aim is to recruit 30 per annum into each grade. Table 11 shows the expected numbers of community physicians produced by the present training patterns; in compiling the table the following assumptions were made: (1) The durations recommended by the faculty for the registrar and senior registrar grades will be two years and three ten
(2)
years, respectively. Half the registrars at present in post have
completed
one
year’s training. (3) Half the senior registrars at present in post have completed one year’s training. (4) New recruits will enter at the rate of 30 per annum. (5) No delays will result from examination failure, or inability to
obtain substantive posts.
(6) No specialists will withdraw from
a post after appointment. It would seem that a steady output of trained people will not be achieved until 1981, although several of the assumptions could be challenged. However, data from
TABLE III-FILLING OF VACANCIES IN COMMUNITY
MEDICINE,
1975-1984
SCHEMES OF TRAINING
It is, therefore, apparent that training must be both sound and attractive. There are three basic patterns:
(1) (2)
(3)
Full-time university courses with one year’s academic work plus a year spent in research for a thesis. Part-time university courses involving two to three day’s academic work per week during term, the remainder being spent in a service training post with a recognised authority-candidates on both courses usually obtain a M.sc. and will normally proceed to the M.F.C.M. Part-time academic work undertaken in "modules", these being interspersed by periods of practical training; the latter is divided between region, area, and district to broaden the experience
Pattern 3 is adopted in, for instance, the Northern Consortium, covering the north of England and North-
Ireland. Since many of the recruits could well be married with families, training must take account of this. The fulltime course is probably only suitable for those with a centre close enough for them to attend and still maintain normal family contacts. Ideally, more universities should run such courses, but there are difficulties both in gathering the necessary combination of teaching skills and in recruiting sufficient trainees. The part-time course is a compromise and assumes that the centre is within reasonable travelling distance. In both full-time and part-time courses the student obtains academic and professional qualifications simultaneously incorporating into the training a research element as recommended in the Royal Commission’s
ern
Report.2 The consortium approach combines elements of the other two: there is some discontinuity in both academic and practical training and travelling time can be considerable. Students travel to several centres for periods of one to three weeks to take academic modules, each university being responsible for teaching one or more aspects of the academic curriculum; the practical training is organised through the various regional health authorities. Students will take the M.F.c.M. as before, but without the opportunity to obtain a M.sc. degree. DISCUSSION
I
I
*[ncluj,ng 119 posts currently vacant 71ncluJlOg 38 people who, it is assumed, will fill substantive posts after further IfawJn,5
Manpower planning in community medicine has recently received a severe setback after the direction from the Secretary of State that costs of administration must be reduced. All community physicians recognise that administrative costs have become excessive, although it must be said that, before reorganisation, many of
84 them warned that this would
happen and that the patadopted was unsatisfactory; a more cautious, experimental and piecemeal approach was felt to be desirable. Now we are faced with no development during 1976/77 and a possible reduction in expenditure of between 5 and 10% over 1977/79. Community medicine should bear its share of these cuts, but we must be quite certain that this share is a fair one in comparison with non-medical and non-nursing administrative staff whose numbers have increased by up to 30-40% in some cases. The risk of an excessive burden on community medicine follows from two important facts. Firstly, the total number of practitioners originally working in public health before 1974 was cut by a significant proportion during reorganisation, and is only now beginning slowly to recover as establishments expand. Secondly, the standstill in 1976/77 is based on staff in post in March, 1976, thereby excluding all vacant posts an important point in a specialty with approximately 20% of its estab-
than it has ever been, despite the widely spread responsibility for management in the more complex patterns of the new organisation.
lished posts vacant. All manpower forecasts must be integrated with economic objectives, particularly at the present time, and it would be unwise to attempt to expand community medicine at an unrealistic rate. However, the rate of increase must take full account of the numbers already partially trained and who wish to return to community medicine, in addition to a core of highly trained new recruits. The D.H.S.S. target of 30 new recruits per year to the registrar grade is equivalent to a rate of increase of 4% (taking Department of Health doctors into account), falling steadily to 3-5% per annum after 5 years and continuing to fall slightly thereafter. This rate of increase may be thought inadequate in view of the present number of vacancies, but it is unlikely that any higher rate could be sustained in view of lack of finance and of the recruitment possibilities. The morality of the action of Government in allowing administrative structures to build up and in recommending recruitment-rates comparable with those in clinical specialties, whilst being aware of the inevitable need eventually to make drastic cuts, must be questioned. But it may be appropriate under these circumstances, taking into account the nature of community medicine, to look carefully at the need for a permanent sub-specialist grade, possibly employed part-time. This would enable many people to contribute to the specialty who might not otherwise be in a position to do so. Many specialists have taken advantage of the opportunity to purchase "added years" and their early retirement could well make a considerable difference to the picture within the next few years. The importance of manpower planning in such a small specialty cannot be over-emphasised. There is, in addition, a need for counselling and advice at all stages in the careers of those who are in the training grades, which should be a specific responsibility of regional faculty advisers, but which cannot be ignored by any community physician. The people whom we should aim
CHOLERA TRANSMISSION NEAR A CHOLERA HOSPITAL
tern
have had an adequate training in the basic subjects of their specialty and the type of course offered must be no less rigorous or satisfying, in both content and presentation, than equivalent training programmes in clinical specialties. It is essential that the community physician of the future should be able to command the respect and confidence of all those with whom he or she will need to work; medical leadership in the provision of health care to populations is no less vital to attract must
We thank Dr R. A. Franklin and Dr A. G. Brown for advice and assistance in the preparation of this article. Requests for reprints should be addressed to P.J.H., Sheffield Area Health Authority (Teaching), Westbrook House, Sharrow Vale Road, Sheffield S 11 8EU. REFERENCES
1. 2.
Heath, P. J. Community Hlth, 1974, 5, 178. Report of the Royal Commission on Medical Education. H.M. Stationery Office, 1968. 3. Report of the Working Party on Transferred Medical Officers. British Medical Association, 1974. 4. Third Report of the Review Body on Doctors’ and Dentists’ Remuneration (First Supplement), H.M. Stationery Office, 1973.
Public Health
RICHARD J. LEVINE* STANISLAUS D’SOUZA
MOTIUR R. KHAN DAVID R. NALIN
Center for Disease Control, United States Public Health Service, Atlanta, Georgia, U.S.A., Epidemiology Division, Cholera Research Laboratory, Dacca, Bangladesh; Johns Hopkins University School of Hygiene, Department of Biostatistics, and Johns Hopkins University International Center for Medical Research, Dacca, Bangladesh, and Baltimore, Maryland 21205, U.S.A.
A review of the incidence of cholera from 1964 through 1974 in Matlab, Bangladesh, revealed that among the villages several had very high incidence-rates. Investigation indicated that high cholera-rates in two of these villages were probably related to water contamination from a nearby cholera hospital established in 1963. The data imply
Summary
heavy contamination can overcome resulting from repeated exposure.
that
any
immunity
INTRODUCTION
FIELD surveillance for cholera and collection of demographic data began in Matlab in late 1963 and a local cholera hospital, first on a canal-barge, then in a building, was established. Free ambulance boats were available day and night 1968-71 to bring patients to the hospital. area included 225 000 persons By 1968 the surveillance in 234 villages. 1-5 McCormack et al.’ reviewed data for 1964-1966 and found that most cases occurred during major winter and minor spring epidemics and were geographically widely scattered. He noted that the establishment of the vaccine trial area and hospital might alter natural cholera epidemiology. In the present study, the incidence of cholera over 11 years in Matlab was reviewed. While the overall pattern described earlier remained, several villages had consistently high incidence-rates. This report examines the hypothesis that high rates in two of the villages (8.6, 10-9 per 1000 annually) were related to contamination of canal water associated with the nearby cholera hospital. *Present address: Epidemiology Bureau, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
National Health Service
the M.F.C.M.; and the need to provide increasing responsibility at a rate acceptable to the trainee and the trainers. In clinical specialties, the senior registrar will already have a higher qualification, and be able to take important
responsibility.
COMMUNITY MEDICINE: HAS IT A FUTURE? CONSIDERATIONS OF MANPOWER
PAUL J. HEATH
WILFRID H. PARRY
Sheffield Area Health Authority (Teaching) PATTERN OF TRAINING
COMMUNITY medicine represents a progressive combined development of medical administration and public health. As with any other discipline, the subject matter is continually changing, and important factors which have emerged from the reorganisation of community medicine are: (a) increased utilisation of techniques derived from many sources, in particular the behavioural sciences;’ (b) rationalisation of training; (c) founding of the Faculty of Community Medicine (referred to subsequently as the faculty); and (d) continuing change in the organisation of patient care. Comparisons are often drawn between the training of specialists in community medicine and in clinical subjects, but in practice there are many differences. The period up to and including general professional training, recommended in the report of the Royal Commission on Medical Education,2 is similar for all branches of medical practice. A doctor planning a career in community medicine should obtain a varied clinical experience, preferably in both hospital and general practice, before starting specific training. There are special posts in various parts of the country which attempt to combine clinical experience with an introduction to community medicine, thus retaining flexibility in early training in case trainees should feel that the specialty had less of an appeal than was felt initially. At the stage of registrar in community medicine, the individual is in a position not unlike that of the senior house officer in clinical specialties, in that he or she will be working for part I of the appropriate professional qualification (in this case Membership of the Faculty—M.F.c.M.), and most will be new to the specialty, their clinical training having provided no practical introduction. Thus they cannot be given satisfactory responsibility, and efforts should be directed towards grasping the essential principles of a very different type of specialty whilst covering the academic work for the first part of the M.F.C.M. The Royal Commission2 recommended that, to smooth the transition from clinical to social medicine, the third year of general professional training should be spent in a junior administrative appointment or a research or teaching post, a pattern since adopted by the faculty. As more recruits to the specialty enter by way of such training posts, the position of the community medicine registrar will become more like that of his clinical
colleague. During the early senior registrar period, unlike most clinical specialties, the full higher professional qualification will still not have been obtained, and this period may be regarded as a combination of the following: the development of an ability to think in terms of community health; work carried out under supervision and aimed at completion of the thesis for part u of
Numerically, the specialty of community medicine always remain small, representing approximately 6-5% of the total of consultants (including academics) in England and Wales. At present there are, in England and Wales, a disproportionate number of vacancies in all grades, together with doctors who, before reorganisation, were working in either medical administration or public health, and who are not in a substantive post (the "latched-on" medical staff). In addition, there are a few registrars and several senior registrars in post, but a major problem is the number of retirements expected within the next ten years (31% of those in post), reflecting the general age distribution of those appointed in
will
1974. In September, 1975, there were 119 vacancies in England and Wales, of which 40% were in health-care planning and information posts. The Working Party on Transferred Medical Officers in 19743 sent a questionary to all doctors working in either public health or medical administration before reorganisation, or in community medicine after that date. Of 366 questionaries distributed, 251 (68%) were returned, and of these, 94 respondents indicated that they wished to pursue a career in community medicine. There were also 27 who indicated an interest, but preferred to await the report of the Court Committee. Of the 94 doctors 51will retire within the next five to ten years (assuming normal retirement ages). Only 19 (20%) would be prepared to move house, whilst 57 (61%) would be prepared to commute to a new job; most need to find posts near to their homes (even allowing for commuting); therefore, many of those involved will be unlikely to take substantive posts and should be found posts either in a supernumerary grade or as defined in paragraph 8 of the Report on Doctors’ and Dentists’ Remuneration.4 TABLE I--COMMUNITY PHYSICIAN POSTS LIKELY TO BECOME VACANT DUE
TO RETIREMENT, BY YEAR AND TYPE OF POST
This table
that all doctors retire medical officer. medical officer.
assumes
at
65.
R.M.o.=regional A.M.o.=area
c.B.=capital building M.s.=medical staffing, R=region, A=area. H.c.p.=health-care planning; R=region; A=area. s.s.=social services. c.H.=chlld health. E.H.=environmental health. D.c.p.=distnct community physician. *General duues. tDlstnct support.
83 TABLE 11-PROGRESS OF TRAINEES THROUGH RECOMMENDED TRAINING
PROGRAMME, 1975-1984
At
a
generous
estimate, 25% of the 75 who would
not
prepared to move house (approximately 19 people) might be so placed that they could, after further training, take career posts within commuting distance. Thus 38 career posts might be filled from this source. The numbers of those expected to retire in the next
applied to the national picture to construct which III attempts to show the rate at which currently empty posts will be filled assuming the situation shown in table n obtains. Vacancies do not start to decline steadily until 1979/80. This date may vary slightly with the training time required for the 38 people included for the year 1977. In practice, recruitment may be at a rate well below 30 per annum, when stabilisation would take considerably longer. Similarly, there may be losses of personnel currently in post for reasons other than retirement, plus losses during training. Thus, for some considerable time community medicine, at the levels covered in this discussion will have a significant proportion of vacancies within the career grades.
table table
II were
be
years are shown in table i. The totals show three peak years: 1979, 1980, and 1982. As recruitment becomes more regular, losses from this cause will probably show less fluctuation. An important point when considering retirements is the rate at which the key posts of regional and area medical officers fall vacant and the likely field of recruitment for their successors. The importance of these vacancies is the potential of their new incumbents for influencing the development of the specialty. At present there are 44 registrars and 10 senior registrars in post, and the aim is to recruit 30 per annum into each grade. Table 11 shows the expected numbers of community physicians produced by the present training patterns; in compiling the table the following assumptions were made: (1) The durations recommended by the faculty for the registrar and senior registrar grades will be two years and three ten
(2)
years, respectively. Half the registrars at present in post have
completed
one
year’s training. (3) Half the senior registrars at present in post have completed one year’s training. (4) New recruits will enter at the rate of 30 per annum. (5) No delays will result from examination failure, or inability to
obtain substantive posts.
(6) No specialists will withdraw from
a post after appointment. It would seem that a steady output of trained people will not be achieved until 1981, although several of the assumptions could be challenged. However, data from
TABLE III-FILLING OF VACANCIES IN COMMUNITY
MEDICINE,
1975-1984
SCHEMES OF TRAINING
It is, therefore, apparent that training must be both sound and attractive. There are three basic patterns:
(1) (2)
(3)
Full-time university courses with one year’s academic work plus a year spent in research for a thesis. Part-time university courses involving two to three day’s academic work per week during term, the remainder being spent in a service training post with a recognised authority-candidates on both courses usually obtain a M.sc. and will normally proceed to the M.F.C.M. Part-time academic work undertaken in "modules", these being interspersed by periods of practical training; the latter is divided between region, area, and district to broaden the experience
Pattern 3 is adopted in, for instance, the Northern Consortium, covering the north of England and North-
Ireland. Since many of the recruits could well be married with families, training must take account of this. The fulltime course is probably only suitable for those with a centre close enough for them to attend and still maintain normal family contacts. Ideally, more universities should run such courses, but there are difficulties both in gathering the necessary combination of teaching skills and in recruiting sufficient trainees. The part-time course is a compromise and assumes that the centre is within reasonable travelling distance. In both full-time and part-time courses the student obtains academic and professional qualifications simultaneously incorporating into the training a research element as recommended in the Royal Commission’s
ern
Report.2 The consortium approach combines elements of the other two: there is some discontinuity in both academic and practical training and travelling time can be considerable. Students travel to several centres for periods of one to three weeks to take academic modules, each university being responsible for teaching one or more aspects of the academic curriculum; the practical training is organised through the various regional health authorities. Students will take the M.F.c.M. as before, but without the opportunity to obtain a M.sc. degree. DISCUSSION
I
I
*[ncluj,ng 119 posts currently vacant 71ncluJlOg 38 people who, it is assumed, will fill substantive posts after further IfawJn,5
Manpower planning in community medicine has recently received a severe setback after the direction from the Secretary of State that costs of administration must be reduced. All community physicians recognise that administrative costs have become excessive, although it must be said that, before reorganisation, many of
84 them warned that this would
happen and that the patadopted was unsatisfactory; a more cautious, experimental and piecemeal approach was felt to be desirable. Now we are faced with no development during 1976/77 and a possible reduction in expenditure of between 5 and 10% over 1977/79. Community medicine should bear its share of these cuts, but we must be quite certain that this share is a fair one in comparison with non-medical and non-nursing administrative staff whose numbers have increased by up to 30-40% in some cases. The risk of an excessive burden on community medicine follows from two important facts. Firstly, the total number of practitioners originally working in public health before 1974 was cut by a significant proportion during reorganisation, and is only now beginning slowly to recover as establishments expand. Secondly, the standstill in 1976/77 is based on staff in post in March, 1976, thereby excluding all vacant posts an important point in a specialty with approximately 20% of its estab-
than it has ever been, despite the widely spread responsibility for management in the more complex patterns of the new organisation.
lished posts vacant. All manpower forecasts must be integrated with economic objectives, particularly at the present time, and it would be unwise to attempt to expand community medicine at an unrealistic rate. However, the rate of increase must take full account of the numbers already partially trained and who wish to return to community medicine, in addition to a core of highly trained new recruits. The D.H.S.S. target of 30 new recruits per year to the registrar grade is equivalent to a rate of increase of 4% (taking Department of Health doctors into account), falling steadily to 3-5% per annum after 5 years and continuing to fall slightly thereafter. This rate of increase may be thought inadequate in view of the present number of vacancies, but it is unlikely that any higher rate could be sustained in view of lack of finance and of the recruitment possibilities. The morality of the action of Government in allowing administrative structures to build up and in recommending recruitment-rates comparable with those in clinical specialties, whilst being aware of the inevitable need eventually to make drastic cuts, must be questioned. But it may be appropriate under these circumstances, taking into account the nature of community medicine, to look carefully at the need for a permanent sub-specialist grade, possibly employed part-time. This would enable many people to contribute to the specialty who might not otherwise be in a position to do so. Many specialists have taken advantage of the opportunity to purchase "added years" and their early retirement could well make a considerable difference to the picture within the next few years. The importance of manpower planning in such a small specialty cannot be over-emphasised. There is, in addition, a need for counselling and advice at all stages in the careers of those who are in the training grades, which should be a specific responsibility of regional faculty advisers, but which cannot be ignored by any community physician. The people whom we should aim
CHOLERA TRANSMISSION NEAR A CHOLERA HOSPITAL
tern
have had an adequate training in the basic subjects of their specialty and the type of course offered must be no less rigorous or satisfying, in both content and presentation, than equivalent training programmes in clinical specialties. It is essential that the community physician of the future should be able to command the respect and confidence of all those with whom he or she will need to work; medical leadership in the provision of health care to populations is no less vital to attract must
We thank Dr R. A. Franklin and Dr A. G. Brown for advice and assistance in the preparation of this article. Requests for reprints should be addressed to P.J.H., Sheffield Area Health Authority (Teaching), Westbrook House, Sharrow Vale Road, Sheffield S 11 8EU. REFERENCES
1. 2.
Heath, P. J. Community Hlth, 1974, 5, 178. Report of the Royal Commission on Medical Education. H.M. Stationery Office, 1968. 3. Report of the Working Party on Transferred Medical Officers. British Medical Association, 1974. 4. Third Report of the Review Body on Doctors’ and Dentists’ Remuneration (First Supplement), H.M. Stationery Office, 1973.
Public Health
RICHARD J. LEVINE* STANISLAUS D’SOUZA
MOTIUR R. KHAN DAVID R. NALIN
Center for Disease Control, United States Public Health Service, Atlanta, Georgia, U.S.A., Epidemiology Division, Cholera Research Laboratory, Dacca, Bangladesh; Johns Hopkins University School of Hygiene, Department of Biostatistics, and Johns Hopkins University International Center for Medical Research, Dacca, Bangladesh, and Baltimore, Maryland 21205, U.S.A.
A review of the incidence of cholera from 1964 through 1974 in Matlab, Bangladesh, revealed that among the villages several had very high incidence-rates. Investigation indicated that high cholera-rates in two of these villages were probably related to water contamination from a nearby cholera hospital established in 1963. The data imply
Summary
heavy contamination can overcome resulting from repeated exposure.
that
any
immunity
INTRODUCTION
FIELD surveillance for cholera and collection of demographic data began in Matlab in late 1963 and a local cholera hospital, first on a canal-barge, then in a building, was established. Free ambulance boats were available day and night 1968-71 to bring patients to the hospital. area included 225 000 persons By 1968 the surveillance in 234 villages. 1-5 McCormack et al.’ reviewed data for 1964-1966 and found that most cases occurred during major winter and minor spring epidemics and were geographically widely scattered. He noted that the establishment of the vaccine trial area and hospital might alter natural cholera epidemiology. In the present study, the incidence of cholera over 11 years in Matlab was reviewed. While the overall pattern described earlier remained, several villages had consistently high incidence-rates. This report examines the hypothesis that high rates in two of the villages (8.6, 10-9 per 1000 annually) were related to contamination of canal water associated with the nearby cholera hospital. *Present address: Epidemiology Bureau, Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
