D istrib u tedto th e Council

and th e M embers C. 27 , M. 13 . 1923. h i .

of th e League.]

Geneva,
J a n u a ry 25th, 1923.

LEAGUE OF NATIONS

HEALTH COMMITTEE

M INUTES OF THE FIFTH SESSION

HELD AT GENEVA, JA N U AR Y 8th TO i 3th, 1923

 LIST OF MEMBERS OF THE COMMITTEE

T he following m em beis ol th e C om m ittee particip ated in the delibeiations of th e fifth session:

Professor Th. M a d s e n , D irector of th e S tate Serum In stitu te , Copenhagen.

Chairman.

Sir George B u c h a n a n , Senior Medical Officer of th e M inistry of H ealth , London.

C. B ., M .D ., Vice-Chairman.

Professor Léon B e r n a r d , Professor of H ygiene a t th e F acu lty of M edicine of th e University

of Paris.

Dr. F . C a r o z z i , H ead of th e In d u strial H e alth Section of the International

L abour Office.

Dr. H . C a r r i è r e , D irector of th e F ederal H e alth D ep artm en t, Berne.

Dr. C h o d z k o , M inister of Public H ealth, W arsaw.

M. K usama of th e K ita sa to In stitu te for Infectious Diseases, Tokio; Pro­

( s u b s t it u t e fo r D r . MiYAjlM A), fessor of th e M edical College, Keio U niversity, Tokio.

Dr. L u t r a r i o , D irector-G eneral of th e H ealth D ep artm en t a t th e Ministry ol

th e In terio r, Rom e.

Professor B . N o c h t , of th e In s titu te of Tropical Diseases, H am burg.

Professor D r. S a n t o l i q u i d o , A dviser on M atters of In te rn a tio n a l H e alth to th e League of

R ed Cross Societies.

M. O. V e l g h e , D irector-G eneral of th e H ealth D ep artm en t a t th e Ministry of

th e In terio r an d of H ealth , Brussels.

D r. R a j c h m a n , th e M edical D irector, acted as S ecretary of th e Com m ittee.

A bsent: D r. Josephine B a k e r ,
Professor C a l m e t t e ,
Dr. Carlos C h a g a s ,
Sir H avelock C h a r l e s , G. G. V. O.,
Dr. Angel P u l i d o .
 AGENDA.

Approved by the Committee January 8th, 1923.

1. R eport on th e w ork of th e H ealth O rganisation since August 1922.

R apporteur: Medical D irector.

2. R eport on th e two Serological Conferences.

Rapporteur : Prof. T h. Madsen.

3. R eport on th e Conference of Medical Officers of H ealth p articipating in th e first experim ent

in interch an g e of public h ea lth personnel.
R apporteur: M. Velghe.

4. R eport on th e w ork of th e Epidem ic Commission.

Rapporteur : Sir George B uchanan.

5. R eport of th e W aterw ays Sub-C om m ittee.

Rapporteur: Dr. Chodzko.

6. R eport of th e N ear E a st Sub-C om m ittee.

Rapporteur : Sir George B uchanan.

7. R eport of th e F a r E a s t Sub-C om m ittee.

R apporteur: Professor C alm ette.

8. R eport of th e J o in t O pium Sub-Com m ittee.

R apporteur: D r. Carrière.

9. Service of Epidem iological Intelligence and Public H ealth Statistics.

10. R eport on th e S tan d ard isatio n of Biological Products by H. D r H. Dale.

11. Miscellaneous :
(a) A p po intm ent of a represen tativ e of th e U nited S tates Public H ealth Service as
m em ber of th e H ealth Com m ittee.
(b) C ollaboration w ith th e In tern atio n al S anitary B ureau at W ashington.
(c) M useum of H ygiene a t Dresden.
 F IR S T MEETING

Held on January 8th, 1923, at 3 p.m.

1. Opening of the Session.

T he C h a i r m a n , declaring th e m eeting to be open, welcomed th e m em bers of th e Committee

an d greeted Professor N ocht on behalf of th e Com mittee.
H e reg retted th e absence from the C om m ittee of Dr. C alm ette, D r. Pulido, Sir H avelock Charte
and D r. Chagas, who h a d begged to be excused. M. M iyajim a was replaced b y M. K usam a.
H e inform ed th e C om m ittee th a t D r. Josephine B aker was prev en ted , for reasons of health,
from assisting in th e w ork of th e Com mittee, and proposed to address to h er th e good wishes of
th e C om m ittee for her recovery and to express th e hope th a t she would ta k e p a rt in the next
session.
T h is proposal was adopted.

2. Collaboration between the Health Committee and the Public Health Service of the United
States.

T he C h a i r m a n rem inded the C om m ittee of th e term s of th e in v ita tio n w hich he h a d addressed

to Surgeon-G eneral C um m ing, of the Public D e p artm en t of H e a lth a t W ash in g ton (Annex 1).
H e inform ed th e C om m ittee th a t Surgeon-G eneral Cum m ing h ad replied th a t he w ould be happy
to sit on th e H ealth C om m ittee of th e League in an advisory capacity.
T he C om m ittee, hav in g ta k e n cogniscance of the correspondence betw een Prof. Madsen and
Surgeon-G eneral Cum ming, decided :
(a) To express its sense of th e desirability of its w ork being associated w ith that of
th e Public H e alth Service of th e U nited S tates ;
(b) To com m unicate th e correspondence in question to th e Council for such action
as it m ay desire.

3. Collaboration between the Health Comm ittee and the People’s C om m issariat for Public
Health at Moscow.

T he C h a i r m a n rem inded th e C om m ittee th a t th e E pidem ic Com mission h ad concluded an

arran g em en t a t Genoa w ith th e representatives of th e R ussian G overnm ent, which guaranteed
to th e agents of th e Com mission th e im m unities a n d privileges necessary for th e ir w ork and assured
th em of th e assistance of th e Soviet authorities. This arran g e m e n t p ro vid ed th a t th e Epidemic
Commission should be considered for its w ork in R ussia as th e execu tiv e org an of a n international
com m ission com posed of th e H ealth C om m ittee of th e L e a g u e of N ations a n d a representative
of th e P eople’s C om m issariat for Public H ealth . T he m eeting of th e H ealth C om m ittee in August
1922 provided an o p p o rtu n ity for convening th e In te rn a tio n a l Com mission in accordance w ith this
arrangem ent. T he H e alth C om m issariat a t Moscow only replied, how ever, to th e notification
addressed to it afte r th e A ugust session of 1922. The C om m issariat h ad been inform ed that the
n ex t session would tak e place in J a n u a ry 1923. Dr. Siem ashko, C om m issary of th e People for
P ublic H ealth, h ad come to G eneva in order to discuss th e questio n of th e epidem ics in Russia
an d th e C hairm an proposed th a t he should assist a t th e m eetings w hich d is c u s s e d questions
concerning R ussia in regard to which the inform ation a t his disposal m ight be valuable.
Sir George B u c h a n a n drew th e a tte n tio n of th e C om m ittee to th e d an g er of creating a p rece'
dent. I t m ust n o t be supposed th a t any M inister of P ublic H e a lth who h ap p en ed to be staying
in G eneva should regard him self as havin g a rig h t to b e p resen t a t th e m eetings of th e Committee
to discuss questions of in tere st to his country.
 Dr. R a j c h m a n , in order to explain th e character of th e in v itatio n addressed to D r Siemashko
read the telegram w hich he h ad sen t to D r. Siem ashko w ith th e au th o rity of th e Chairman!
He reminded th e C om m ittee th a t Dr. Siem ashko m ight ask for a m eeting of the In tern atio n al
Commission, of w hich th e E pidem ic Commission in R ussia was the executive organ. He thought
it w ould be useful to h e a r Dr. Siem ashko on the situ atio n in Russia.

Sir G e o rg e B u c h a n a n a p p r o v e d t h e p r o p o s a l o f t h e C hairm an, s u b j e c t t o t h e r e se r v a tio n th a t

in order t h a t f u t u r e p r o c e d u r e m i g h t n o t b e p r e ju d ic e d , Dr. Siem ashko s h o u ld n o t b e in v it e d to t h é
discussion o f c e r t a i n q u e s t i o n s w h i c h s h o u l d b e d e a lt w it h s o l e ly b y m e m b e r s o f t h e Committee.

Following a n exchange of views, in which Professor Léon B e r n a r d , M. V e l g h e and the

Chairman to o k p a rt, it was agreed th a t th e Com m ittee was free a t all tim es to invite strangers to
be present in p a rtic u la r cases an d when precise questions were under discussion.
The C om m ittee decided to convene on th e following d ay th e In tern atio n al Commission,
composed of th e H e alth C om m ittee and of th e rep resen tativ e of the People’s Commissariat for
Public H ealth. (F or m in u tes of th e m eetings of th e In tern atio n al Commission see Annex 2.)

4 . Centenary of Pasteur.

The C h a i r m a n inform ed th e C om m ittee th a t he had already, in th e nam e of th e H ealth

Committee, on th e occasion of th e celebration a t th e P asteu r In stitu te on December 27th, sent
a telegram to Dr. R oux an d received a message of th an k s for it.
On th e proposal of th e C h a i r m a n , th e C om m ittee proposed th e following resolution :
"The H e a lth C om m ittee, conscious th a t its technical activ ity is deeply rooted in
th e w ork of P a ste u r, an d convinced th a t th e ideas of P asteu r harm onise in their
h u m a n ita ria n c h a ra c te r w ith th e spirit which inspires th e League of N ations and in
w hich th e League of N atio ns was co n stitu ted , suggests to th e Council th a t th e League of
N ations should associate itself, b y some m eans to be hereafter determ ined, w ith th e trib ­
u tes p aid on th e occasion of P asteu r's centenary b y all th e nations of th e world to the
m em ory of th e g reat scientist and benefactor of hum an ity .
This resolution was unanim ously adopted.

5. Report of the M edical Director.

The C h a i r m a n in v ited th e Medical D irector to present his report to th e Committee. He

suggested th a t, a fte r th e rep o rt h a d been presented, the C om m ittee should proceed w ith a general
discussion a n d su b seq u en tly ta k e th e rep o rt in detail. Certain sections of th e report m ight be
discussed a t once, b u t th e sections on w hich special repo rts would be presented to th e Committee
might be conveniently postponed.
Dr. R a j c h m a n presen ted h is rep o rt (Annex 3 ).
The C h a i r m a n th a n k e d D r. R ajch m an for his report and in v ited a general discussion.
M. V e l g h e d o u b te d w h eth er ït was advisable to s ta rt a general discussion im m ediately.
There were, how ever, special p o in ts which m ight be tak e n at once. As one who h ad been present
at the discussions of th e Second C om m ittee of th e T hird Assembly he would like to assure th e Com­
mittee th a t th e m ost fav o urable views h ad been entertained by th e Assembly regarding the work
of the H ealth O rganisation. All th e criticism raised h ad been due to financial considerations and
had not been aim ed a t th e H e alth O rganisation in particular. I t h ad been due to a general wish
to cut down exp end itu re. T h e C om m ittee m ight continue its work w ith confidence pending a
settlement of th e financial problem .
Sir George B u c h a n a n suggested th a t th e order of th e discussion of th e report should be fixed.
He thought it w ould be useful to h av e a discussion on each of th e separate sections of the report
°n which no special re p o rt w ould be m ade to th e C om m ittee. T he C om m ittee m ight tak e in turn
the section on the resolutions of th e Council, th e section on the decisions of the Assembly, the section
on the agreem ent of th e Rockefeller F ou n datio n, and th e section on tropical diseases. None of
these questions h a d been p u t sep a rately on th e agenda.
The C h a i r m a n th o u g h t th a t the rep o rt should be finally discussed a t a later meeting.
This proposition was approved.

The Question of Publicity.

H ,After an exchange of views it was decided th a t th e occasion did not yet present itself for
0 °mg a m eeting in public.
 SECOND M EETING

Held on Jan u ary gth, 1923 at 3.30 p.m.

7. Report of the M edical Director.

The C h a i r m a n in v ited discussion on the sections of th e rep o rt on w hich no special report

w ould be m ad e to the C om m ittee.
S e c t i o n i : the Resolutions of the Council.

S ir George B u c h a n a n , referring to p arag ra p h (b) of th e above section, suggested th a t the

second sentence should b e red rafted. T he Council h ad accepted th e principle th a t a general infor­
m atio n service m ig h t usefully be organised b y th e H ealth O rganisation. T he sentence as drafted
was too im p erativ e in form.
R eferring to p arag ra p h (c) of th e sam e section, he p ointed o u t th a t th e H e a lth Committee had
itself stip u la ted th a t th e cred it referred to should be used for th e collection of inform ation on the
sp read of epidem ics. H e asked th a t th e la st sentence of th e p arag ra p h should b e am ended accord­
ingly.
These proposals were accepted.
S e c t i o n 2 : Decisions of the T hird Assem bly.

Sii George B u c h a n a n , referring to th e p arag raph concerning th e E u ro p ean H e alth Conference

a t W arsaw , suggested th a t th e te x t of th e resolution passed b y th e Assem bly should be quoted
in extenso.
The proposal was adopted.
Sir George B u c h a n a n , referring to th e p aragrap h concerning th e co n stitu tio n of th e Perma­
n en t H e alth O rganisation, again suggested th a t it would be advisable to quote th e resolution of
th e A ssem bly tex tu ally . T he te x t of th e A ssem bly’s resolution im plied th a t th e Committee
w ould h av e m ore tim e an d la titu d e in th is m a tte r th a n was in d icated in th e condensed version
given in th e rep o rt. H e enquired w h a t precisely was m ean t b y th e decision of th e Assembly that
th e principles ad op ted b y th e F irst A ssem bly for th e technical organisations of th e League should
be ta k e n as a basis in co n stitu tin g th e P erm an en t H ealth O rganisation. W as it necessary th a t the
H e a lth O rganisation should h av e th e sam e m achinery as th e o th er technical organisations, with
a general conference an d a n ex p e rt com m ittee and a section of th e S ecretariat c o n stitu ted according
to a stock p a tte r n ? H ow fa r m ight th e H ealth O rganisation be co n stitu ted w ith d u e regard to
its ow n special d u ties a n d requirem ents ?
D r. R a j c h m a n explained th a t it was th e wish of th e A ssem bly th a t th e H ealth Organisation
should conform to th e sam e general principles as th e o ther technical organisations, for which there
alread y existed a recognised tra d itio n an d practice. L iberty, however, rem ained as regards the
details of th e organisation. T he technical organisations were n ot of an identical p a tte rn . On the
O pium C om m ittee, for exam ple, th ere were n ot only represen tativ es of th e G overnm ents b u t three
technical experts w ho s a t as assessors.
M. V e l g h e said th a t th e Assem bly h ad fully recognised th a t th e existence of the Office
in te rn a tio n a l in tro du ced an im p o rta n t special factor, w hich w ould h av e to be considered in consti­
tu tin g a P erm an e n t H e a lth O rganisation. A tten tio n h a d been draw n to th e necessity of avoiding
overlapping. T here were m an y difficulties involved. H e th o u g h t th e C om m ittee ought to he
e n tru ste d w ith th e stu d y of th e question, as it was b e tte r qualified to deal w ith it th a n the Council
of th e League.
Prof. Léon B e r n a r d th o u g h t th a t it would be wise to proceed in th is m a tte r w ith the utmost
discretion. A greem ent w ould be difficult, and only possible w ith th e goodwill of th e parties. The
question should n o t be h a stily u n d ertak en , and th e C om m ittee should n o t act unless called upon
to do so.
M . V e l g h e said t h a t th e Assem bly h a d undo ub ted ly desired a settlem en t of th e question,
as it h a d co n tem p lated the possibility th a t it mighl be settled before th e n ex t Assem bly meeting,
in S eptem ber 23, an d would b e disappointed if no step were tak e n eith er by th e Council or the
 — 7 —

C o m m i t t e e . The C om m ittee, i f in v ited b y th e Council to tak e action, could a t once take t h e subject
into c o n s id e r a tio n , b u t should proceed w ith the u tm o st prudence and deliberation.
Sir G eorge B u c h a n a n p o in ted o u t th a t th e resolution of th e Assembly presupposed th e meeting
of an international h ea lth conference, which w ould assist in the constitution of the Perm anent
Organisation. No conference was likely to be held before th e n ex t Assembly, which could n o t,
therefore, com plain if a schem e for th e P erm an en t O rganisation was n o t ready.
The P erm anent H e alth O rganisation was, in his view, distinguished from other technical
organisations of th e League in th a t freq uent general assemblies or conferences were absolutely
essential. All th e chief public h e a lth services ought to have an o p po rtun ity of serious meetings
at least once or twice a year, as a t p resen t in th e Office international d ’hygiène publique. W ithout
this, no small com m ittee an d no b ureaucracy, however able, could really m eet th e practical needs
of international h ea lth work.
The C h a i r m a n asked w h eth er it w ould be for th e In tern atio n al H ealth Conference m entioned
in the Assembly resolution to co n stitu te th e P erm an en t H ealth Organisation.
Dr. R a j c h m a n said it w ould be th e d u ty of the In tern atio n al H ealth Conference to elect
the Perm anent H e alth C om m ittee. T he Conference would m eet for this purpose in the event
of the Council h av in g accepted a schem e for a p erm an en t organisation fram ed b y th e Committee.
Sir George B u c h a n a n said he agreed w ith th e views of M. Velghe. The Com mittee should,
of course, tak e up th is question if in v ited to do so by th e Council, b u t hurried solutions m ust at
all costs be avoided.

Dr. Ca r r i è r e said he h ad th e im pression th a t the Assem bly h ad not been altogether satisfied
with the w ay in which th is subject h a d so far been handled. H e tho u g ht th a t a definite step
should be ta k e n b y th e C om m ittee as evidence of its goodwill in th e m atter. The Assembly had
cut down th e b u d g et of th e H ealth O rganisation and h ad drawn atten tio n to th e danger of over­
lapping. H e th o u g h t th e C om m ittee should tak e the initiative, though it should n o t proceed
hastily.
M. V e l g h e assured th e C om m ittee th a t there h ad been no idea in th e Assembly of criticising
the Health C om m ittee for th e w ay in which it h ad d ealt w ith th e m atter.
It was agreed that the Committee was prepared, on the invitation of the Council, to undertake
the preparation of the Perm anent Health Organisation.
Se c t i o n 3 : Agreement with the Rockefeller Foundation.
Sir George B u c h a n a n said th a t as th e con trib ution m ade b y the Rockefeller Foundation
towards th e m ain ten an ce of a n epidem iological service was, except for book-keeping purposes,
not now to b e sep arated from th e funds for th a t service which were provided by the League, it
was im p ortan t th a t th e jo in t fu n d should in all respects be trea ted as a unit.
It was still necessary to be able to continue to consider this service as a whole, a p a rt from other
parts of th e H e alth O rganisation, w hen necessary, to have separate reports on this service, and
to know w h a t th e service cost as a whole from y ear to year. This point was especially im portant,
as the m oney provided b y th e R ockefeller F ound atio n was only certain for a lim ited period.
Dr. L u t r a r i o e m p h a s i s e d t h e d e s i r a b il it y o f h a v i n g s e p a r a t e a c c o u n ts , b u t a g re e d t h a t th e
fund s h o u ld be e m p l o y e d a s a c o m m o n fu n d .
Dr. R a j c h m a n explained t h a t th e arrangem ent described in his report was based strictly
upon th e term s of th e c o n tra c t w ith th e Rockefeller Foundation.
S ection 4 : the Expert Committee on Tropical Diseases.

(No a m e n d m e n t ) .
Se c t i o n 9 : Courses for P ublic Health Personnel.
Sir George B u c h a n a n enquired from w h at source th e £ 5,000 m entioned in th e last paragraph
°f this section h a d been derived.
Dr. R a j c h m a n s ta te d th a t th e m oney had been found by the League of Red Cross Societies.

- Report on the Enquiry in the Far East.

Sir George B u c h a n a n presented th e rep o rt of Dr. C alm ette (Annex 4). In so doing he laid
stress on th e efforts m ade b y m em bers of th e Sub-Com m ittee, in pursuance of th eir instructions,
0 secure a full com m ission, an d he re g retted th a t, from circum stances noted in the report, their
efiorts in th is direction h a d n o t been successful. He hoped, however, th a t it would be possible
I®send out a m ore extended m ission a t a la te r d ate an d he drew a tten tio n to th e statem en t in
"r- Calm ette’s rep o rt to th is effect. T he work of Dr. N orm an W hite would doubtless enable a
further stu d y to be m ade of th e im p o rta n t questions which he was a t th a t m om ent investigating.
It had been suggested to th e B ritish Colonial Office by th e authorities in Singapore th a t the
^ g u e of N ation s H ealth C om m ittee should consider a resolution relating to beri-beri adopted
®t the F o u rth Congress of th e F a r E a ste rn Association of Tropical Medicine, held at B atav ia in
*'u g u s t 1 9 2 1 . The suggestion appeared to be th a t a local international agreem ent m ight impose
a differential d u ty on different kinds of rice, in order to d ete r coolies from consum ing the highly
m illed varieties. H e w ould suggest th a t D r. N orm an W h ite should be asked to investigate the
m a tte r a n d collect info rm ation as to the arran g em en t proposed.
I t was agreed that Dr. N orm an W hite should be instructed accordingly.
Mr. K u s a m a said h e wished, on behalf of D r. M iyajam a, to express ap p reciation for th e way
in w hich th e C om m ittee h a d ta k e n u p th e question of th e m ission to th e F a r E a st, an d thanked
th e Sub-C om m ittee an d th e M edical D irector for th eir valuable w ork. D r. M iyajam a had anti­
cip a te d th a t th e m ission w ould be a m ore ex tended one an d agreed w ith Sir George Buchanan
th a t a fu rth e r en q uiry should be organised la te r on. T h e C om m ittee was to b e congratulated on
h av in g secured for th is m ission th e services of Dr. N orm an W hite. D r. M iyajim a was now in
J a p a n a n d would welcome th e m ission on its arrival.

9. Pneum onic Plague in M anchuria.

A le tte r was read from th e D irector of th e P lague P rev entio n Service of N o rth e rn Manchuria
p ro testin g ag ain st th e s ta te m e n t in th e re p o rt of th e H ealth C om m ittee d ate d J a n u a ry 6th, 1922,
regarding th e prevalence of pneum onic plague in M anchuria an d Siberia an d in v itin g th e Commis­
sion of th e L eague to visit th e statio n s a t H a rb in (Annex 5).
I t was decided that this letter should be forwarded to Dr. N orm an White.

10. Health M useum at Dresden.

D r. R a j c h m a n p resented to th e C om m ittee correspondence betw een th e D irector of the

G erm an Museum of H e alth a t D resden a n d th e C hairm an of th e H e a lth Committee
T he D irecto r of th e H e alth M useum h ad asked w h ether it w ould be possible for th e Chairman
of th e H e alth C om m ittee to in terest th e R ockefeller F o u n d atio n in th e w ork of th e Museum,
w hich was in need of assistance.
T h e C haiim an of th e H e alth C om m ittee h ad assured th e D irecto r of th e M useum that the
H e a lth Section of th e League w ould be able to place an order am o u n tin g to £500 w ith th e Museum
p ro v ided its w orkshops could u n d erta k e to prep are m odels for th e h e a lth courses organised by
th e section a t W arsaw , Moscow an d K harkov. T he Medical D irector h a d also w ritten to the
rep resen tativ es of th e Rockefeller F oundatio n.
In answ er to Sir George B uchanan, Dr. R ajch m an said th a t th e £500 w ould be supplied by
th e League of R ed Cross Societies.

11. Proposed collaboration between the Health Section of the League and the International
Sanitary Bureau at W ashington.

D r. R a j c h m a n read a le tte r which he h a d received from Dr. Rowe suggesting th a t a plan

of co-operation should be d raw n u p (Annex 6).
Sir George B u c h a n a n th o u g h t th a t th e in v itatio n to collaborate m ig h t be accepted in prin­
ciple, b u t suggested th a t th e n a tu re of th e collaboration should b e considered b y th e sub-com­
m itte e w hich was to discuss th e organisation of epidem iological intelligence.
The Committee agreed that the invitation to co-operate be accepted in principle.
 T H I R D MEETING

Held on J a n u a ry 10th, 1923, at 11 a.m.

Present : All th e m em bers of t h e C om m ittee together w ith Dr. S i e m a s h k o , People’s Commis­

sary for P ublic H e a lth a t Moscow.

12. The Epidem iological Position in the Far East.

Professor S a n t o l i q u i d o said th a t th e League of R ed Cross Societies was of th e opinion th a t

the Conference of R ed Cross Societies to be held a t Bangkok afforded a valuable o p p o rtu nity of
drawing th e a tte n tio n of th e N atio n al R ed Cross Societies of th e principal countries interested
to the problem of epidem ics in the F a r E ast, and of inducing these societies to collaborate, w ithin
their available m ean s an d in an ap p ro p riate field, in th e work und ertak en b y th e League of Nations.
He p re sen ted a n o te on th e epidemiological problem s of the F a r E a st prepared by th e Secre­
tariat of th e L eag u e of R ed Cross Societies for th e Conference of th e League a t Bangkok.

13. Interchange of Health Personnel.

M. V e l g h e p ie se n te d his rep o rt (Annex 7). H e said his report did n o t contain any personal
expression of opinion. H e h a d sim ply wished to indicate th e opinion of those who had taken p art
in the first of th e in terchang es of h ea lth personnel. This opinion was unanim ous, and for his p art
he agreed co m pletely w ith th e rem arks an d conclusions inspired by th e first experim ent. The
interchange h a d been regarded b y all as extrem ely useful. Everyone participating had shown
the utm ost zeal, alth o u g h th e program m e had been heavy. The division of th e program m e into
lectures, v isits of inspection, a n d p ractical instru ctio n h ad proved to be excellent, th e lectures and
inspections b ein g a p re p ara tio n for th e period of practical instru ctio n which was th e essential p art
of the p rogram m e. * I t w ould be well to fix in advance th e details of th e program m es, so th a t each
health ad m in istratio n m igh t ap p o in t officials m ost qualified to benefit from th e experim ent.
According to circum stances, th e h e a lth adm inistrations m ight appoint specialists on tuberculosis,
on the p ro tec tio n of in fan ts, or in lab o rato ry work. In considering the candidature of officials
engaged u p o n g en eral public h ea lth w ork, it was necessary to tak e account of the age of th e official,
his titles a n d qualifications. Such officials should be neith er too young nor upon the eve of their
retirement, b u t sho u ld enjoy a certain au th o rity , so th a t th eir experience m ight be of practical
service to th e ir ad m in istratio n s.
The p erio d of p ractical in stru ctio n w as th e m ost im p o rtan t p art of th e system . In allowed
the officials to g e t in to to u ch w ith th e population of jthe country, to ascertain its needs, and to
understand local custom s an d th e legislation and h ealth organisation of th e country.
I t was clear from th e valuable experim ents which h ad ju st been m ade th a t the system of
interchanges sh o u ld be con tin ued even a fte r th e th ree years, during which th e assistance of the
Rockefeller F o u n d a tio n was assured.
Dr. L u t r a r i o furnished c e rtain p articu lars on th e interchange which h ad been organised in
Italy from N o v em b er n t h to D ecem ber 16th, 1922 (Annex 8). F o u rteen officials had taken p art.
A course- of 35 d a y s h ad been divided in to four periods. There was a first period of ten days
at Rome d ev o ted t o lectures, to visiting h ea lth constructions of an tiq uity, and new constructions
such as th e g a rd e n city , a san ato riu m for tuberculosis, etc. D uring th e second period, various
establishments w ere visited a t N aples an d F errara. The period of practical instruction came
next, during w hich sm all groups of tw o or th ree officials were sent to Milan, Turin, Genoa and
Florence to p a rtic ip a te in th e w ork of th e Italian officers of health. Finally, th ey had all m et at
Milan for a s h o rt w hile before separating.
The officials h a d show n them selves extrem ely am enable and zealous, b u t it was necessary to
avoid in th e fu tu re overloading th em w ith work, and it would be well to cut down the num ber of
lectures an d th e o re tic a l in stru ction . I t w as also necessary as far as possible to prolong the period
°f interchange u p to five or six weeks. G enerally speaking, th e results had been very satisfactory,
and a very re m a rk ab le spirit of co-operation had arisen between th e Italian and foreign officials.
 — 10 —

P ractical in stru ctio n should be given only in a single co u n try in order th a t those participating
m ight h av e th e tim e th o ro u g h ly to u n d ersta n d th e sp irit of th e co u n try . T he n um ber of those
p a rtic ip a tin g should no t exceed 20 or 25.
D r. C h o d z k o said th a t P olan d h ad been h ap p y to welcome four Ita lia n h ea lth officials in
N ovem ber a n d D ecem ber 1922. T hey h a d visited every thin g of in tere st a t W arsaw . They had
m ade v isits of inspection in E aste rn P o lan d d u rin g very inclem ent w eath er in order to study the
cam paign ag ainst epidem ic diseases. On th e ir re tu rn to W arsaw , lectures h ad been organised for
th eir benefit on tuberculosis, alcoholism a n d venereal diseases, a n d th e Ita lia n officials had given
a v ery in terestin g account of th e h ea lth situ atio n in Ita ly , p artic u la rly as regards m alaria.
F inally, th e y h a d ta k e n p a r t in th e activities of th e various services of W arsaw a n d its neigh­
bourhood. A trib u te should be p aid to th e ir zeal an d to th e ir goodwill. H e endorsed th e conclu­
sions of M. Velghe and D r. L u tra rio in regard to th e system of interchanges, and said th at the
Polish officials h ad derived g reat benefit from th e ir period of in stru ctio n abroad.
D r. R a j c h m a n su b m itted to th e C om m ittee a d ra ft budget. T aking th e fiscal period as a
whole, w hich began on O ctober 1st, 1922 (the d a te on which th e p a y m e n t of th e Rockefeller
F o u n d atio n began), an d extend ed to D ecem ber 31st, 1923, th e available cred it am ounted to
75,000 dollars plus 10,000 dollars (50,000 Swiss francs).

The sum available was, th e r e f o r e .................................. 85,000 dollars

The first in terch an g e in Belgium an d Ita ly h ad cost . 13,000 »
The interchange in E n g lan d and C entral E urope
w ould c o s t ................................................................. 25,000 »
The interchange in th e U n ited S t a t e s ......................... 25,000 »
The interchange of lab o rato ry staff would c o s t. . . 12,500 »
The stu d y of m alaria in Ita ly , in which 12 persons
belonging to nine countries would engage for a
period of six weeks, would c o s t.............................. 5,000 »

I t w ould th u s be possible to devote a sum of 4,000 dollars to eight or ten individual fellowships.
T he choice of th e candid ates was extrem ely difficult, for it was necessary to look a t the m a tte r both
from th e p o in t of view of p articu lar persons and of h ealth organisations w ith o u t forgetting that
th ere w ould b e no control over th e persons holding th e fellowships. P erhaps th e best w ay was to
proceed experim entally during th e y ea r 1923. A sm all com m ittee, composed, for exam ple, of the
C hairm an, th e Vice-Chairman, one of the m em bers of th e C om m ittee a n d th e Medical Director,
m ight tak e th e first appointm ents.
T he p lan of interchange which would ta k e place in E n g lan d was different from th a t which had
tak e n place in Belgium a n d Italy . A fter stu d y in g ten days in London, th e officials w ould take a
p ractical course of four weeks in th e provinces in groups of five.
I t was necessary to choose a co u n try of C entral E urope. G erm any h a d asked th a t the inter­
change in G erm any m ight be postponed. I t w ould be b e tte r to accept a t th e m o m ent th e invita­
tion of A ustria, in order th a t th e experim ent m ight n o t be m ade sim ultaneously in two great
in d u strial countries like E n g lan d an d G erm any. I f th is proposal were ad opted, a detailed plan
m ight b e p repared in tw o o r th ree weeks. 27 officials w ould p artic ip a te in this second experiment,
T he rep ly of eleven G overnm ents h a d alread y been received, n am ely : Belgium, F in lan d , France,
Greece, Ita ly , R ussia, N orw ay, P oland, Sweden, th e K ingdom of th e Serbs, C roats an d Slovenes,
an d D enm ark. Replies were aw aited from eight G overnm ents.
I t w as necessary to w ait for th e n e x t session in order to decide on th e details of th e interchange
w hich was to tak e place in th e U n ited S tates. N egotiations were proceeding. No replies had as
y e t arrived from South America.
T h e interchange of lab o rato ry staff should tak e place in two or th ree m o n th s o r be p o stp o n ed
to a la te r period, O ctober for exam ple. O nly S tate laboratories w ould be in v ited to appoint
candidates. The C hairm an an d th e Medical D irector h a d draw n u p th e following list of States
w hich w ould be in vited : E ngland, U n ited S tates, G erm any, Czechoslovakia, A ustria, France,
P oland, R ussia, D enm ark, t h e K ingdom of t h e Serbs, C roats a n d Slovenes, Italy , t h e N e th e rla n d s
an d Belgium.
T he larger S ta te s would send two representatives. T here would be altogether som e 20 persons.
D r. L u trario h ad proposed th e e n d of May as a d ate for th e stu d y of m alaria. R ep resen tativ es
of nine countries p articu larly in terested, com prising some tw elve doctors, would tak e p art. The
countries w ere: Russia, P oland, th e K ingdom of th e Serbs, C roats an d Slovenes, Greece,
B ulgaria, th e N etherlands, Italy , Spain, a n d finally A lbania, for whom th is q u estio n was vital.
If th is program m e were applied, m ore th a n 100 h ealth officials w ould benefit from th e system
of interchange during th e first fiscal period, including th e officials who h ad tak en p a rt in the first
experim ent already completed.
Sir George B u c h a n a n raised th e question of travelling expenses from E urope to America.
T ravelling expenses, in his opinion, m u st be given to E uropean officials p articip atin g .
D r. R a j c h m a n explained th a t th e question of travelling expenses h a d n o t y et been settled.
T he im p o rta n t point was th a t an interchange should be organised in A m erica in conform ity with
th e first resolution of the Assembly an d w ith th e desire expressed by th e delegates of S o u t h America
A s regards a n interchange in the F a r E ast, it would be well to aw ait th e re tu rn of D r. Norman
W hite.
Dr. S i e m a s h k o th o u g h t th a t th e first experim ent h a d given excellent results. The system
of interchange had a double ch aracter: ad m in istrativ e and scientific. In his opinion it was necessary
to develop th e ad m in istrativ e side. The R ussian G overnm ent was sending hundreds of do ctors
to study abroad.
He tho ug h t th a t th e d etailed program m e of th e courses should be known in advance in order
that the h ealth ad m in istratio n s m ig h t ap p o in t officials qualified to benefit from them . These
officials should n o t be too young.
In conclusion, he felt th a t th e system of inspection and visits h ad a great practical importance.
Prof. Léon B e r n a r d said t h a t experience h ad justified his expectations. The results of the
in te rc h a n g e w ere excellent f r o m th e m oral p oin t of view, b u t it was evident th a t the instruction
should be given as p ractical a ch a rac ter as possible.
If lectures, visits a n d inspections w ere to be a necessary p reparation for practical instruction,
it followed th a t p ractical in stru ctio n should only be given in th e country where th e lectures’,
visits and inspections h a d ta k e n place. I t seemed difficult in three m onths to become familiar
with the custom s an d in stitu tio n s of tw o countries.
Account m u st be ta k e n of th e d istin ctio n d raw n b y M. Velghe betw een health officials dealing
with general questions of public h e a lth a n d those who were specialists. C andidatures for fellow­
ships should be confined to specialists. F ran ce h a d perhaps n o t very m uch to teach foreign coun­
tries as regards general h e a lth organisation, b u t she was able, on the other hand, to offer m any
interesting achievem ents in c e rtain p articu lar fields, as, for example, in the cam paign against
tuberculosis.
The in terch an g e of personnel m u st n o t be organised upon too rigid lines, b u t a certain
elasticity m u st b e p e rm itted in order th a t th e conditions peculiar to each country m ight be taken
into account. I t was necessary to insist, as D r. Siem ashko had said, on the adm inistrative and
practical c h a ra c te r of th e program m e.
In terest in social h ea lth w as considerably on the increase, and it m ight be said th a t th e new
spirit which insisted on th e social ch aracter of health measures was gradually p enetrating the
universities of F rance.
The U n ited S ta te s of A m erica offered a m agnificent exam ple in this connection, and it was
desirable t h a t a n interch an g e should be organised in th a t country to th e great advantage of those
who would p a rtic ip a te in th e experim ent.
 F O U R T H M EETING

Held on Jan u ary i r h , 1923, at 10.30 a.m.

P resent: All th e m em bers present a t th e previous m eeting to g eth er w ith D r. S iem ashko ,
P eople’s C om m issary of Public H e alth a t Moscow.

14. Interchange of Health Personnel (continuation).

Sir George B u c h a n a n th o u g h t it would be p rem atu re to define th e system of interchange

too rigidly.) A t this stag e a certain degree of elasticity was necessary, especially in reg ard to the
c h a rac ter of th e interchanges. H e th o u g h t, for exam ple, th ere w as a danger th a t too m uch im­
p o rtan ce m ig h t be a tta c h e d to th e in stru ctio n of m edical officers of h ea lth in th e details of foreign
h ea lth services. M. Velghe h a d insisted on th e im portance of careful selection of candidates ap­
p ro p riate to th e p artic u la r course of collective interchange w hich is being u n d ertak en . F or this
selection one m u st depend on th e S ecretariat an d th e com m unications and enquiries addressed
to th e h ea lth d ep a rtm en ts of th e various countries. A p articu lar difficulty arose in reg ard to the
choice of represen tativ es belonging to coun tries n o t M em bers of th e League, as, for example,
Russia, w ith w hom o th er countries h ad no diplom atic relations. I t w as desirable th a t som e autho­
rita tiv e bo d y should be able to g u aran tee th a t th e persons chosen h a d th e necessary qualifications,
Personally, he was in favo u r of selecting n o t m ore th a n tw o persons from each country. He
accepted, th ou g h w ith some hesitatio n , th e very sm all scale on w hich individual interchange
or individual "fellowship” was to be provided th is year. H e proposed th a t a sm all sub-committee
should be ap p o in ted to consider th e choice to be m ade am ong those who h a d applied and the
in v itatio n s w hich m ight be issued for in d iv id u al arrangem ents. Such a C om m ittee w ould work
adm irably if it w ere allowed a reasonable discretion. H e d o u b ted w hether, for collective inter­
change, it was advisable to h av e tw o consecutive courses in different countries, an d h e would like
to h av e a fu rth e r exp lan ation of th is system .
H e th o u g h t th e C om m ittee owed a g re at d eb t to those m em bers who h a d so largely contri­
b u ted to th e success of th e first experim ent in Belgium and Ita ly , a n d also to Dr. R ajchm an for
th e energy h e h a d throw n in to th e arrangem ents.
D r. R a j c h m a n said it would be difficult to ap p o in t a com m ittee which w ould guarantee
th e qualifications of candidates. E xperience h a d shown th a t such g uarantees w ere hardly
necessary. R ussian represen tatives h a d ta k e n p a rt in th e interchange in Ita ly im m ediately after
th e F ascist revolution. T he th ree R ussian representatives proposed for th e next experim ent
appeared to b e d uly qualified m edical experts'
Sir George B u c h a n a n said it w ould be sufficient if D r. R ajch m an h ad personal knowledge
in regard to th e w ork a n d scientific qualifications of th e persons selected, o r if these persons were
know n to th e officers of th e Epidem ic Commission. Sir George B u ch an an o utlined th e proposed
program m e for th e E nglish interchange. H e w ould n o t be able to tak e as direct a personal
share in th e arrang em en ts as had M. Velghe or D r. L utrario, owing to th e w ay in which
th e w ork w ould h av e to be carried out. T he interch an g e would be co nd u cted by the
Society of Medical Officers oi H ealth , w hich was a body ind ep en d en t of th e B ritish Govern­
m ent and included m edical officers from all p a rts of th e U n ited K ingdom . H e h a d discussed
th e program m e w ith th e council of th e society, and h a d u n d e rta k e n to sit on th e com m ittee
which w ould be responsible for th e arran g em en ts an d expenditure. H e w ould act as inter­
m ediary betw een th e B ritish C om m ittee and th e H e alth Section w henever his services could be
useful.
The Society of Medical Officers of H e alth proposed to ta k e for th e experim ent four or five
specific areas, each of which w ould include a large city, a p o rt, a n d one or tw o co u n ty or agri­
cultu ral districts. In each area th e m edical officers w ould form a com m ittee, w hich would show
th e visitors th e p ra ctical working of th e local system and give dem onstrations. T here w ould be
a prelim inary general in stru ctio n of th e visitors in L ondon beforehand. In stru c tio n in special
subjects, such as m edical insurance, tuberculosis, venereal diseases, etc., w ould be left to the
local officers. H e feared it would n o t be possible to issue a detailed program m e of th e interchange
sufficiently early to p rep are th e visitors for th e course, though he recognised the im portance of
this for fu tu re arran g e m e n ts
He asked for an ex p lan atio n of th e passage in Section 6 of [the Medical D irector’s report
which appeared to insist t h a t th e n atio n al h ea lth adm inistratio ns should have credits a t their
disposal for th is interchang e o th er th a n those supplied b y th e Rockefeller Foundation or the
L eague.
He said he w ould su b m it a form al resolution for th e ap po intm ent of a sub-com m ittee to
assist in th e choice of candidates.

M. V e l g h e w as h a p p y to n ote th a t his rep o rt h a d not provoked criticism. As stated in his

report, em phasis h a d been laid in Belgium on th e ad m inistrativ e and p ractical character of the
interchange, as Prof. B ern ard h ad suggested in A ugust 1922, and experience h ad shown th a t in
acting in th is w ay th e rig h t d irection h ad been given to th e experim ent.
The C om m ittee, if it ad o p te d th e th ree final conclusions of th e report, m ight be regarded as
having ad op ted th e re p o rt as a whole. These conclusions were, in fact, th e conclusions draw n from
the first ex p erim en t w hich has been m ade. T he experim ent ju st m ade seemed to show th a t the
period of th e interchang e should be three m onths, divided into a period of six weeks for lectures
and inspections a n d a period of six weeks for p ractical instruction. T his rule, however, should
not be regarded as abso lu te, fo r it was necessary to tak e into consideration p articu lar conditions
in each co u n try .
I t was necessary t h a t th e h e a lth officials tak in g p a rt in an interchange should get into touch
with th e p riv a te a n d official organisations of the country, b u t it was clear th a t it was th e health
administration of th e co u n try w hich should serve as an interm ediary for th e organisation of th e
interchange.
Dr. C h o d z k o th o u g h t th a t th e interchange should be m ade in two countries successively, a
small c o u n try and a large co u n try , in order th a t those p articipatin g m ight become acquainted
with as m a n y h ea lth in stitu tio n s as possible. T hey m ight pass two m onths in th e large country
and one m o n th in th e sm all co u n try . H e th o u g h t th a t it was unnecessary to devote six weeks to
practical in stru ctio n , as M. Velghe proposed.
He su b m itte d a form al proposal th a t th e Com m ittee should enquire into th e position as
regards th e s tu d y of social hygiene in th e universities of E urope an d America. He would subm it
a draft resolution to th is effect.

Dr. R a j c h m a n d id n o t th in k i t was possible to judge y et w hether th e interchanges should be

effected am ong h e a lth officiais dealing w ith general questions of social hygiene or am ong specialists.
The choice of officials w as extrem ely difficult. T he form s filled in b y th e health adm inistra­
tions gave useful inform ation, b u t in th is field th e y had as y et n o t h ad sufficient experience.
It was im possible to fix finally th e nu m b er of officials to be appointed by each country. There
were countries w hich m ig h t derive m ore profit from th e interchange th a n other countries, and it
was necessary to tak e in to account b o th th e nu m b er of th e population and th e needs of each country.
As reg ards in div id ual fellowships, th e best course was to ad o pt th e proposal of Sir George
Buchanan th a t a sub-com m ittee should be en tru sted w ith th e p rep aratio n of a scheme for th e
next fiscal period.
I t seem ed preferable in every w ay to organise tw o consecutive courses. I t appeared from
conversations w hich h e h a d h a d w ith those who h ad tak e n p a rt in th e first interchange th a t it was
difficult to p ro fit from a period of p ractical instruction which exceeded one m onth, and it was
necessary to ensure th a t th e p ra ctical instru ctio n was n o t a repetition of the inspections, as had
at times been th e case in Ita ly a n d in Belgium.
It w as advisable for m an y reasons th a t th e interchange should be held in two countries.
Health officers should h av e th e o p p o rtu n ity of seeing as m uch as possible. F o r th is reason it
seemed advisable to organise th e interchange in a large an d in a sm all country. In a sm all country
a territory w as n o t too extensive ; it was easy to visit ; it did n o t present wide differences between
the provinces. In six weeks one m ight com pletely visit Belgium, b u t n o t a large co u n try like
England, G erm any or F rance. T his p lan would enable th e h ea lth officials to m ake useful com pa­
risons betw een such countries as G erm any and Sw itzerland, w ith entirely different social system s.
They would see how th e sam e problem s m ight be differently solved. I t was, of course, necessary
to avoid draw ing u p rigid rules, an d advisable to aw ait th e results of experience.
The observations of Sir George B u ch an an a n d M. Velghe h ad shown the necessity of com m u­
nicating in ad v an ce a detailed program m e. H e hoped to be able to su b m it to th e Com mittee
three m onths in ad v an ce a p rogram m e for th e y ea r 1924.
The reference to su p p lem en tary credits a t th e end of Section 6 of his repo rt m erely implied
that the h ea lth ad m in istratio n s w ould h ave a t th eir disposal o th er funds th a n those provided b y th e
Rockefeller F o u n d atio n . These su p plem en tary funds were at present provided b y th e League of
Nations.
It was, of course, un d erstoo d th a t th e relations betw een th e H ealth Com m ittee and the
countries in w hich interch an g es took place would necessarily be official in character.
The enq u iry proposed b y Dr. Chodzko would be extrem ely useful, a n d it would, in any case,
®necessary to h av e an en q u iry in order to organise th e interchanges. I t would be better, however,
that such a n en qu iry should n o t be official in character.
There was a t C h arlo tten b u rg an A cadem y of Social Hygiene, which m ight render valuable
services in th e org an isatio n of a n interch ang e in G erm any. I t m ight be ascertained w hat were the
'restitutions existing in each co u n try , and a rep o rt m ight be su b m itted to th e Com m ittee in six
m°nths’ tim e. X
 — 14 —

T here w as un d er consideration th e p rep aratio n of a h ea lth m an u al for each country. This

w ould enable th e officials who took p a rt in th e interchanges to inform them selves as regards the
h ea lth organisations of th e various countries.
I n conclusion, h e asked th e C om m ittee w hether it ap proved th e o rganisation of an interchange
in E n g lan d and sim ultaneously in A ustria.
Dr. R u l o t , m em ber of th e H ealth Section, gave certain inform ation as a h ea lth official who
h a d ta k e n p a r t in th e interchange organised in Belgium . E xperience h a d show n t h a t the inter­
change should be differently organised according to th e age of th e officials. Those who were
young a n d a t the beginning of th eir career requ ired a long period of p ractical instruction. Older
an d m ore experienced officials considered a period of th ree or four weeks as sufficient.
Prof. Léon B e r n a r d p o in ted o u t th a t th e m em bers of th e C om m ittee were agreed on prin­
ciples b u t th a t th ere were differences concerning th eir application. E v ery o ne was agreed th a t the
interch an g e should be of a p ractical ch aracter, b u t th e word “s ta g e ” needed to be defined. In all
in stru ctio n , there were th ree degrees of progress : lessons, d em o nstratio n s w ith inspections, and,
finally, th e “stage ” or period of practical instruction, during w hich th e pupils collaborated in the
work of th e officials. T he period of p ractical in stru ctio n varied according as th e pupils were young
or experienced. One p o in t seem ed to be generally ad m itted : nam ely, th a t th e lectures and the
p ractical in stru ctio n should ta k e place in th e sam e country. As regards th e question whether the
in terch an g e should be organised in one or tw o countries, it was necessary to define th e object aimed
a t, an d th e ch a rac ter of those who took p a rt, before it was possible to give a considered opinion.
H e h ad never in ten d ed to under estim ate th e im portance o r necessity of close relations between
th e H e alth C om m ittee an d th e h ea lth adm inistrations, b u t in certain cases these relatio n s might be
p u rely form al. Foi exam ple, as regards th e question of tuberculosis in F rance, i t w ould be neces­
sary first a n d forem ost to get in to touch an d collaborate w ith th e “Com ité n a tio n a l”.
H e su pp o rted th e proposal of Dr. Chodzko for an enquiry in to th e in stru ctio n on social hygiene
a t th e universities, as such in stru ctio n was assum ing great im p o rtan ce in E u ro p e an d America.
D r. C a r r i e r e again drew atte n tio n to th e a ttitu d e of Sw itzerland tow ards th e system of
interchanges. S w itzerland h ad n o t accepted th e first in v ita tio n addressed to her. T h is was not
from lack of in terest in th is new enterprise of th e H e alth Com m ittee. I t was only, as he h ad already
explained to th e C om m ittee, owing to th e difficulties presented b y a choice of cand id ates in a coun­
t r y like Sw itzerland, which, b y th e side of a cen tral h ea lth organisation, h a d a whole series of cantonal
services organised according to very different plans. H e hoped, however, th a t th e difficulties which
resulted from th is s ta te of affairs were n o t insurm ountable and th a t Sw itzerland m ig h t be able
to p a rtic ip a te in th e n ear fu tu re in an interchange. H e asked th a t Sw itzerland m ig h t not be
fo rg otten in th e in v ita tio n s w hich w ould be sent o u t w hen fu tu re interchanges were organised.
Sw itzerland would b e h a p p y to welcome delegates of foreign h e a lth services. If th e Health
C om m ittee th o u g h t th a t th ere was a n y th in g to b e learned in Sw itzerland, an d th a t it would be of
in tere st to organise an interch an g e in Sw itzerland, Sw itzerland would, of course, do everything
in her pow er to assist in p u ttin g th e p lan in to execution.
M. V e l g h e th o u g h t th a t th e discussion h a d shown th e im p ortan ce of th e qu estio n and that
th e views expressed w ould be useful in th e p rep aratio n of fu tu re interchanges. H e th o u g h t that
D r. Chodzko h ad been to o categorical in his declaration statin g th a t th ere should necessarily be
an in terch an g e in tw o countries. A lthough Belgium was a little co un try , it h a d n o t been possible
to show m an y things of in te re st to th e officials in th e course of th e first interchange. As P ro f e s s o r Ber­
n ard h a d said, th e d u ratio n of th e period of in stru ctio n m u st necessarily v ary according to the
countries a n d th e circum stances. T he length of th e p ractical in stru ctio n could n o t, however, be
cu rtailed , for it was this in stru ctio n w hich enabled th e officials to becom e ac q u ain ted w ith the daily
life of th e co u n try and to realise th e difficulties w hich h a d to b e overcome.
A lluding to th e final sentence in Section 6 of th e rep o rt of th e M edical D irector referred to by
Sir George B uchanan, he th o u g h t th a t th is sentence should be retained, for it w ould accustom the
G overnm ents to th e idea of bearing a share in th e expenses occasioned b y th e interchanges and
of assuring th e perm anence of th e system of interchanges progressively w ith th e assistance of the
League of N ations.
T he C h a i r m a n insisted on th e im portance of p ractical instruction, b u t it was necessary to
ensure th a t th e p ractical in stru ctio n should n o t overlap in structio n b y inspections.
Sir George B u c h a n a n said he h a d n o t been entirely convinced b y th e ex p lan atio n s given in
regard to th e sentence in Section 6 of th e report. T he allusion to su p p lem en tary credits intro­
duced a new principle. H e would be prepared to suggest a n alteratio n in p hrase which would
in dicate th a t this principle m ig h t h av e to be considered in future, b u t h e w ould n o t be disposed
to go beyo n d this.
H e endorsed th e observation of Dr. Carrière. The fact th a t a co u n try h ad n o t been invited,
or h a d declined a n in v itatio n , should n o t hin d er i t from tak in g p a r t in a fu tu re interchange, "e
hoped th a t an in v itatio n w ould be addressed to th e B ritish Dom inions.
D r. L u t r a r io th o u g h t th a t th e length of th e course in a c o u n try m u st necessarily v ary accord­
ing to th e co u n try . A course of 35 day s in Ita ly h a d been quite in ad eq uate. A t least two months
w ould b e necessary.
D r. R a j c h m a n asked w hether th e C om m ittee was o f th e opinion th a t a n interchange should
be organised in A u stria as second p a rt of th e interchange beginning on M arch 1st in E n g la n d .
T h is proposal was adopted.
 — 15 —

Dr. B ernard asked w h eth er th e C om m ittee was of th e opinion th a t the courses should be
prolonged in a single co u n try o r organised to ta k e place in two countries consecutively.

M. V e l g h e asked th e C om m ittee w hether it was disposed to adopt his three final conclusions.
The first conclusion affirmed generally th a t a period of three m onths was necessary for an inter­
change in certain countries su ch as Belgium a n d Ita ly , b u t the conclusion was drafted in such a
way th at it would p erm it of a different experim ent being tried in England, where a period ol six
weeks would be sufficient. T his would leave full latitu d e for the organisation of interchanges in
other countries.
Dr. R a j c h m a n th o u g h t th a t Prof. B ern ard h ad raised the m ost im p ortan t question in his
reference to th e ch a ra c te r of th e persons p articip atin g . I t was necessary to ascertain th e object:
whether it w as desired to organise m issions of en qu iry or scientific instruction. This question had
already been th oro u gh ly exam ined. If th e fellowships of th e Rockefeller F oundation were destined
first and forem ost for y o ung doctors who were p u rsuin g th eir studies, th e interchange m ight be
reserved for h ea lth officials. T he b est course would be to m ake a few further experim ents before
reaching a definite decision.
The Committee adopted the three resolutions of M . Velghe's report.
Sir George B u c h a n a n su b m itte d th e following resolution, which was also adopted :

“T h e C om m ittee asks th e C hairm an to nom inate a sub-com m ittee to consider the

m ost ap p ro p riate use of th e p o rtio n of the funds earm arked for individual arrangem ents
for interch an g e d u rin g th e presen t financial year and to consider th e possibilities of
ad o p tin g th e system of individual arrangem ents on a larger scale next year. ”

This proposal was adopted.

The C om m ittee ap p o in ted as m em bers of th e Sub-Committee, th e Chairman, Sir George
Buchanan a n d M. Velghe.
D r. C h o d z k o p r e s e n t e d t h e f o llo w in g p r o p o s a l:

“T h e H e alth C om m ittee asks th e Medical D irector to collect inform ation concerning

th e position in th e universities of E urope, Am erica and J a p a n as regards th e stu d y of
m edical a n d social hygiene and to present th e results of his enquiries a t the next session
of th e C om m ittee. ”

This proposal was adopted.

 F IF T H M EETING

Held on J a n u a ry n t h , 1923, at 5 p.m.

15. Standardisation of Sera: Report of the Chairman.

T he C h a i r m a n p resented a rep o rt on th e Second In tern atio n al Conference on th e Standardi­

sation of Sera an d Serological Tests, w hich h a d been convened b y th e H ealth C om m ittee in Novem­
ber 1922 a t th e P a ste u r In s titu te in Paris.
H e briefly sum m arised th e progress achieved by th e special sub-com m ittees and by the
Conference.
T he Sub-C om m ittees on A n ti-D ip hth eritic a n d A nti-T etanic Sera h ad ap proved th e resolutions
ad o p ted a t th e Serological Conference held a t G eneva in S eptem ber 1922.
T he G eneva Conference h ad finally se ttle d th e question of th e s ta n d a rd of th e diphtheria
an tito x in , and h ad ad op ted in principle an in tern atio n al u n it for th e te ta n u s serum .
The Sub-C om m ittees on th e Anti-M eningococcus Serum, th e A nti-Pneum ococcus Serum and
th e A nti-D ysen tery Serum h a d as y e t reached no definite conclusion. Im p o rta n t progress had been
m ade tow ards th e stan d ard isatio n of an ti-d y se n te ry serum , a n d th ere was hope of achieving
good results in th e n ear future.
In th e sero-diagnosis of syphilis no definite results h ad been achieved.
H e proposed th a t th e resu lts in reg ard to th e an ti-d ip h th eritic serum a n d th e anti-tetanic
serum should be com m unicated to th e Office intern atio n al, which m ight consider th e question
w h eth er th e G overnm ents should be ap p ro ach ed w ith a view to th e adoption of th e u n it proposed
for a n in tern atio n al stan d ard .
H e asked for a u th o rity to continue th e researches which were in progress, to convene sub­
com m ittees of experts w hen th e researches were sufficiently advanced, and to send experts to
th e different in stitu te s w hich were p artic ip a tin g in order to com pare th e results b etter.
H e suggested th a t th e rep o rt on th e Second In tern atio n al Conference should be forwarded
to th e Office in ternational.
Sir George B u c h a n a n co n g ratu lated th e C hairm an on th e progress achieved, which was so
largely due to D r. M adsen’s personal efforts. This work h ad alread y a ttra c te d considerable atten­
tion, an d public opinion h ad been g reatly stru ck b y its practical u tility . In th e B ritish Press, for
exam ple, there h ad been very favourable com m ent, n o t only in th e m edical journals b u t in the
ord inary new spapers.
M. V e l g h e su p p o rted th e proposal th a t th e Office in tern a tio n a l should be in v ited to under
tak e enquiries w hether th e n atio n s were p rep ared to ad op t th e u n its alreadyrecom m ended by
th e Sub-C om m ittees. H e was sure th e Office intern atio n al would feel itself in d eb ted to th e Health
C om m ittee for its valuable w ork in carry ing forw ard a task in w hich th e Office itself h a d taken the
in itiative.
The Committee approved the proposal of the Chairman.

16. T he Standardisation of Biological R em edies.

The C h a i r m a n presented a rep o rt w hich he had received from Dr. Dale, upon his invitation,
on th e possibility of establishing in te rn a tio n a l stan d ard s for rem edies, other th an sera and bac­
teriological products, th e a c tiv ity and safety of which could only be controlled b y biologic^
m ethods (Annex 9).
The rep o rt concluded w ith a suggestion th a t an intern atio n al conference on th e lines of the
In te rn a tio n a l Serological Conference m ight do valuable work in th is direction. I t was suggested
th a t such a conference m ight be called in E d inb u rgh in J u ly 1923, w hen ex p erts from th e United
S tates would be a tten d in g th e In te rn a tio n a l Physiological Congress which h a d been c o n v e n e d
for th a t date.
T he C hairm an considered th a t it w as p rem atu re to convene a conference to settle final!)
an in tern a tio n a l stan d ard , b u t th a t it w ould be possible to assem ble a n u m b er of ex p erts in
 — 17 —

for a preliminary excliangc of views. It was im p o rtan t to establish the principle th a t the Health
Organisation of th e League should tak e the initiativ e in seeking intern ation al agreem ent before
too many G overnm ents h ad introduced different stan d ard s into their regulations. He asked
whether the Com m ittee w ould authorise him to com m unicate w ith the experts of different coun­
tries, and to stu d y th e questions m entioned by Dr. Dale.
Sir George B u c h a n a n sa id th a t Dr. Dale wished it to be understood th a t this report was,
strictly speaking, o n ly a m em orandum of his personal views, com m unicated by request to thé
Chairman. I t was none th e less valuable on th a t account. If such a m eeting were held in the United
Kingdom, the B ritish M inister of H ealth and th e B ritish m edical health officials would be happy
to assist. H e th o u g h t i t desirable th a t in such discussions there should be a collaboration between
the scientific specialists a n d th e a d m in is tra tiv e officials who were, or m ight be, concerned with
the practical a p p lic a tio n of these stan d ard s, and th a t ad m in istrativ e considerations should not
be neglected in selecting sub jects for th e Conference.
Prof. B e r n a r d p ointed o u t th a t no ad m in istrativ e action was involved until the experts had
first studied the qu estio n and form ed some opinion of th e possibility of fixing standards and inviting
the Governm ents to accept them . I t was advisable to tak e up the problem im m ediately in order
to prevent th e ex p erts in various countries from proceeding in different directions and introducing
a diversity of stan d ard s an d m ethods, as h ad happened in th e case of sera an d serological tests.
Dr. R a j c h m a n w arned th e C om m ittee th a t it would n o t be in a position t o finance any
additional researches in Ju ly , th o u gh perhaps th e Council m ight be induced to find a small sum
for the purpose.
M. V e l g h e , referring to th e p arag ra p h in Dr. D ale’s rep o rt on salvarsan, pointed out th a t
in Belgium th ere w as official control of th is product.
Dr. C a r r i è r e said th a t official control was exercised in Germ any, where t h e product was
a monopoly.
Prof. N o c h t said th a t th e situ atio n in regard to this control was com plicated. H e w a s not
sure w hether th e p ro d u ct was controlled officially b y th e G overnm ent.
The C h a i r m a n pointed o u t th a t the question of an official and form al agreem ent w a s not yet
involved. T here w'ould first h av e to be a prelim inary investigation b y th e experts, b u t they would
include m en used to th e p ractical questions involved, for instance, those concerned w ith th e p har­
macopoeias. The Office in tern atio n al was already dealing w ith the question of salvarsan a n d
was reporting o n th e various system s of control.
It was agreed that the Chairm an should be authorised to get into touch with the American experts
and to convene a conference to study the question.
Dr. R a j c h m a n enquired w h eth er it would be possible to consider th e possibility of m aking
use of th e new m eth o d of vaccination per os, recently discovered a t the P asteur In stitu te. The
new m ethod m ig h t b e inv estigated by experts, who m ight decide under w hat conditions it should
be applied an d how th e results m ight be controlled. The Epidem ic Commission was at present
vaccinating on a large scale against dysentery in Greece, and Dr. Calm ette was ready to supply
the vaccine.
Sir George B u c h a n a n d o u b ted w hether such investigation was w ithin the field of work of
the H ealth C om m ittee, th o u g h he was entirely in favour of tak in g steps to secure the trial of
the m ethod, un d er satisfacto ry conditions, b y th e responsible public health authorities.
Prof. B e r n a r d did n o t th in k th a t a body m aking such an enquiry should be regarded a s repre­
senting th e H e alth C om m ittee. I t w ould have to act as a body of experts in collaboration with
Greek specialists a n d officials.
After som e discussion, D r. R a j c h m a n w ithdrew his proposal.
 S IX T H M E ETIN G

Held on J a n u a ry 12th, 1923, at 10 a.m.

17. Study of Malaria in Italy.

D r. L u t r a r i o inform ed th e C om m ittee th a t th e Ita lia n G overnm ent w ould welcom e th e experts

who were com ing to s tu d y m alaria in Ita ly an d w ould endeavour to assist th e m in their work.
H e read a teleg ram (Annex 10) w hich w as cordially welcom ed b y th e C om m ittee. T h e Committee
asked Dr. L u tra rio to fo rw ard to th e M inister its w arm est th an k s.

18. Letter from S ir Havelock Charles.

T he C h a i r m a n com m unicated a le tte r from Sir H avelock Charles, who reg retted that he
was u n ab le to a tte n d , b u t hoped to be p resen t a t th e n ex t session of th e C om m ittee.

19. Publication of the Reports of the Serological Conference.

T he C h a i r m a n said th a t th e financial position did n o t p erm it of th e pu b lication of these

re p o rts in th ree languages. In these circum stances th ey could n o t be published in Germ an in
extenso. T he F ren ch te x t m ig h t ap p ear as an annex to th e A nnals of th e P a ste u r Institute. As
regards th e E nglish te x t, he h a d received a proposal of w hich Sir George B u ch an an would give
p articu lars.
Sir George B u c h a n a n said th a t if th e C om m ittee desired a special volum e in English, he
was p rep ared to do all in his pow er to assist in the necessary arrang em en ts th ro u g h the General
M edical Council. H e h a d ju s t received a telegram from Sir W a lte r F le tch er to th e effect that the
M edical R esearch Council w ould endeavour to m eet all th e wishes of th e H e alth Committee in
th e m a tte r, b u t suggesting th a t th e re p orts m ight besum m arised a n d th a t th e L eague ot Nations
should b u y 750 copies a t a price of £150. I n th is w ay no m ateria l charge on th e B ritish Treasury
w ould be involved.
D r. R a j c h m a n said th a t th e p u b licatio n of the F ren ch te x t in th e A nnals of th e Pasteur
In s titu te w ould cost 4,000 francs a n d th a t th e p ublication of th e E nglish te x t w ould cost 3,000
francs. T his m ade a to ta l of 7,000 francs, while th e bu d g et only p rovided 15,000 francs for all
th e publicatio n s of th e section. I t would, m oreover, be im possible to h av e a com plete French text
a n d a sum m arised E nglish te x t.
T h e C h a i r m a n said th a t th e reports w ould be difficult to sum m arise. In view of these diffi­
culties i t w ould perh ap s be necessary to publish them only in F ren ch, since th e A nnals of the
P asteu r In s titu te were d istrib u ted to all laboratories.
D r. R a j c h m a n said it w as an established principle th a t th e publication s of th e League of
N atio n s should be p rin ted in th e tw o official languages.
D r. Ca r o z z i enquired w h ether it would n o t b e possible to h ave th e rep o rts p rin te d a t a cheaper
ra te in A ustria.
M. V e l g h e d o u b ted w hether it was advisable to h an d over these re p o rts for publication to
a p riv a te body. H e w ould m ore readily h av e u nderstood th e ir pub licatio n b y th e H e alth Section
in th e B ulletin of th e Office in tern atio n al, w ith whom th e H e alth C om m ittee w as in close associa
tion. T he B ulletin h ad as wide a circulation as th e A nnals of th e P a ste u r I n s t it u t e , afl
m easures could b e ta k e n to ensure th a t all scientists a n d laboratories needing the report
should receive copies. These re p o rts should, in his opinion, be published like all th e w orks authorise
b y th e H e alth C om m ittee, a n d n o t as a n annex to a p riv a te review.
D r. R a j c h m a n associated him self w ith th e views of M. Velghe. H e p o in ted o u t, however,
th a t th e A ssem bly h a d decided in principle against th e g ratu ito u s d istrib u tio n of League pu
cations. T he C om m ittee m ig h t ask th e Council to m ake an exception in th is p a rtic u la r case.
 — ig —

Sir George B u c h a n a n agreed t h a t th e general conclusions of the reports were likely to interest
wide public a n d th o u g h t t h a t these conclusions should be published under the au th o rity of
the L eag u e. H e d o u b ted , how ever, w h eth er a detailed account of th e laboratory work would he
of interest to a n y b u t scientific m en able to read F iench, E nglish and German,
I t w o u ld su ffic e t o p r in t t h e s e d e t a i l e d a c c o u n t s in o n e l a n g u a g e o n ly or t o let e a c h c o n tr i
bution be in t h e l a n g u a g e i n w h i c h i t w a s c o n t r ib u t e d .

Dr. R a j c h m a n p o i n t e d o u t th a t th e A m ericans a t th e Serological Conference h ad insisted

n E nglish tran slatio n s. H e th o u g h t t h e b e s t w a y w a s to publish th e reports as ordinary League
publications i n th e cheapest m a rk e t an d to re stric t th eir g ratu ito u s circulation.
M. V e l g h e m ade a stro n g app eal to th e C om m ittee n o t to economise in publications which
were of general in tere st a n d value.
The Ch a i r m a n said t h a t th is w as th e first tim e th a t such an effective collaboration h ad been
established betw een scientific in s titu te s in different countries; he em phasised the im portance of
publishing t h e resu lts of these researches collectively. The great value of th e work done was th a t
t permitted com parison b etw een different m eth o d s an d bro u g h t th em into closer relation. I t would
v>oof immense value to p re sen t th e resu lts a s a whole.
After som e discussion, it was agreed, on the proposal of M . Velghe, that the report should be printed
by the Health Section of the League in E nglish and French and issued as an ordinary League publi­
cation. I t was understood that there would be a gratuitous distribution to the principal institutes
md laboratories according to a list obtained from the editors of the A nnals of the Pasteur Institute,
Ike Bulletin of the Office international, and the M edical Research Council.

20. Report of the M ixed O pium S ub-C om m ittee.

Dr. Ca r r i è r e , acting as R a p p o rte u r for th e Mixed Sub-Com m ittee, presented his report and
summarised th e conclusions of th e Sub-C om m ittee (Annex n ) .
M. V e l g h e re g re tte d th a t th ere was no reference to Belgium in the report, though Belgium
had replied to all E nq uiries a n d h ad succeeded in obtaining precise figures regarding her legitim ate
requirements for in tern a l consum ption. Belgium h ad applied w ith success th e first of the methods
for arriving a t tiu s tw o rth y statistic s m entioned in th e repo rt of Dr. Carrière. No im ports or exports
could take place w ith o u t th e san ctio n of th e M inistry of H ealth. Only a certain num ber of im porters
were authorised to im p o rt drugs, a n d these im porters were controlled b y the h ealth authorities
md required to keep a register of drugs received, sold, or used for m anufacture. The im porters
were allowed to sell only to druggists, who were, in tu rn , required to keep a register of their p u r­
chases, sales a n d stocks. T here w ere tw o inspectors of druggists, who regularly m ade tours of
inspection. No p riv a te person could get drugs w ith o u t a m edical prescription. Breaches of the
regulations were severely punished.
The second a n d th ird m eth o d s of checking th e statistics m entioned in the report were neces­
sary only in th e absence of tru s tw o rth y statistic s obtained b y the first m ethod.
No m ethod, how ever, was effective for dealing w ith th e illicit commerce in drugs, except a
control of th e ir p roduction. In spite of all vigilance a t th e frontiers and penalties for offences
igarnst the regulations, i t was p ra ctically im possible to stop smuggling. The Academ y of Medicine
Th b ad also com e to th e conclusion th a t only a control of production could be effective,
here should be a control of p ro d u ctio n in every country, and the Opium Com mittee m ight assist
y enabling th e G overnm ents to p re v en t a n overlapping of th eir activities, and by co-ordinating
®eir efforts.

^ r - Ca r r i è r e explained th a t B elgium did n o t figure in his report, as it was based on replies

0 the questionnaires of th e A dvisory O pium C om m ittee which h a d been com m unicated to the
■ Lxed Sub-Com m ittee. In these replies Belgium was n o t m entioned. The Belgian system , which
mignt be regarded as a m odel, w as already know n, and it would be well if th e exam ple of Belgium
''ere followed. H e h ad expressly observed in his report th a t, as soon as the system of im port
export licences, on w hich th e B elgian sy stem was based, were generally applied, other methods
enquiry w ould be superfluous.
1 C h o d z k o re g re tte d th a t th e opium question, which was purely a m edical question.
Th + have been en tru ste d to a b o d y w hich lacked th e m edical com petence to deal w ith it.
3-t the position was u n satisfac to ry was show n by th e fact th a t it had been found necessary
o appoint a Mixed Sub-C om m ittee, on w hich m edical exports m ight sit in order to assist in defining
e egitirnate needs of th e various countries. M edical opinion was unanim ous th a t only a control
P ^ u c tr o n could be effective. This question h a d been w arm ly d ebated in the Opium Committee
, ,agam in th e M ixed Sub-C om m ittee. H e urged th e H ealth C om m ittee to adopt a resolution
e effect th a t control of p ro d u c tio n w as necessary. Such a resolution would serve as a m oral
pport for th e m em bers of th e O pium C om m ittee wrho agreed w ith th e views taken by the medical
exPerts on th e subject.
comK f- Presented for th e consideration of th e C om m ittee three proposals for a plan of action in
a th e abuse of dangerous drugs a n d controlling their production. These were th e pro-
;hes S wbich allusion w as m ad e to w ard s th e conclusion of t h e report of th e S u b -C o m m itte e . In
e Proposals he insisted : (i) on th e necessity of controlling production ; (2) on th e advisabm y
 — 20 —

of centralising this co n tro l in th e Opium C om m ittee and of exercising it b y m eans of special

com m issioners of th e L eague ; and (3) on th e ad v an tag e of m aking th e h ealth administrations oi
th e various countries responsible for centralising statistics, issuing licences, etc.
M. V e l g h e th o u g h t th e Com m ittee w ould approve in general th e proposals of Dr. Chodzko.
The m ethods he suggested would, however, lead p erhaps to difficulties. W as it possible for the
League of N ations to exercise control over factories b y m eans of special com m issioners ? Most
countries would oppose such a suggestion. H e tho ug h t it w ould b e b e tte r to leave the control
in th e h an d s of the h ea lth ad m in istratio n s them selves.
Dr. Ca r r i è r e suggested th a t Dr. Chodzko should p u t his proposals in a m ore general form,
insisting on the need for a stric t control, b u t n o t m entioning officials of th e League.
Sir George B u c h a n a n said he w ould su p p o rt a general resolution, b u t th e proposals as they
stood w ould require consideration.
H e assum ed th a t th e M ixed S ub-C om m ittee would continue its w ork and w ould examine the
results of th e enquiries th a t h ad been decided upon. H e hoped th a t Dr. C arrière would act
continuously as ra p p o rteu r, w ith whom th e other m em bers of th e H ealth C om m ittee might
correspond from tim e to tim e.
Dr. C a r r i è r e said th a t th e M ixed C om m ittee would continue its work w ith th e help of the
S ecretariat.
Dr. C h o d z k o said th a t th e principle of control by special com m issions h a d already been
ad m itte d b y the O pium C om m ittee. Am ong these special com m issions th ere were included repre­
sen tativ es of th e League. H e d oubted w h eth er control b y th e h ea lth ad m in istratio n s would in al
cases be tru stw o rth y . H e th o u g h t it w ould be an ad van tage to m en tio n in his proposal th e method
of control by special com m issions, as it h a d been accepted b y th e O pium C om m ittee. He would
fu rth e r like to insert a provision th a t an n u a l rep orts on th e control of production should be sent
to th e H ealth Com m ittee.
D r. L u t r a r i o said th a t th e health ad m in istratio n s had n o t sufficient officials to carry out the
con tro l them selves. In Ita ly , control w as left to th e Custom s, a n d th e control was adequate.
D r. R a j c h m a n called th e atte n tio n of th e C om m ittee to th e resolution of th e T h ird Assembly
asking th a t th e question should be stu d ied a n d a scheme presented to th e F o u rth Assembly.
Dr. Anselm ino h ad been asked to m ake th e necessary enquiries an d to p resen t a repo rt. It had
been decided th a t a m em ber of the H ealth C om m ittee should be placed a t th e service of the Mixed
Sub-C om m ittee for this purpose. I t w ould be necessary for Dr. Anselm ino to consult members of
th e H e alth C om m ittee concerning th eir own countries. The H e alth Section w as prepared to
assist b y delegating one of its m em bers fo r th is special service.
As regards com petence, th e H ealth C om m ittee was fully e n titled to ad o p t a n y resolution it
desired on th e subject of th e control of opium . I t w ould be for th e Council, if it so decided, to act
on such a resolution or to forw ard it to th e O pium C om m ittee for advice.
M. K u s a m a , referring to th e proposal for an an n u al report, do u b ted w hether th e results would
be satisfactory. Only few replies h ad been received to th e last questionnaire issued b y the Mixed
Sub-Com m ittee.
A fter fu rth e r discussion, it was agreed that a draft resolution should be prepared on the basis oi
Dr. Chodzko’s proposals for the consideration of a later meeting of the Committee.

21. Report of the Sub -C om m ittee on M easures of P ublic Health and Quarantine in the Near East,

Sir George B u c h a n a n su b m itte d th e re p o rt of th e Sub-C om m ittee (Annex 12). H e explained

th a t th e Sub-C om m ittee h a d th o u g h t it advisable to lim it itself to th e conclusion of th e Commission
of E n q u iry of last spring. H e reg retted it h a d n ot been possible to tak e in to consideration a note
w hich h a d been addressed to him b y Dr. L u trario . This h ad only reached him a few days before
th e m eeting of th e C om m ittee. H e did n o t know w hat w ould be th e result of th e decisions taken
a t L ausanne, b u t th e re p o rt of th e Commission of E n q u iry to th e N ear E a sth ad been r e c o g n i s e d
as a valuable co n trib u tio n to th e principles w hich should govern m easures of h ea lth a n d quarantine
No objection h ad been raised to the technical recom m endations. H e suggested th a t th e Commis­
sion should rem ain in being in order to advise th e G overnm ents if it should be necessary.
Dr. L u t r a r i o rem inded the C om m ittee of th e discussion w hich h a d tak e n place in Paris, and
read to th e Com m ittee som e in tro d u cto ry p arag rap h s of his n ote to th e Medical D irecto r (Annex 13V
H e h a d draw n a tte n tio n to th e tendency for pilgrim s to Mecca to ab an d o n th e old sea ro u te s and
to trav e l b y rail, and h a d su p p o rted a recom m endation to the effect th a t a body of an i n t e r n a t i o n a l
ch a rac ter should b e e n tru ste d w ith th e d u ty of co-ordinating th e work of th e several sanitary
au th o rities responsible for th e h ealth of th e pilgrim s. The te x t of th is recom m endation as pu^
lished w as to th e effect th a t a co-ordinating bo d y "should be fo rm e d ”. T his w as n o t th e text whic”
h a d been ad o pted in P aris on th e m otion of him self and of M. B arrère. I t h a d been desired to
avoid th e im pression th a t th e form ation of a new in tern atio n al body was contem plated.
Sir George B u c h a n a n said th a t he a n d Dr. L utrario were agreed th a t a co-ordinating b°d)
should be en tru sted w ith these duties an d th a t th is body should be placed in relationship with the
H e alth Com m ittee. T h ey differed, however, on th e im p o rtan t question of m eth od . Dr. Lutran0
 — 21 —

desired the H ealth C om m ittee to ac t through its own officers, whereas he would leave the actual
,rganisations on th e sp o t to arrang e a system of co-ordination, to be approved by the H ealth Com­
mittee. He did n o t th in k th e H e a lth Com m ittee w as in a position to accept responsibility for
:0-o rd in a tin g q u aran tin e m easures. The principle of a co-ordinating body placed in defined
«relation with th e H e a lth O rganisation of th e League had been accepted by th e Technical Committee
of the Lausanne Conference, w hich w as considering a special article which would apply not onlv to
the co-ordinating body concerned w ith the Mecca pilgrim age b u t to any sim ilar body which might
be set up u n d er th e P eace T reaty , such as th e proposed san itary commission for the S traits
The article in question w as based on A rticle 154 of th e d ra ft H ealth Convention suggested by the
jjear E ast C om m ittee.
M. V elghe said it w as difficult to discuss a question of drafting in th e absence of th e m inutes
of the Paris m eeting. T he ad v a n tag e of th e P aris tex t, however, was th a t it left open th e question
whether it w as necessary to create a new organisation or w hether it was possible to have recourse to
an existing organisation. I t w as th is consideration which, in his opinion, h ad determ ined the
acceptance b y th e C om m ittee of th e Office in tern atio n al of th e draft proposed by M. B arrère and
Dr. Lutrario.

It was decided that the Sub-Committee on P ublic Health Measures and Quarantine should con­
tinue its work, with Dr. Lutrario as an additional member.
 SEV E N T H M EETING

Held at on January 12th, 1923, 5 p.m.

22. National Council for Com bating Venereal D iseases.

Sir George B u c h a n a n said he h ad received a letter from th e S ecretary of th e N ational Council |

for com bating V enereal Diseases statin g th a t there would be a m eeting in P aris in January 1
th e various v o lu n tary n atio n al societies interested in th is w ork. The League of R ed Cross Societies I
was providing th e secretariat. The object of th e m eeting w as to consider plans for th e establish-1
m en t of an in tern atio n al council to com bat venereal disease. T he S ecretary of th e Council hoped"
th a t it w ould be possible for a m em ber of the H ealth Section to be presen t a t th e meeting,
proposed to send a form al in v itatio n to th a t effect.
H e felt th a t some response should be m ade to th is suggestion. The v o lu n tary bodies whicl
weie fighting venereal disease rendered valuable assistance in form ing public opinion.
M. V e l g h e agreed th a t th e work of p riv ate bodies was p articu larly valuable in th e direction I
of education and p ro p a g an d a, and th a t it was im p o rtan t to encourage th eir efforts. He had not I
h eard of th e m eeting which was about to be held in Paris, and feared th a t th e N ational Council |
h a d neglected to p rep are th e ground sufficiently in advance.
Sir George B u c h a n a n said he did n o t press for an im m ediate decision th a t a representative I
be sen t to th e m eeting, b u t he felt the in v itatio n should n o t be ignored and th a t th e interest of |
th e H e alth C om m ittee in th e question should in some w ay be indicated.
I t was agreed that the Chairman, in consultation with the M edical Director, should communiait|
with the N ational Council.

23. Epidem iological Intelligence and Health Statistics.

Dr. R a j c h m a n , referring to his m em orandum on th e subject said it w as proposed toI

u n d ertak e a sy stem atic stu d y of the organisation of the h ea lth ad m in istratio n a n d the condi-1
tions un der which public h ea lth statistics and epidemiological re tu rn s w ere collected in the various I
countries, an d of th e possibility of introducing some uniform ity in to these m eth o d s and appre-1
ciating the results as a whole. M r. Sydenstricker would p u t him self in to u ch w ith authorities andI
experts in G reat B ritain , Belgium , Ita ly and G erm any, a n d a list of m edical c o rr e s p o n d e n ts ill
the various countries w ould be drafted, as h ad been suggested b y M . Velghe a y ear ago. In the I
course of 1923 it w ould be possible to assemble m aterial which w ould form th e basis of further I
investigation.
H e h a d discussed th e organisation of epidemiological intelligence in R ussia w ith D r. Siemashko, I
an d h ad arran g ed th a t an enquiry should b e conducted into th e question of ty p h u s immunity I
and th e lim its of th e endem ic area of cholera in E uropean Russia.
Sir George B u c h a n a n , referring to a note he h ad presented on th e m em orandum of the Medical I
D irector alluded to th e prom ise he h ad m ade to arrange for a m em orandum to be prepared I
by his advisers for consideration by th e H ealth Com mittee. H e h a d consulted his British I
colleagues on th e subject a n d come to th e conclusion th a t, before suggesting m ethods or line»I
of w ork, i t was desirable th a t th e m a tte r should first be discussed w ith Mr. Sydenstricker himself I
One reason for th is was the im portance of prelim inary consultation in order to sep arate the wo* I
which m u st be un dertaken, after suitable preparation a t th e C entral Office, a n d th e work which I
th e H e alth O rganisation could prom ote m ore effectively b y using statistic al a n d ep id em io lo g ica l
investigation in different countries.
H e laid stress on th e in tern atio n al n atu re of m uch of th e w ork already done in E n g l a n d , as I
in o th er countries.
H e enquired w hether th e assistance to be appointed in accordance w ith th e suggestion con­
tain ed in th e m em orandum of th e Medical D irector would be highly train ed statistical experts
or only w ork assistants.
F inally, he suggested th a t, afte r the prelim inary enquiries in to th e problem s in v o lv e d had
proceeded for a ce rtain tim e, it m ight be advisable to ap p o in t a sm all stand ing com m ittee of mem­
bers of th e H ealth C om m ittee to consider and advise on th e n a tu re of th e work to b e undertaken
 — 23 —

M. V e l g h e said th a t, before tak in g an y fu rth e r steps, it would be well to await the arrival
of M. Sydenstricker. A t a la te r stage i t m igh t be advisable for certain members of th e H ealth
C o m m i t t e e to m eet Mr. S y d enstricker an d discuss w ith him th e n atu re and progress of the work.

Dr. R a j c h m a n explained th a t th e tw o assistants to be appointed under his memorandum

would be two M embers of Section of C ategory B, w ith m edical qualifications.

24 The Recent Work of the Epidem ic C om m ission.

Sir George B u c h a n a n read his rep o rt on th e recent work and th e present position of the Epi­
demic Commission (Annex 14). H e drew a tte n tio n to certain discrepancies which he had noted
between the E nglish a n d F ren ch tex ts, a n d reserved th e rig ht to revise th e figures given in the
report in th e ev en t of som e error having passed unnoticed.
Dr. R a j c h m a n proposed certain am endm ents of detail, which were approved by the Com­
mittee and duly noted.
The report was adopted.

25. Campaign against E pidem ics in G reece.

Dr. R a j c h m a n inform ed th e C om m ittee th a t th e Italian Governm ent had just decided to

place at the im m ediate disposal of th e Epidem ic Commission san itary equipm ent for the cam paign
against epidemics in Greece w hich w ould be restored b y the Commission later on. Thanks to this
contribution, an d to th e p hilanthrophic action of the Italian Governm ent, th irty movable shower-
baths had been obtained.

26. Red Cross Conference at W arsaw.

Dr. R a j c h m a n inform ed th e C om m ittee th a t a conference of th e R ed Cross Societies would

be convened a t W arsaw on A piil 9th, 1923. T he R ed Cross Societies from the following countries
had arranged to a tte n d : B ulgaria, E sth o n ia, H ungary, R oum ania, the Kingdom of the Serbs,
Croats and Slovenes, an d Czechoslovakia. In v itatio n s h ad been sent to the Comité international
de la Croix-Rouge, th e S ecretariat of th e League of N ations, the International Labour Office, the
Pasteur In stitu te , an d th e R ockefeller F oundation.
Dr. Chodzko, as th e result of an enquiry addressed to him by the Medical Director, had
replied th a t the Polish G overnm ent was in terested in this Conference.
The Medical D irector h a d enquired as to th e program m e of the Conference, and h ad pointed
out th at, in th e view of th e E pidem ic Commission, the cam paign against epidemics was the
duty above all of th e G overnm ents. I t appeared th a t this also was the opinion of the Red Cross
Societies.
The Conference h a d p u t on its agenda th e following questions :
D evelopm ent of th e R ed Cross Societies in E astern Europe;
C o-operation of th e R ed Cross Societies w ith th e Governm ents and priv ate asso­
ciations ;
Im m ed iate relief work ; and
Services to be rendered b y th e League of Red Cross Societies to national societies.
He h a d been inform ed b y the Comité intern ation al de la Croix Rouge th a t the Soviet Red
Cross was asking for its assistance in th e cam paign against m alaria in Turkestan. T he Comité
international enquired w h ether th e Epidem ic Commission could help.
He proposed to reply th a t all th e inform ation a t th e disposal of th e Epidemic Commission
would be placed a t the disposal of th e Comité international, and th a t the Epidemic Commission
was prepared to draw u p a p lan of action in co-operation w ith th e Comité international if there
were funds for th e work.
Dr. C h o d z k o th o u g h t th a t th e H e alth O rganisation of the League should be represented at
the W arsaw Conference. T he Conference w ould have an im p o rtan t result if it definitely decided
what should be th e duties of th e R ed Cross Societies in tim e of peace.
Sir George B u c h a n a n th o u g h t th a t, in view of th e wish expressed b y Dr. Chodzko and of
4 e relations betw een th e H ealth C om m ittee a n d th e Red Cross Societies, it was necessary 0
accept th e invitation.
The Committee decided to send a representative to the Conference of Red Cross Societies at \\ arsau
and to leave the choice of this representative to the Chairman.
 E IG H T H M EETING

Held on Jan u a ry 13th, 1923, 10.30 a.m.

Present: A ll th e m em bers of th e Com m ittee w ith th e exception of Prof. Léon B e r n a r d ,

27. Report of the Sub-Com mittee on W aterways.

Dr. L u t r a r i o presented a sum m ary of th e work of th e Sub-Com m ittee. A p lan of investi- I

g ation had been draw n up for th e purpose of collecting as m uch inform ation as possible. Enquiries I
h ad been sent to Germ any, A ustria, th e K ingdom of th e Serbs, C roats and Slovenes, and Italy. I
E ach of these countries had been th e subject of a rep o rt w hich h ad been n o ted by the I
Sub-Com m ittee.
The plan of work which he h ad been in stru cted to draw up consisted of tw o p a rts : (1) prie- I
ciples on which a set of regulations was to be based; (2) a plan of action. In th e second part,
two periods were contem plated. T here would be a first period of p rep aration , du rin g which each
S tate w ould in stru ct its officers, an d th ere would be a second period w hen th e organised sendee
w ould en ter upon its duties. A distinction was draw n in th e w orking of th e service betw een normal
conditions and em ergency conditions in tim es of epidemic.
The discussions of th e Mixed Sub-C om m ittee had d ealt w ith questions of principle. It had
been th o u g h t necessary to define th e m ain principles of action, since th e ta sk was of a novel
character.
The m em bers of th e Sub-Com m ittee, after thorough discussion, h ad reached agreement on
th e principal questions. I t had seemed unnecessary for th e H e alth C om m ittee to give an opinion
in advance of th e T ran sit Com m ittee, a n d th e fear of a possible interference w ith commerce by
river had been cleared away. I t had been agreed th a t th e costs arising o u t of th e regulations should
n o t be m et b y m eans of taxes on navigation.
I t h ad also been recognised th a t th e m easures to be ta k e n should be ta k e n as fa r as possible
a t th e place of origin of th e epidemic. I t h ad been felt th a t th e control should b e exercised under
th e direction of th e health adm in istratio n s of th e various countries, an d th a t th e question of
an agreem ent should be exam ined concerning a possible collaboration w ith existing international
organisations.
T he essential principles on which th e m em bers of th e Mixed S ub-C om m ittee h ad agreed
were as follows :
W aterw ays of intern atio n al concern m u st be tak e n p a rtic u la rly in to consideration, but it
was also necessary to consider riv er basins and lakes from th e point of view of navigation.
The declaration of diseases should b e com pulsory, regard being h ad to th e following distinc­
tions : diseases such as plague and cholera should, in accordance w ith th e in te rn a tio n a l convention
of 1912, be declared as soon as a case occurred. Diseases such as ty p h u s, relapsing fever and small­
pox should be declared as soon as th e existence of an epidem ic centre was notified. Infectious
diseases should be m ade th e object of a declaration before hav in g become a t all widespread in a
given region.
The m easures to be tak e n should n o t be unduly restrictiv e so th a t riv er commerce might
n o t be im peded. Measures would be com pulsory for one class of diseases ; th e y w ould be optional
for an o th er class, and no m easures w ould be tak e n except for th e diseases actu ally mentioned.
In tern al w aterw ays would be under th e control of th e S tate. As regards in tern atio n al water­
ways, th e Sub-Com m ittee was unanim ously of th e opinion th a t, w here an in ternatio n al body
existed, its collaboration should be invited.
In organising a service of control, it w as necessary to m ake as m uch use as possible of the
services and staff a t present existing, and a n y new organisation should be of an extrem ely simple
character. E ach S tate should organise its service in such a w ay as to be able to assist in case oi
danger a t th e place of origin of th e epidemic.
T he co-ordination of natio n al action m ight be secured by m eans of conferences, in which
th e officials of th e interested S tates w ould ta k e p art. In addition, a collaboration between the
H e alth C om m ittee and the T ransit C om m ittee an d existing in te rn a tio n a l bodies m ight be o r g a n i s e d .
Several questions h ad been raised d u rin g th e discussion. T he m em bers of th e S u b - C o m m i t t e e
h ad agreed th a t riv er navigation ought n o t to bé b u rd en ed w ith duties and taxes. Each State
m u st accept th e responsibility of m eeting th e cost of th e m easures of p ro tectio n an d control. As
regards sanctions, it seemed advisable to reserve this question for a C om m ittee of Jurists.
The Sub-C om m ittee had also reserved th e question of th e co n tam in atio n of waterways. ft
was difficult to decide when a river was contam ined, to w h a t e x te n t it was contam inated, and
w hen it ceased to be contam inated. I t seem ed sufficient in m an y cases to issue a w arning to the
 — 25 —
a u t h o r i t i e s on th e lower reaches of th e river. C ertain S tates m ight also be invited to undertake
works to avoid co n tam in atio n , p a rtic u la rly b y sewage.
In conclusion he hoped th a t th e H ealth C om m ittee would endorse these principles which
had been unanim ously ap p ro v ed b y th e Mixed Sub-Com m ittee.
The C h a i r m a n th a n k e d Dr. L u tra rio and Dr. Chodzko, th e Chairm an of th e Mixed Sub-
Committee, for th e ir work.
M. V e l g h e associated him self w ith th e th an k s of th e Chairm an. This question of waterways
was very im p o rtan t, for it w as to b e expected th a t epidemics from E astern Europe would spread
in proportion as com m ercial a n d o th er relations were resumed. H e approved th e principles des­
cribed by Dr. L u tra rio , w hich w ere in conform ity w ith those of m odern preventive science. He
thought, however, th a t i t was useless to distinguish betw een diseases so far as th e obligations
to declare th em w as concerned. T his distin ctio n was n o t scientific and m ight produce a regrettable
uncertainty in th e h ea lth services of th e various countries. I t would be b etter to ask all riparian
States to n otify all diseases w ith o u t distinction, an d to accustom them to publishing frankly
all th at happened in th e ir te rrito ry in accordance w ith th e recom m endations of th e health au th o­
rities of th e v arious countries, w hich ten d ed to become increasingly definite in this respect. In
this way progress w ould be m ade tow ards a general agreem ent which would serve as the basis
for an in tern atio n al convention. M utual confidence was essential. W ith m utual confidence it
was possible to reduce to a m inim um m easures of prevention taken against adjacent countries.
Dr. L u t r a r i o explained th a t th e Sub-C om m ittee, in distinguishing between different diseases,
was inspired b y th e H e a lth C onvention of 1912 an d th e W arsaw Conference, which provided th a t
for certain diseases a single case should suffice to m ake a declaration com pulsory, whereas for other
diseases th e existence of an endem ic area should be notified. Personally, he would be delighted
if it were possible to o b ta in a declaratio n in every case of disease which broke out.
Sir George B u c h a n a n th a n k e d Dr. L u trario for th e clear sum m ary which he had m ade of
a difficult a n d com plicated question. In order to arrive at principles, certain hypotheses appeared
to have been m ade. A n im ag in ary co n tin en t h ad been taken, w ith an im aginary internatio nal
waterway, h y p o th etica l reip arian S tates, an d well-organised san itary services. I t was perhaps
good to begin w ith a s tu d y of principles, b u t it m ust be realised where these principles were
leading, a n d th e ir ap plicatio n h ad to be considered. H e was convinced from personal experience
that in s ta rtin g p u blic h e a lth reform s or new san itary m easures it was often best n o t to press a
comprehensive program m e based on irreproachable general principles. B etter practical results
were som etim es o b tain ed b y m ak in g an a tte m p t to deal effectively w ith one or two m atters which
urgently required a tte n tio n . T he best procedure m ight be to tak e an actu al river—for example
the D anube, which needed specially to be w atched a t th e present tim e— and to send an expert
of the H e alth C om m ittee w ith a n ex p e rt of th e T ran sit Com m ittee to enquire on th e spot exactly
what was done, w h a t w as w an ted to m eet present risks, and to stu d y how these risks m ight be
met in practice. C o-ordination of effort was sound, b u t one first needed to know w hat there
was to co-ordinate in th e p a rtic u la r instance.
As regards tax es, he felt th a t th ey should be as far as possible avoided. If a riparian State,
however, was obliged to organise a new an d extensive service of control, one could hardly prevent
it from levying on n av ig a tio n in o rd e r to raise th e necessary money.
Dr. L u t r a r i o th o u g h t it was im possible to tak e up p ractical questions w ithout previous
agreement as to principles. T he Sub-C om m ittee h ad contem plated a general system of rules,
the application of w hich m ig h t v a ry according to th e different w aterw ays. The same was true
of all in tern a tio n a l conventions. H e was read y to support th e proposal of Sir George B uchanan,
but it m ust be a d m itte d as a prelim inary th a t a general system of rules was necessary. There
already existed for th e D an u be an in tern atio n al commission and a h ealth com m ittee.
As regards tax es, it h ad been decided in principle n o t to impose them , in order to give satisfac­
tion to th e T ra n sit C om m ittee, b u t it was possible th a t in certain cases th ey could not be avoided.
M. V e l g h e th o u g h t th a t th e p ra ctical suggestions of Sir George B uchanan were well founded,
but the S ub-C om m ittee h ad done well, in his opinion, to begin w ith the definition of certain principles.
It appeared from th e reply of D r. L u tra rio th a t in recognising different categories of diseases,
subject to reciprocal inform ation, th e Sub-C om m ittee h ad respected precedents by existing con­
ventions. H e asked th e Sub-C om m ittee to reconsider th is question and to tak e account of th e
new spirit w hich in spired th e h e a lth ad m in istratio n s and p rom pted them to develop th e system
°f a m u tu ally sincere exchange of all th e inform ation a t th e ir disposal.
The T ra n sit C om m ittee h a d decided against th e levying of san itatio n taxes. As health expert,
be agreed w ith th is a ttitu d e . If th ere w as need of resources they should be raised otherwise
than by tax in g riv er navig atio n . Too often taxes were m erely an excuse for m aking money.
He proposed to a d d to th e principles defined b y the Sub-Com m ittee th e following corollary :
'f taxes are necessary, th e sum s raised b y m eans of them shall be devoted exclusively to
health m easures.
Dr. Ch o d z k o observed th a t, if a S ta te decided to tak e m easures of health, it was in the first
^stance for its own defence. I t was therefore unj ust to impose burdens upon navigation in tra n s it.
He read th e following resolutions, which h ad been unanim ously adopted b y the Mixed Sub-
Committee :
1. T he Sub-C om m ittee considers th a t, in principle, it is the d u ty of the riparian
S tates of an in te rn a tio n a l w aterw ay to declare regularly and frankly an y inform ation
a t th e ir disposal on questions relatin g to infectious diseases of every kind.
(M. Baldw in alone abstained.)
 — 26 —

2. T he Sub-C om m ittee su p po rts firm ly th e principle laid dow n in th e In te rn a tio n a l

H e alth C onvention of 1912 to th e effect th a t m easures ta k e n again st infectious diseases
should, as far as possible, avoid a n y im pedim ent to th e m ovem ent of commerce and
com m ercial relations b o th in th e in terio r a n d w ith neighbouring countries.
3. T he Sub-C om m ittee th in k s it essential th a t th e sa n ita ry control of traffic on
in te rn a l w aterw ays should be th e d u ty of th e public h e a lth au th o rities of th e State.
F o r w aterw ays of in te rn a tio n a l concern, w ith o u t prejudice to th e possibility of special
provisions for p o rtio n s of these w aterw ays carry in g a n im p o rta n t m aritim e traffic,
th e control of s a n ita ry m easures should be th e d u ty of th e public h e a lth service of the
rip a ria n States.
In cases w here an in te rn a l body, qualified from th e s a n ita ry p o in t of view, has been
or is to b e estab lish ed over these w aterw ays, th is b o d y w ill be responsible for t h e execu­
tio n of th e necessary m easures.
4. T he Sub-C om m ittee recom m ends th a t th e service of co ntrol should be organised
in n o rm al tim es in such a w ay th a t it m ay be able to deal w ith a n y em ergency.
W ith th is object in view, i t em phasises th e necessity of reso rting as m uch as possible
to th e resources an d m ach in ery alread y existing in th e co u ntry , directing th e ir activity
tow ards th e new d u ties w hich th e y m ay hav e to perform . T he new m achinery should
be of an ex trem ely sim ple character, an d should consist as fa r as possible of material
alre ad y available.
5. T he Sub-C om m ittee recom m ends th e organisation of periodical conferences
betw een th e head s of th e h e a lth services concerned to ensure th e good conduct of the
service.
6. The Sub-C om m ittee is of th e opinion th a t th e collaboration of th e H ealth Com­
m itte e a n d th e C om m ittee on C om m unications a n d T ra n sit of th e League of Nations
should be close a n d p erm a n en t in all th a t concerns th e above problem s, which are of
eq u al in tere st to b o th bodies.

T h e C h a i r m a n suggested th a t th e C om m ittee, h av in g n o ted th e o b servatio ns of Sir George

B uchanan, should a d o p t these resolutions, which sum m arised th e s ta te m e n t of D r. Lutrario.
These were general instru ctio n s w hich could enable th e Mixed S ub-C om m ittee to continue its
work. H e expressed th e hope th a t, in future, d ra ft resolutions of th is im p o rtan ce w ould be sub­
m itte d in advance in order th a t th e C om m ittee m ight h av e tim e to exam ine them .
Sir George B u c h a n a n d id n o t th in k it w as necessary to ad o p t a form al resolution. The
C om m ittee h a d n o t h a d tim e to s tu d y in th e ir details th e d ocum ents concerning w aterw ays. All
h e could do as a resu lt of th e clear s ta te m e n t of D r. L u tra rio was to ap p ro ve th e general instruc­
tions, w hich w ould enable th e Sub-C om m ittee to continue its work.
D r. C h o d z k o said th a t every discussion should norm ally be w ith a resolution, a n d t h a t the
S ub-C om m ittee expected to receive instructions. If th e d ra ft resolutions u nanim ously adopted
b y th e Sub-C om m ittee were n o t ad o p te d b y th e H e alth C om m ittee, th is w ould m ean t h a t the
question w as adjourned, a decision which he was p repared to accep t if th e C om m ittee so decided.
T he C om m ittee h a d alread y h a d to tak e decisions du rin g th e session on o th er rep o rts w h ich had
been su b m itte d to it on th e sam e day. This raised th e whole questio n of th e m eth o d of work
of th e C om m ittee.
S ir George B u c h a n a n said he w as re ad y to approve th e resolutions in a sp irit of accom m oda­
tion, b u t he felt b ou n d to s ta te t h a t i t was co n tra ry to good procedure to h a v e to ap p rov e an impor­
ta n t te x t w ith o u t h a v in g h a d th e tim e to exam ine it.

The Committee adopted the resolution of the M ixed Sub-Committee.

28. Resolution concerning the Control of the Production of O pium.

D r. C a r r i è r e presented to th e C om m ittee a resolution concerning th e control of th e produc­

tio n of opium .
H e explained th a t th e la s t p arag ra p h was a com prom ise betw een th e te x t suggested o n the
previous d a y b y D r. Chodzko an d th e views of th e C om m ittee. D r. Chodzko h a d asked t h a t the
control should be exercised b y special com m issioners of th e League. C ertain m em bers o f the
C om m ittee h a d p ro tested against th is suggestion. A ccording to th e p resen t te x t, resort would
be h a d to special com m issioners in countries w here con tro l b y th e health ad m in istratio n was
reg arded as inadequate.

M. V e l g h e asked th a t th e la s t p arag rap h should be am ended, as in its p resen t form it was

am biguous. I t was desired to control th e delivery of th e drugs b y th e countries a n d not their
m anufacture.

D r. C a r r i è r e agreed to accept th e am en dm ent proposed b y M. Velghe.

 — 27 —

The resolution, w ith th e am en d m en t of M. Velghe, was as follows:

"T h e H e a lth C om m ittee,

' ‘H a v in g h ea rd a re p o rt presen ted b y th e M ixed Opium Sub-Committee on the m ethods
of e n q u iry to be used in determ ining th e legitim ate needs of a country in respect of
opium , d eriv ativ es of opium a n d o ther narco tic drugs ;
" A n d being of th e opinion th a t th e legitim ate needs of a country are its needs exclus­
ively m edical an d scientific ;
" A d o p ts th e p ro posals co n tain ed in th e re p o rt of th e Sub-Comm ittee and recommends
th a t th e enquiries should be u n d ertak en as rap id ly as possible.
" I t fu rth e r feels it necessary to declare its opinion th a t in order to com bat effectively
th e abusive use of these drugs, it is necessary strictly to control th e delivery of these
p ro d u c ts b y th e centres o f p roduction. T his control should be exercised b y th e health
au th o rities in collaboration, if necessary, w ith th e m ixed commissions m entioned in the
resolution ad o p ted b y th e A dvisory C om m ittee on the Traffic in Opium during its session
of M ay 1922.”

Sir George B u c h a n a n en qu ired w h e th e r th e second p arag ra p h im plied th e acceptance of the

view th a t th ere was no possible leg itim a te use of opium o th er th a n medical and scientific uses.
Did it m ean th a t no o th e r use o u g h t to be regarded as proper ? H e was n o t entirely convinced
th at this in te rp re ta tio n could be app lied to countries such as India. He did n o t wish to say th a t
the view w as m istak en , b u t he could o nly assent to a resolution in this sense w ith reservation.
Dr. C a r r i è r e said it w as th e in te n tio n of th e resolution to assert th a t there could be no legi­
timate use of th e drugs ex cept for m edical and scientific purposes. This point of view had been
accepted b y th e O pium C om m ittee, subject to a reservation m ade by Mr. Campbell.
Sir George B uchanan accepted the resolution with the reservation that be expressed no
opinion on the interpretation of the term "legitimate needs” in the second paragraph, in so far as
this term related to the use of opium in Eastern countries.
The resolution was adopted by the Committee.

29. Report of the M edical Director.

Sir George B u c h a n a n said it h a d been agreed th a t th e discussion an d adoption of th e report

by the Medical D ire cto r should be reg arded as an o p p o rtu n ity for mem bers of th e Committee to
raise any q u estion th a t seem ed advisable concerning th e general work of the H ealth Organisation.
H e en q u ire d w h e th e r it w ould b e possible for Dr. Carozzi, the representative on the Committee
of the In te rn a tio n a l L ab o u r Office, to p resen t from tim e to tim e a rep o rt on the work of the In te r­
national L ab o u r Office in m a tte rs of in d u strial hygiene an d the position w ith regard to intern a­
tional co nventions dealing w ith questions of health.
Dr. C a r o z z i said he w ould b e v ery glad to present a re p o rt to th e Com m ittee a t its n ex t
session.
 NIN TH MEETING

Held on January 13th, 1923, at 3 p.m.

Present : All th e m em bers w ith th e exception of Prof. Léon B e r n a r d an d Prof. S a n t o l iq u id o .

30. Report of the Medical Director.

S ir George B u c h a n a n said he had freq u en tly had occasion to refer to th e h eav y character of
th e w ork which had to be u n d erta k en d u rin g th e sessions of th e C om m ittee. An improvement
had to som e e x te n t been m ade, th an k s to th e efforts of th e Medical D irector, a n d th e able conduct
of th e proceedings of th e C om m ittee b y th e C hairm an. T he w ork of th e sessions, however, was
still h e a v y an d left little tim e for an exchange of views am ong in d iv id u al m em bers.
T he w ork w ould perhaps be appreciably lightened if th e re p o rt of th e M edical D irector were
circu lated well in advan ce of th e session. T here w ould in th is case be tim e for explanations and
am endm ents before th e C om m ittee cam e to g eth er.
T h e w ork of th e C om m ittee w ould also b e easier if its m em bers were k e p t m ore fully informed
of th e progress of th e v ario u s questions d u rin g th e in terv als of th e ir m eetings. In particular,
m em bers should be k e p t inform ed of th e w ork of th e Sub-C om m ittees. H e m entioned several
instances th a t h ad occurred since th e la st session of th e C om m ittee. H e suggested th a t it should
be a reg u lar p ratice of th e Sub-C om m ittees to h ave a rap p o rteu r, who w ould be responsible for
keeping m em bers of th e C om m ittee inform ed thro u g h th e C hairm an as to th e resu lts of their
m eetings.
H e fu rth e r suggested th a t, in circu latin g com m unications an d docu m en ts to m em bers of the
Com m ittee, th e S ecretariat should ad o p t a definite system of num berin g th e docu m en ts according
to th e series in w hich th e y occurred, an d giving p artic u la rs as to subject, d a te an d origin.
H e hoped th e C om m ittee would n o t th in k he was insisting too g re a tly on p o in ts of procedure.
T he position of th e B ritish m em ber of th e C om m ittee was a little difficult, as a g re a t num ber of
ad m in istratio n s w ere in tere ste d in th e various problem s discussed, an d m u st be consulted before
he was in a position to give a considered opinion, or p a rtic ip a te in a v ote of th e Com m ittee.
D r. R a j c h m a n apologised to th e C om m ittee for th e u n avoidable delay w h ic h h a d occurred
in th e circulation of his re p o rt, a n d agreed as to th e necessity of com m unicating it to th e members
a t an early date.
H e replied in d etail to th e observations of S ir George B u ch an an concerning th e work of the
Sub-C om m ittees. H e accepted th e suggestions of Sir George B u ch an an in reg ard to th e s y s t e m a t i c
num berin g of th e d ocum ents d istrib u ted .
Sir George B u c h a n a n said he h ad no idea of criticising th e p a s t work of th e secretariat.
H e h a d m erely desired to p u t forw ard certain suggestions as to fu tu re procedure. H e w o u ld like
to insist on his proposal th a t on each Sub-C om m ittee th ere should b e a ra p p o rte u r responsible
for inform ing th e o th er m em bers of th e C om m ittee of th e progress a n d results achieved. I t would
b e for th e ra p p o rte u r a n d n o t th e s e c re ta ria t to d ra ft such com m unications.
M. V e l g h e said he th o u g h t th a t D r. R ajch m an h ad replied to th e com plete satisfaction of the
C om m ittee on th e p o in ts raised b y Sir George B uchanan.
T he C h a i r m a n th o u g h t th e C om m ittee was prep ared to accept th e suggestions of Sir George
B u ch an an as to fu tu re procedure. H e asked, however, th a t a n y com m unications circulated by the
sec retariat, acting on th e advice of th e ra p p o rteu rs of th e Sub-C om m ittees, should b e sent to all
th e m em bers of th e C om m ittee a n d th a t he m ig ht th u s be relieved of th e responsibility of deciding
w h eth er a p artic u la r docum ent should be circulated or not. H e agreed as to th e extrem e desira­
b ility of having early repo rts, b u t he w as sure th a t th e Medical D irecto r h ad done his u tm o st in the
m a tte r. H e th an k e d th e M edical D irector for th e splendid w ork h e h ad done.
The report of the Medical Director was adopted.
 — 29 —

,J D a t e of the N ext Session.

The C h a i r m a n said th a t th e d a te of th e n e x t session would depend on the P asteur Centenary

celebrations and th e m eeting of th e Office in te rn a tio n a l a t th e end of May. I t m ight be possible
to hold the session of th e H e a lth C om m ittee betw een th e m eeting of th e Office international and
the Pasteur celebrations.

M. V e l g h e said he w ould en q u ire as to th e d a te of th e celebrations and th e program m e of th e

Office in tern atio n al. H e w ould endeav ou r to arran g e for the session of the Committee of the
Office to be held a t a convenient d a te a n d of H e alth Com m ittee of th e League of Nations.

On th e proposal of Sir George B u c h a n a n , a v o te of th an k s to th e C hairm an was carried w ith

acclamation for th e able w ay in w hich he h ad conducted th e business of the session.
 — 30 —

Annex i.

PROPOSED COLLABORATION BETW EEN THE HEALTH C O M M IT T E E

A N D THE U N IT E D STATES PUBLIC HEALTH SERVICE

L E T T E R FRO M Dr. M ADSEN TO D r. GUMMING:

D ecem ber 1922.

D ear D octor Gumming,
I very m uch regret th a t I was unable to go to P aris for th e last m eeting of th e Office interna­
tion al a n d so h ad n o t th e o p p o rtu n ity for a long discussion w ith y o u of th e w ork of th e Health
O rganisation of th e League.
I am v ery grateful for all th e in terest you are tak in g in th e activities of th e organisation,
m ore p articu larly for th e personal p a rt you h ave tak en in th e first experim ent of th e interchange
of public h ea lth personnel b y giving an adm irable lecture in Brussels.
I am v ery glad to learn th a t arrangem ents h av e been com pleted for Mr. Sydenstricker,
statistic ia n of y o u r service, to ta k e charge of th e Service of Epidem iological Intelligence and Public
H e alth S ta tistics of th e H e alth Section a t Geneva.
I h av e also h ea rd from Sir George B u ch an an a n d Dr. R ajch m an th a t y o u in te n d com
sioning some of y o u r m edical officers to p artic ip a te in one of th e fu tu re interchanges of public
h ea lth personnel in E urope, a n d fu rth er, th a t yo u h av e suggested very kindly th a t one of the
in terch an g es should tak e place in th e U n ited States.
T he Second Serological Conference h as ju st term in ate d in Paris. I t was, I think, most
successful, a n d th e p ractical results o b tained in th e discussions concerning meningococci and
pneum ococci were due very largely to th e presence of Dr. W adsw orth, representing th e Rockeleller
In stitu te . T he agreem ent reached regarding th e d ip h th eria an tito x in a n d th e v ery satisfactory
conclusions concerning th e tetan u s u n it could n o t h av e m aterialised w ith o u t th e assistance of
D octor McCoy, of your service, and I am very anxious to express to you once m ore m y gratitude
for havin g facilitated his collaboration w ith us.
I a m sure I am voicing th e unanim ous opinion of all th e m em bers of th e H e alth Commi
in asking y o u w hether i t w ould be possible for you to stren g th en still fu rth e r th e ties of your colla­
b o ratio n b y becom ing a m em ber of th e H ealth Com m ittee. O ur n e x t session begins on January
8 th, 1923, a n d I am m ost anxious to be able to announce to m y colleagues you r acceptance of this
inv itatio n . I should be glad, therefore, if y o u would kindly send y o u r answ er b y cable, addressing
it to G eneva : “M adsen N ations G en ev a”.
Believe me, dear D octor Cumming,
Y ours very sincerely,

(Signed) T h. M a d s e n ,
C hairm an of th e H e alth Committee.
Surgeon-General H . S. C u m m i n g ,
B ureau of th e Public H ealth Service,
W ashington.

R E P L Y O F Dr. CUMMING TO Dr. M ADSEN.

Telegram, December 31 st, 1922.

A ppreciate last p arag rap h y ou r letter. W ill gladly act in advisory a n d co nsultativ e capacity
H e alth Com m ittee League if desired. Im possible a tte n d all meetings.
C u m m in g .
 — 31 —

Annex a.

MEETING OF T H E INTERNATIONAL COMMISSION

F IR S T M E E T IN G

Held on Ja n u a ry gth, 1923, at 10 a.m.

Present : The m em bers of th e C om m ittee, together w ith Dr. S i e m a s h k o , People’s Commissary

for Public H e a lth of th e R epublic of th e Soviets.

The Position in R u ssia : S tatem en t by D r. Siem ashko.

The C h a i r m a n welcomed Dr. Siem ashko an d said th a t the Committee would be happy to
hear a statem en t on th e position in R ussia.
Dr. Siemashko began b y saying th a t the presence of a People’s Commissary of the Soviets
at a meeting of th e H e alth C om m ittee need n o t cause an y surprise, as certain newspapers had sug­
gested, an d did n o t change in a n y w ay th e a ttitu d e of th e G overnm ent of the Soviets towards the
League of N ations. T he H e alth C om m ittee was dealing w ith hum anitarian and n ot w ith political
questions, a n d contained rep resentatives of countries which were n o t Members of the League of
Nations.
I t m ig ht be claim ed t h a t th e position in R ussia as regards epidemics had generally improved.
In 1922, th ere h ad been m ore th a n a million cases of typ hus and as m any cases of relapsing fever,
but since th e m iddle of th e y e a r th e figures had tended to decrease progressively. Cholera had
raged, above all in th e fam ine districts, during th e sum m er of 1922, b u t since July th e epidemic had
decreased. I t m ig h t generally be said t h a t sm allpox, scarlatina and diphtheria were not widespread.
On th e o th er h an d , n ea rly a m illion cases of m alaria had been notified in 1922, and even in the
north, in th e province of Archangel, 6,000 cases h ad been notified as com pared w ith 400 in 1913.
The figures for ty p h u s furnished b y P rof. Tarassevitch, according to which alm ost half of the
population h a d becom e im m une, were too optim istic. T yp hus was always a menace, and the popu­
lation was fa r from becom ing im m une. To get a tru e idea of th e real position, it was necessary to
multiply b y 2.5 th e official statistic s of cases registered.
The general h e a lth situ atio n w as v ery serious. This w as due in large p a rt to the famine,
which had stru c k a th ird of th e population, an d which prevailed anew in certain districts of the
Ukraine, th e Caucasus, th e Crim ea a n d Arm enia. B ad housing conditions aggravated the situation,
md the epidem ics h ad weakened th e resistance of th e inhabitants. Russia still remained a
centre of epidem ics which m ig h t spread to neighbouring countries.
The P eople’s C om m issariat h ad u n d erta k en a vigorous cam paign in order to rem edy the
position. I t exercised a control over th e local adm inistrations b y m eans of h ealth inspectors.
According to a decree concerning th e cam paign against typhus, a h ealth organisation was contem-
>lated allowing a t least one m edical officer for every 5°,000 inh ab itants in the towns, and one
nedical officer a n d an a ssista n t for every 200,000 in h ab itan ts in th e villages. There was in the
towns an in sp ecto r of houses for every 50,000 inh ab itan ts. . .
The cam paign a gainst cholera w as conducted principally b y m eans of vaccination, particularly
f the soldiers. 90 per c e n t of th e soldiers h a d been vaccinated, and were to be vaccinated annua y.
he supply of vaccine w as sufficient, w hereas th ere was a deficiency in the supply of serum, acci-
lation h ad also been successfully em ployed against smallpox. M aterials for disinfection were
generally a d e q u ate. ., , ,
The H e alth Congress w hich h a d been convened a t Moscow in Decem ber 1922 had deci e o
ake all th e m easures possible to com b at epidemics and to im prove the health situation. or 1
^rpose, in sp ite of financial difficulties, an effort h ad been m ade to increase the num ber ot ospi a
lnd am bulances a n d to ta k e m easures ag ainst social diseases. . . ,
There were no exact statistic s as regards venereal diseases, b u t a com m ittee o speci
lad exam ined 37,000 soldiers a t P etro g ra d a n d 33,000 soldiers a t Moscow. Ih e resu o
lam in atio n was as follows :
Petrograd Moscow

Syphilis 0.9 % 0.4%

Gonorrhoea 2.23% 0.7%
 — 32 —

These figures, com pared w ith those of previous years, showed a decrease, p a rtly explained bv
th e fa c t t h a t th e recru its exam ined were young.
T h e exam ination a t Moscow of 1,071 stu d en ts h ad shown th a t th e n u m b er of cases for the two
diseases ta k e n to g eth er am ounted to 15.5 p er cent as com pared w ith 22.7 per cen t in 1905. InqUj.
ries m ade in variou s regions h a d shown th a t, generally speaking, th e epidem ics of venereal disease
w ere less grave th a n th e o th er epidemics, b u t t h a t certain villages were grav ely infected.
Tuberculosis h ad g re atly increased, above all in th e fam ine districts. M ortality tables for
P etro g ra d gave th e following figures :

1 9 1 2 ....................... 34 d eath s per 10,000 in h a b ita n ts.

1 9 1 8 ....................... 37 » » » »
192 0 ....................... 51 » » » »
192 1 ....................... 36 » » » »

I t should be n oted t h a t dem ographical statistic s were being reorganised. The registration
of b irth s an d d ea th s h ad been com piled u n d er the old regim e b y th e Church, b u t since the separa­
tion of C hurch an d S ta te a general statistic al service h ad ta k e n charge of th e work. The last census
of th e population, ta k e n on A ugust 28th, 1920, showed t h a t th e po p u latio n of R ussia in Europe
h ad decreased b y 13 per cent, an d t h a t of R ussia in A sia b y 3 per cent.
I n order to co m bat venereal diseases an d tuberculosis, dispensaries h a d been constituted
in each governm ent tow n a n d in som e of th e sm aller towns. Associations h ad been organised
to assist in th e w ork of each dispensary, a n d prop ag an d a weeks were periodically organised. The
Congress of D ecem ber 1922 h ad tak e n steps to register diseases, b u t th e results had n o t been very
considerable so far. T h irty -tw o statio n s h ad been set u p to deal w ith m alaria, p articu larly in the
Caucasus an d T u rk estan . H e alth m issions h ad been organised, as well as special courses fo r doc­
tors. P urchases were m ade yearly, p a rtic u la rly in G erm any, of in stru m en ts an d drugs, parti­
cularly of quinine. Two m illion gold roubles h ad been expended.
P artic u la r a tte n tio n was p aid to th e pro tectio n of m others a n d in fan t children. The new
legislation on th e su bject ensured for w om en workers eight w eeks’ leave before a n d afte r childbirth
an d six weeks for wom en w orking in offices. I n R ussia (excluding th e U kraine) a n d in Siberia,
580 crèches h a d been opened w ith accom m odation for 27,000 children. T h ey provided for only 3.3
p er ce n t of th e requirem ents of th e coun try . C onsultations h ad been organised corresponding to
10 p e r cent of th e requirem ents. There were 136 children's homes, which represen ted only 3.2 per
cen t of w hat was necessary. The in fan t m o rtality tables a t Moscow for children up to twelve
m o n th s gave th e following figures :

191 4 .....................27.9 per 100 b irth s

1 9 1 5 ................................................. 3 0 . 3 » » >'

191 6 .....................34.2 » » »
1917 ..................... 35-4 » » »
191 8 .....................27.8 » » »
1919 ..................... 33 » » «
192 0 .................... 22.5 » » »
192 1 .....................26,5 V » »

The b irth -ra te statistics for Moscow gave th e following figures:

191 4 .....................31 p er 1,000 in h ab ita n ts

191 5 .....................2 6 .9 » » »
191 6 .....................2 2 .8 » » »
191 7 .....................1 9.5 » » »
191 8 .....................14.8 » » »
1919 .....................1 7 .4 » » »
1920 .....................2 2 .1 » » »
192 1 .....................3 0 .2 » » »

In order to pro tect older children, th e Com m issariat of P ublic H ealth was endeavouring to
develop physical culture. T here was a t Moscow a C entral In s titu te of Physical Culture, which
train ed instru ctors for factories an d workshops. T hree-m onth courses were given. F o r instructors
in schools, courses of three years were organised. Exercises were com pulsory in th e provinces
in schools an d barracks.
There was in R ussia a large n um b er of abandoned children who h a d been collected and housed.

At Moscow 1,045 children

In R ussia 13,170 » (physically and m orally abnorm al)
» 811,000 » (placed in educational in stitu tes).

T he situation, as will be seen from this statem en t, was grave. Commerce an d a g r ic u ltu r e
were only gradually recovering a fte r a period of fam ine which h a d atta c k e d a th ird of the popula­
tion of E u ro pean Russia, The C om m issariat of Public H ealth, which was only a central a d m i n i ­
stra tiv e body, hoped to succeed in its ta sk w ith the assistance of th e health in stitu tio n s of other
countries acting for th e welfare of R ussia and of hum anity.
 — 33 —

The Chairman , on beh alf of th e Com m ittee, th an k e d Dr. Siemashko for his statem ent.
Professor Léon B ernard asked w hat m easures h a d been taken against alcoholism.
Dr. Siemashko said th a t it h ad been necessary to m ake concessions for financial reasons
Wine with an alcoholic co n te n t of m ore th a n 18 degrees was prohibited. Energetic measures were
taken for the suppression of " sa m a g o n k a ” , w hich the peasan ts distilled a t home. Police measures
had been taken, a n d assistance w as rendered b y in d u strial and h ea lth organisations. Brandv
was only sold on th e p rescription of a doctor.
M. V elghe asked w h eth er th e decrease in the epidemic diseases registered during the last
months in th e sta tistic a l tables which h av e been shown m ay be attrib u te d to a prohibition by
decree of m igration of th e population.
Dr. Siemashko said t h a t th e decrease in th e m ovem ent of the population had certainly
checked th e p ro p a g atio n of epidem ics, b u t t h a t in this field, decrees could not have a very great
effect, above all in tim es of fam ine. A decree prohibiting such m ovem ents would as a result lead
to the creation a t p a rtic u la r points, in railw ay statio ns for example, of centres of infection. I t was
better to regulate these m ovem ents th a n to prohibit them , and it was for this purpose th a t 10,000
beds had been organised along th e railways.
Dr. L utrario asked w h e th e r in th e struggle against m alaria, pure quinine alone was employed,
or else th e secondary alcaloids of q u in quin a such as chinchonin, which had given excellent results
in Italy; w h at were th e seasonal v ariatio n s of m alaria has broken out in the cold districts of N orthern
Russia-whether th e extension of ex tra-g en ital syphilis is still as great as it was stated to be in
medical literatu re, and w h eth er p ro stitu te s were subm itted to an obligatory medical examination.
Dr. Siemashko replied th a t quinine was alm ost exclusively used. The question of substitutes
was being stu d ied b y specialists who would derive advantages from the courses organised b y the
League of N ations. T here was a decrease of m alaria in th e winter. E xtra-genital syphilis was more
widespread th a n o th e r forms, above all am ong the peasants. P rostitutes were n ot subm itted
to a com pulsory exam ination, b u t th e professional women were segregated.
Sir George B uchanan asked w hether, in order to com pare usefully th e statistics of infectious
diseases, it w ould b e possible to determ ine th e num ber of deaths for a particular disease or the
total num ber of d ea th s in a given region.
Dr. S iemashko said it w as difficult to m ake com parisons owing to the large num ber of pro­
vinces. M o rtality tab les were n o t y e t v ery satisfactory. F o r this reason it was only possible to
give figures for certain towns.
Dr. Chodzko drew a tte n tio n to th e statem en t th a t R ussia rem ained a centre of epidemics
which th reaten ed P o lan d an d E urope. H e asked Dr. Siemashko to give still further- details regard­
ing the cam paign against epidemics, th e num ber of beds for epidemic diseases which are available,
the quarantine stations, th e in stitu te s of bacteriology, the organisation of 32 stations to deal
with m alaria, a n d th e general program m e of th e cam paign against epidemics.
Dr. S iemashko replied t h a t th e H e alth O rganisation comprised 30,000 beds for epidemic
diseases in ad d itio n to 10,000 beds co n stitu ted for th e railways. There were isolation stations
in each im p o rta n t railw ay sta tio n an d an in stitu te of bacteriology in every capital city of a pro­
vince. Medical officers were n o t dependent on th e Commissariat a t Moscow, b u t were paid by the
Commissariat. T hey were responsible to local bodies of the central adm inistration, and the Moscow
Commissariat exercised its control b y m eans of h ea lth inspectors. The stations to deal w ith m alaria
were m aking enquiries in order to determ ine th e places of origin and the forms of the disease
with a view to its suppression. T he stations were organising exhibits and conferences. In each
station there was a lab o ra to ry , a dispensary an d often a hospital.
Dr. R ajchman observed t h a t th e R ussian Delegation had said a t the E uropean H ealth Confe­
rence at W arsaw in M arch 1922 t h a t th ere wrere 70,000 beds for epidemic diseases, and in an
official report it w as s ta te d t h a t th ere were 75,000 beds. According to the figures of Dr. Siemashko,
there had been a considerable decrease.
Dr. S iemashko replied t h a t th e n u m b er of beds varied according to the gravity of the epi­
demics, an d t h a t a t th e present m om ent 30,000 beds were sufficient.
The program m e for 1923 co n tem p lated th e organisation of enquiries, strong propaganda in
the Press,inspection of hom es, houses an d persons, the free distribution or cheap sale of ho t w ater
ind soap, th e org anisation of n ig h t shelters, th e organisation of beds for epidemic diseases, a
ctose collaboration w ith th e railw ay organisations, a n d the constitution of extraordinary local
commissions, etc.
Replying to a question of th e C hairm an, Dr. Siemashko said th a t the situation was much
jhe same in th e w est a n d east of R ussia, an d th a t the m ovem ents of th e population across the
frontier had g re atly dim inished.

3
 — 34 —

SECOND M E E T IN G

Held on Ja n u a ry 10th, 1923, at 10 a.m.

All th e m em bers w ho a tte n d e d th e previous m eeting were present, to g ether w ith D r. Siemaskho
People’s Com missary for Public H e alth a t Moscow.

P osition in R u s s ia (Continuation).

T he C h a i r m a n asked Dr. Siem ashko if he could a d d to th e in teresting inform ation which he

h ad furnished regarding Russia certain details of a practical character concerning th e assistance
w hich m ig h t be afforded to his co untry if occasion perm itted.
Dr. S i e m a s h k o said t h a t the chief problem was to check th e progress of the epidemics. It
was in this field th a t assistance w ould be p articularly useful. There w as no lack of means of
disinfection a n d of vaccine, b u t th ere was, on th e other hand, a shortage of drugs, laboratory
ap p a ratu s an d an ti-d ip h th eria serum.
A ssistance would also be welcomed in the cam paign against in fan t m ortality, an d there was
a lack of quinine for th e cam paign against m alaria. There was also a shortage of bedding, of
absorbent lin t a n d soap.
T he C h a i r m a n th an k e d Dr. Siemashko, a n d expressed th e hope t h a t it would be possible to
m eet these requirem ents to a certain ex tent.
Prof. N o c h t asked w h ether vaccination against ty p h u s h ad been tried on an extensive scale
an d b y w h a t m ethod.
Dr. S i e m a s h k o replied th a t different m ethods h a d been em ployed w ith o u t a n y very great
success.
M. V e l g h e asked to w h a t degree it would be possible to develop a n d reinforce, w ith t h e assis-l
tan ce of th e Soviet G overnm ent, th e activities of th e agencies of the E pidem ic Commission andl
of th e philanthropic organisations th a t w ork in Russia.
Dr. S i e m a s h k o said t h a t R ussia was very grateful for th e help afforded h er in foo d stu ffs andl
drugs b y th e charitable organisations and the R ed Cross. I t was necessary t h a t foreign assistance!
should be rendered b y collaboration w ith the R ussian organisations in their daily work, and itl
w ould be v ery useful to organise th is assistance system atically.
T he office of Dr. N ansen organised dispensaries in certain regions for fixed periods. Eachl
ch aritable organisation m ight devote itself to a specific ta sk such as th e protection of children!
the cam paign against tuberculosis, etc. In this w ay th e G overnm ent m ight draw up its programme!
know ing on w h a t assistance it m ight rely.
M. V e l g h e asked w h a t was th e position of the agencies o f th e Epidem ic Commission.
Dr. S i e m a s h k o replied th a t th e y were collaborating closely w ith th e G overnm ent and giving!
entire satisfaction.

T H IR D M E E T IN G

Held on Ja n u a ry 13th 1923, at noon.

All th e Members of th e H e alth C om m ittee (except Prof. Léon B ernard) an d D r. S ie m a s h k o

P eople’s Com missary for P ublic H ealth , Moscow, atten d ed .

Anti-Dysentery Vaccination in Russia.

The C h a i r m a n in v ited Dr. Siem ashko to inform the C om m ittee of th e experim ents made
R ussia in th e m ethod of vaccination per os.
Dr. S i e m a s h k o said t h a t th is m ethod h a d been tried in R ussia w ith favourable results
Dr. T arassevitch had received th e vaccine from the P a ste u r In s titu te a n d h a d issued two report’
 — 35 —

Xhe vaccine h ad b een trie d in th e first instance on the m edical staff. The cases numbered several
There h a d been no case of infection am ong those vaccinated, and the results of the
h u n d re d .
vaccination on th e h e a lth of th e persons v accin ated h ad not been m ore serious than those observed
under the ordinary m ethod. I t had been decided to continue the experim ents on a more extensive

iCa He had drafted a letter to th e C hairm an of th e H ealth Com m ittee recording this decision
and expressing the hope that the experiments might be conducted in correspondence with the
P a ste u r Institute and with the collaboration of an expert appointed by the H ealth Committee
(see Appendix).
The Chairman th a n k e d D r. Siem ashko for his inform ation, I t was most desirable to have
fu rth er experim ents an d to a p p recia te th e results. H e congratulated Dr. Siemashko on having
secured for th is ex p erim en t th e service of m edical m en whose qualifications were widely known
and respected. I t w as necessary t h a t these experim ents should be carried out in accordance with
a definite program m e a n d t h a t th e re su lts should be carefully controlled.

M. V elghe said t h a t th e C om m ittee w as h ap p y to accept th e proposal of Dr. Siemashko.

He enquired w hether, pen ding definite final results, it would be possible for th e experts to give
some indications as to th e success or failure of th e experim ent a t th e next session of the H ealth
Committee.
The Chairman suggested t h a t S ir W illiam Leishm an should be appointed as expert to decide
on the conditions of th e ex perim ents an d to control th eir results. If Sir William Leishman were
unable to accept th e in v ita tio n , th e C om m ittee m ight authorise him to appoint someone else in
consultation w ith th e Medical D irector. I t would perhaps be necessary for the expert appointed
togo to the spot, o r a t least to confer w ith D r. T arassevitch and Dr. Siemashko.
Dr. Siemashko said th a t a liquid vaccine for vaccination per os was being prepared a t Moscow,
:ut thathe w ould prefer th e use of th e vaccine of th e P asteur In stitu te . The latter vaccine, however,
vas expensive, a n d he w ould ask w h e th e r it would be possible for assistance to be given in pro­
wing an a d e q u ate supply.
The Chairman did not think there would be any difficulty in arranging for an adequate
upply of vaccine.
In conclusion, he th a n k e d D r. Siem ashko on behalf of the Committee.

A P P E N D IX TO A N N EX 2.
V accination “per o s ’’

(Letter from Dr. Siemashko to the Chairman of the Health Committee.)

Geneva , Jan u a ry 12th, 1922.

ir,
W ith reference to th e discussion w hich took place yesterday a t the meeting of th e H ealth
ommittee of th e League of N atio ns on th e problem of vaccination through the m outh, I beg to
'orm you t h a t th e People’s C om m issariat for Public H ealth of th e R.S.F.S.R. is now engaged
a series of experim ents on a v e ry large scale, w ith vaccines against dysentery, cholera and typhoid
ever.
This w ork w as begun u n d er th e direction of Professor T arassevitch and Professor Zabolotny.
e work will be carried on in close to u c h w ith th e P asteu r Institute.
I beg to s ta te t h a t m y C om m issariat w ould be glad if the In tern atio n al Commission would care
0 appoint an e x p e rt to observe th is w ork afte r previous consultation w ith me.
I have th e h o n o u r to be, Sir, etc.,
(Signed) N. S iemashko,
People’s Commissary for Public H ealth of the R.S.F.S.R.

e Chairman of th e H e alth C om m ittee

of the League of N ations,
Geneva.
 — 36 —

A n n e x 3.

THE REPORT OF THE MEDICAL DIRECTOR.

I. T h e R e s o l u t i o n s of the Co u n c il c o n c e r n in g t h e W ork of the H e a l t h C ommittee .

The resolutions ad o p ted b y th e H e alth C om m ittee during its fourth session were presented
for th e approval of th e Council a t its m eeting of Septem ber 2nd, 1922.
The Council approved w ith o u t com m ent the report on th e w ork of the fo u rth session of tie
H e alth Committee, a n d has therefore given its sanction to th e proposals b ro u g h t forward b y tie
Committee.
F o u r points, however, m entioned in M. H a n o ta u x ’s report to th e Council received special
attention.
(a) This rep o rt referred once m ore to th e negotiations w ith th e In tern atio n al H ealth Board of
th e Rockefeller F o u ndation and expressed satisfaction t h a t the H ealth Com m ittee h a d drawn upa
program m e of th e w ork to be un d ertak en w ith the gra n ts from th e F oundation. The Council
recognised th a t this program m e was purely technical and took n ote of th e correspondence brought
it a t th e J u ly meeting. T he Council ad o p ted th e following resolution:

“The Council, a t its m eeting held on J u ly 20th, 1922, invited th e H ealth Committee
to consider th e em ploym ent an d adm inistration of the funds placed a t its disposal by the
Rockefeller F o u n d atio n for th e purposes proposed b y this F oundation. I t noted the
d ra ft agreem ent draw n up b y th e H ealth Com m ittee for the purpose of developing the
epidemiological intelligence service an d of in stitu tin g an interchange of public health
officials betw een various countries, in agreem ent w ith th e several G overnm ents and in
accordance w ith th e conditions laid down in th e correspondence w ith th e Rockefeller
Foundation.
“The Council therefore authorises the Secretary-G eneral to sign this agreement and
requests him to p ay particular a tten tio n to th e carrying out of Article 4, which provides
th a t th e Rockefeller F o undation shall be kept inform ed of the execution of th e program m e
prepared in agreem ent w ith it.
“The Council once m ore expresses its g ratitu d e to th e Rockefeller F o u n d a ti o n for
its generous sup port to one of th e essential branches of th e work of th e League of Nations,

(b) The Council has expressed its agreem ent w ith th e views of th e H ealth Committee, u,
t h a t it would h ave been q uite impossible to obtain a g ra n t from th e Rockefeller Foundation unless
th e la tte r had been convinced t h a t th e League itself took a deep interest in carrying out the pro­
gram m e draw n up b y com m on agreem ent. In sanctioning th e C om m ittee’s proposal for the
m aintenance of credits in th e b udget of th e H ealth O rganisation to be applied to th e interchange
of public h ea lth personnel an d to the epidemiological service respectively, th e Council has adopted
th e principle t h a t a general inform ation service should be m aintained b y th e H ealth O rganisation
in order to enable it to follow the progress of epidemics th ro ughou t th e world a n d so select t h e prob­
lems on which to concentrate its atten tio n . In the view ot th e Council, th e contribu tion from the
F oundation will allow of extension and im provem ent in th e organisation of th e service already
existing for this purpose.
(c) The special recom m endations of th e H ealth C om m ittee concerning th e w ork of the Epi­
demic Commission were considered very fully in the Council’s report. A le tte r (Appendix 1) waS
addressed b y th e P resident of th e Council to the chief delegates of th e S tates Members of the Leag®
represented a t th e T hird Assembly. The Council decided not to issue a fu rth e r public appeal1”
view of the m eagre response during th e last year, b u t th e a tte n tio n of th e delegates was drawn to
th e findings of the W arsaw E uropean H e alth Conference, to th e decision tak e n by th e Powers at
Genoa, and to th e repeated warnings of th e H ealth Com mittee. The delegates were placed 1°
possession of th e facts and were invited to request th eir G overnm ents, w ith w hom th e ultimate
responsibility rests, to ta k e a definite decision in the m atter.
The m em bers of th e H ealth Com m ittee will rem em ber th a t th ey have also referred to tflr
Council a question of principle. T hey proposed th a t a special credit on behalf of th e Epidemic Com
mission should be placed on the b u dg et of th e League of N ations under th e P erm anen t H e a l
Organisation. On th e understanding t h a t th e credit will be used for th e collection of all info011'
ation on the spread of epidemics, th e Council has accepted th is recom m endation.

1
 (d) The Council also considered th e question of the despatch of a Commission of Epidemiolo­
gical Enquiry to th e F a r E ast. I t decided to sanction this proposal and accepted the view of the
Committee th a t th e cred it should n o t exceed 30,000 francs. In coming to this decision, it took into
Consideration the fact th a t th e spread of epidemics in th e F a r E ast is of very great interest to the
Usiatic Members of th e League of N ations, an d th a t the health conditions of th a t p art of the world
L u st be a m atter of concern to oth er regions. I t expressed the hope th a t the enquiry would contri­
bute to the adoption of useful p reventiv e m easures which m ight perhaps in the future allow of more
complete co-ordination of inform ation on public health.

II. D e c i s i o n s o f t h e T hird A ssembly concerning the W ork of the H ealth

Organisation .

1. The m em bers of th e H e alth Com m ittee will rem em ber th a t the constitution of the provi­
sional H ealth C om m ittee was app ro ved b y th e Second Assembly in Septem ber 1921. The Assembly
[reserved the right, however, to control th e constitution of all the perm anent committees of the
[league and gave its final approval subject to th e consideration of a report on the work of the
[Committee to be presented to th e T hird Assembly. The work of the H ealth Organisation was
[discussed a t several m eetings of th e Second C om m ittee of the T hird Assembly, whose proposals
[were embodied in a re p o rt followed b y three resolutions which were adopted unanim ously by the
[Assembly. I h a d th e ho nour to circulate to the m embers of the Committee this very full
[report, presented b y M. M anuel Rivas-V icuna, the present Prim e Minister of the Republic of Chile.
[His im partial p resen tatio n of yo ur w ork carried conviction to all the members of the Assembly
[Committee which d ealt w ith th e Technical Organisations.. The H ealth Committee will be
[interested to know t h a t this C om m ittee w as presided over by Dr. Chodzko.
The Assembly expressed its satisfaction w ith the work of the H ealth Organisation in the
following term s :

I. The A ssem bly notes w ith satisfaction:

(a) T he assistance given by th e H ealth Organisation to the work of the H ealth

Conference a t W arsaw . I t notes also th a t the Genoa Conference, having considered the
report of th e W arsaw Conference in accordance w ith the request contained in the resolu­
tion of th e Council forw arded on April 3rd, 1922, approved the principles of the anti-
epidemic cam paign ado p ted b y th e W arsaw Conference, and th a t in consequence of this
resolution of th e Genoa Conference, tran sm itted to the H ealth Organisation b y a resolu­
tion of th e Council d a te d J u ly 21st, 1922, the H ealth Organisation has been charged with
the d u ty of carryin g o u t the program m e outlined b y the Conference ;
(b) T h a t th e H e alth O rganisation has been authorised by various countries to
u n d ertak e th e duties of m ediation entrusted to it by certain bilateial sanitary conventions
which h ave been concluded as a result of the W arsaw Conference, and th a t the Council
has approved th e discharge of these duties;
(c) T h e co-operation established between the H ealth Organisation and the other
Technical O rganisations of the League of Nations, notably the Perm anent Advisory
Com m ittee on th e Traffic in Opium, the Advisory and Technical Committee on Commu­
nications an d T ian sit, and th e P erm anent M andates Copmmission ;
(d) T he assistance given b y th e H ealth Organisation in the work preparatory to the
revision of th e In tern atio n al S anitary Convention of 1912, the co-operation w ith the
Office in tern atio n al d ’H ygiène publique thus effected, and the fact th a t the Council
has decided to place th e H e alth Organisation a t the disposal of the Conference which is
shortly to be convened b y th e “Office international d'H ygiène publique ” ;
(e) T he co-operation effected b y the H ealth O rganisation in experim ental research
concerning th e stan d ard isa tio n of sera and serological tests, the first results of which
will be presented to a conference to be convened a t Geneva in the near future ;
(/) T he developm ent of the activities of the H ealth Organisation with regard to
epidemiological intelligence, which should no t be lim ited to problem s which are of im por­
tance to only a lim ited n u m b er of countries ;
(g) T he in itiativ e tak e n b y th e H ealth Organisation w ith regard to an interchange
of th e san itary personnel of various Governm ents, which it desires should be made appli­
cable to as large a num ber of countries as possible.

II. T he Assem bly desires to express its appreciation to the Rockefeller Foundation
for th e financial assistance which h as been offered to the H ealth Organisation to assist in
the developm ent of certain of its activities.

Having sanctioned th e w ork of the H ealth Organisation during the year 1922 and the pro­
posed program m e for its fu tu re activities, th e Assembly recognised th a t the H ealth Organisation
'fas undertaking a ta s k of perm an en t u tility an d decided th a t it was essential th a t it should con-
tUlUe this work.
. In other words, it is now officially determ ined by the League th a t the H ealth Organisation
^to form a p erm an en t p a r t of th e norm al work of th e League, b u t the exact m anner in which
e Health O rganisation is to be co n stitu ted on a perm anent basis remains to be determ ined a.t
a ‘ater date.
 - 3» -

On this subject th e Assem bly took th e following resolutions :

T h e A ssem bly considers t h a t th e H ealth O rganisation of th e League of Nations

is u n d erta k in g a ta s k of p erm an en t u tility an d t h a t it is indispensable th a t it should
continue its activities.
T h e A ssem bly considers th a t it m ay be possible, before th e m eeting of the Fourth
Assem bly, to prepare, on th e basis an d according to th e principles ad o p ted b y th e First
A ssem bly for th e Technical O rganisations of th e League, th e co n stitu tio n of a Perm anent
H e a lth O rganisation, which will be su b m itte d to th e F o u rth Assem bly for approval.
This O rganisation will u n d ertak e th e duties laid down in th e resolutions of th e F irs t and
th e Second Assemblies. I t m ay, if necessary, function m eanw hile w ithin th e limits of the
bu dget an d in an ticipation of th e above-m entioned approval of th e F o u rth Assembly.
To th is end th e A ssem bly authorises th e Council to ta k e a d v a n tag e of such general
san itary conferences as m ay be convoked, it being understood t h a t all S tates M embers
of th e League of N ations shall be invited to send delegates thereto.
I t also suggests to th e Council th a t an a tte m p t b e m ade a t th e forthcom ing conferences
to m ake such arrang em ents as m a y be necessary to avoid duplication.

2. W hile deciding t h a t th e w ork of th e H e alth O rganisation should be placed on a permanent

basis, th e A ssem bly insisted ra th e r strongly on th e tem p o ra ry ch a rac ter of th e Epidem ic Com­
m ission in so far as th e anti-epidem ic cam paign in E aste rn E u rop e w as concerned.
A fter a very long discussion in its Financial F o u rth Com m ittee, th e A ssem bly decided to reduce
to 50,000 francs th e credit originally placed a t th e figure of 125,000 francs b y th e H ealth Com­
m itte e for epidemiological enquiries an d for a closer co-operation of th e technical san itary admini­
strations. I t was clearly understood by b o th C om m ittees of the League th a t th e epidemic cam­
paign should cease w ork in so fa r as th e cam paign against epidemics was concerned as soon as the
em ergency is over, b u t t h a t th e enquiries an d th e co-operation should be carried o u t by th e Per­
m an en t H ealth O rganisation. In order to give effect to its decisions, th e Assem bly, in its second
an d th ird resolutions, certified th e Epidem ic Commission as a te m p o ra ry commission.
T he discussions in th e C om m ittees were a t tim es difficult, and your p a st w ork was most ably
defended a n d your fu tu re program m e m ost clearly explained b y M. Velghe, to w hom we owe a
real d e b t of g ra titu d e for his help a n d assistance.
3. I regret to have to inform th e m em bers of th e C om m ittee t h a t th e b u d g et of the Organi­
sation was appreciably reduced b y th e Assembly. I t was n o t realised b y m an y mem bers of the
F inancial C om m ittee t h a t th e increase in th e b u d g et for 1923 as com pared w ith 1922 w a s due
to th e fact t h a t th e estim ates for th e previous y ear h a d necessarily no ac tu al experience behind
it a n d represented m ere guesswork. Proposals were m ade d uring th e debate to c u t dow n the budget
b y 500,000 francs, b u t, un d er th e circum stances, I th in k you m a y accept th e final red u ctio n s
introduced into y o u r b u dget as n o t very seriously affecting th e program m e of w ork traced b y yon
for th e coming year. T he item for epidemiological intelligence was reduced from 40,000 francs
to 25,000 francs ; th e item for m iscellaneous expenses was o m itted alto g eth er ; th e credit of 100,000
francs for a system of liaison w as reduced from 100,000 to 50,000 francs, and, as previously men­
tioned, th e g ra n t for th e Epidem ic Commission was b ro u g h t down to 50,000 francs instead of the
proposed 125,000 francs. The to ta l b u dget for 1923 am ou nts to 700,500 gold francs as against
392,125 for th e y ea r 1922.
1923 ism
1 G o ld F r a n c 1 Gold Frao:
= 1 Sw. f-r. = 1 . 0 6 Sw.Fr
BUDGET Gold F ran c s
I nternational H ealth Or g a n is a t io n ..................................................... 700,500 392,125

I. Secretariat.
1. Staff.
(a) Salaries of P erm an en t S t a f f ............................................. 160,600 178,50°
Medical D ir e c to r ................................................. 46,500
Asst. Med. D i r e c t o r ........................................ 31,500
M ember of Section, Class A ........................... 25,200
Technical Officer ....................................... . 25,200
Secretary of Section ................................... 12,000
2 Asst. Secs, and S te n o g r a p h e r s ................ 20,200
(b) T em porary Staff of S e c r e t a r i a t .................................... 92,400
D raftsm an, Technical C l e r k s ...................... 32,000
4 Members of S e c t i o n .................................... 60,400
(c) Travelling and rem oval expenses of S ecretariat . . 31,500 31,500

2. Publications and Scientific W orks:

(a) P rinting, publishing, e tc .................................................... 15,000 23,625
(b) Epidem iological Intelligence............................................. 25,000
(c) S an itary notifications a n d notifications in case of
epidemics. Cables, tleegram s, e tc ................................... 21,000 21,000

3. Unforeseen expenses 5,000

 — 39 —
1923 1922
1 Gold Franc 1 Gold Franc
= 1 Sw. Fr. = 1 0 6 S w .F r.
Gold Fran c s
II. Health Committee and Conferences.
1. Sessions of H e alth C o m m itte e ................................................. 50,000 63,000
2. Special E nquiries and Investigations (this includes expen­
ses of technical sub-com m ittees appointed b y H ealth
Com mittee) ................................................................................ 150,000 63,000
3. Technical Conferences of G overnm ent representatives or
experts to p rep are in tern atio n al san itary m easures . . 50,000 __
4. Expenses in connection w ith a system of liaison between
th e various natio n al public h ealth s e r v i c e s ...................... 50,000 __

III. Epidemic Commission (grant for epidemiological enqui­

ries, e tc .)................................................................................................ 50,000 —

II I. A g r e e m e n t w it h th e R o c k e f e l l e r F o u n d a t io n .

(1) In conform ity w ith th e R esolution of th e Council of Septem ber 2nd, the Secretary-General
has signed an agreem ent w ith th e Rockefeller F oundation in the term s subm itted b y the H ealth
Committee (Annex 5(6), A .B., of th e m eeting of th e fourth session of the Committee, C. 555. M. 337.
1922. III). Two m inor changes were, however, subsequently introduced at th e request of the
I Executive C om m ittee of th e In tern atio n al H ealth Board :
In p arag rap h 1 of th e agreem ent, it is suggested th a t the phrase "acting through the E xe­
cutive Com m ittee o f” be changed to “on behalf of”. The section would then read:

“This A greem ent is m ade betw een the League of Nations, acting through its Secre­
tary-G eneral, on th e one hand, an d th e Rockefeller Foundation, on behalf of the In ter­
n atio nal H e alth B oard, on th e other hand, for th e m aintenance of an international
interchange of public health personnel on an international scale.”

(2) A t th e end of p arag rap h 7 of the agreem ent the addition of th e following sentence is
proposed : “ T h a t unexpended balance over and above outstanding obligations at the end of
each year shall re v ert to th e Rockefeller F o u n d atio n .”
This applies to b o th agreem ents.
(3) In accordance w ith th e desire of the H ealth Com mittee I have asked the International
Health B oard w hether, in ist view, th e funds supplied for th e interchange of public health
personnel could be used for interchange on an individual basis. The following reply has been
received :
“In response to your previous request as to w hether or not some of the funds sup­
plied b y th e In te rn a tio n a l H e alth B oard of the Rockefeller Foundation to the League
of N ations could be used for granting of occasional travelling fellowships for individual
stu d y , I beg to sta te th a t this seems to us to be entirely in keeping with the understanding
betw een th e League of N ations and th e In tern atio n al H ealth Board, and is heartily
ap p ro v ed .”

(4) A m em orandum concerning the ap pointm ent of Mr. E d gar Sydenstricker as Chief of the
Service of Epidem iological Intelligence and Public H ealth Statistics, which I had the honour to
circulate to all th e m em bers of th e H e alth Committee, has been forwarded also to Dr. Wickliffe
Rose, D irector of th e In tern atio n al H e alth Board.
Dr. Rose called m y atte n tio n to the fact th a t in m y m em orandum I stated th a t the selection
was approved b y Surgeon-General H. S. Cumming and b y him. In referring to his correspondence
with me, Dr. Rose observed th a t in giving me inform ation concerning Mr. Sydenstricker he had
taken pains to explain t h a t he was n o t recom m ending him and th a t he was only transm itting
information concerning him, an d he could not accept the statem ent th a t Mr. Sydenstricker s
appointment h a d been approved b y him.
Dr. Rose added th a t, in his opinion, it is highly im p o rtan t th a t the General-Director of the
International H ealth B oard should refrain from approving or disapproving any appointm ent
made by th e H e alth O rganisation of th e League. It is a fundam ental m a tte r of policy th a t his
Board should have no views in determ ining the H ealth O rganisation’s policy or programmes or
any details of its adm inistration. His B oard is interested in keeping in close touch with our service
with a view to ascertaining how the B oard m ay be serviceable and with a view to keeping advised
15 to all th e ex p end iture m ade b y th e Board. H e wished, therefore, to make it clear to me th at
t-he Board is refraining from giving an y views on such details as the appointm ent of personnel
and he hoped th a t th is point w ould be m ade quite clear to th e members of the H ealth Committee.
I m uch regret to have used an expression which was susceptible of m isunderstanding, lh e
Point of view set fo rth in Dr. Wickliffe R ose’s le tter will, I am sure, be very welcome to the members
of the H ealth Com m ittee, as it conforms to th e spirit in which th e Committee has welcomed the
co-operation of th e Rockefeller Foundation.
(5) This p o in t of view is fu rth er explained in a le tter replying to the enquiry made on behalf
the H ealth C om m ittee as to w hether th e expenses of the Tem porary Commission of Lnqurry
 — 40 —

to th e F a r E a s t m ight n o t be in p a rt supported o ut of th e Rockefeller g rant. The attitu d e of the

In te rn a tio n a l H e alth B oard w as sta te d in this letter as follows :

“ i. The B o ard has co n trib u ted tow ards th e L eague’s b u dget for th e maintenance
of its Epidem iological Service.
“ 2. As we understood it, this contrib ution b y th e B oard is not to be segregated. a
fun d has been set aside for the purpose of th is Epidem iological Service; t o w a r d s that
fu n d th e League is contributing a n d th e B oard is co n trib u tin g ; th e fun d is to be treated
as a unit.
"3. I t is our opinion t h a t it w ould n o t be advisable to consider th e contributions by
th e B oard as in an y sense a separate elem ent in th e budget. T he fun d should be treated
as one.
“ 4. I t should n o t be possible for anyone to say t h a t th e p a rt of th e budget which
th e League had supplied has been devoted to a given pu rpose an d th e p a r t which the
B oard h ad supplied been devoted to an o th er purpose.”
“On th e basis of th e above principles you will see t h a t th ere is no objection on
our p a rt to th e exp enditu re of a certain portion of th e m onies to be supplied by the
B oard for th e purposes of th e Epidem iological Commission to th e F a r E ast. Dr. Rose,
in his le tte r to me, concludes as follows :
“Y ou an d Dr. R ajch m an are in a position to know w hen this fund, provided by the
League a n d th e B oard, is being expended for th e purposes for which it is set aside.”

I believe th e a ttitu d e of the In te rn a tio n a l H ealth B oard m ay be rig h tly sum m ed u p by

sta tin g t h a t th e y would n ot like anyone to th in k th a t th e y are assum ing th e rig h t to p a rtic ip a te
in th e discussions of th e H e a lth C om m ittee because they7 h av e m ade a co n trib u tio n tow ards
its work.

IV. T h e E x p e r t C o m m i t t e e on D is e a s e s of E q u a t o r ia l A fr ic a .

T he H e alth C om m ittee will p ro bably rem em ber th a t it decided to in vite th ree experts on
tropical m edicine from Belgium, F rance an d G reat B ritain respectively to u n d erta k e an enquiry-
regarding th e spread of sleeping sickness a n d tuberculosis am ong th e n ativ e population of Equa­
to rial Africa.
Of th e three ex p erts nam ed in th e resolution of th e C om m ittee, Dr. Andrew' Balfour and
Dr. van C am penhout have accepted th e in v ita tio n , b u t as i t w as im possible to secure th e co­
operation of Professor B ru m p t of P aris, who was absent, Professor G ustave M artin was
approached on th e advice of Professor C alm ette a n d Professor Léon B ernard. A fter he h a d accepted
th e in v ita tio n , a m eeting was held in L ondon on N ovem ber 10th and n t h , of w hich Dr. Andrew
B alfour was elected C hairm an. T he C om m ittee h as addressed a n u m b er of letters of enquiry
to th e following ad m in istratio n s :

Conseil S upérieur de S anté des Colonies, P aris;

The M inistry for F oreign Affairs, L ondon ;
Conseil R oyal de la S anté P ublique, M adrid ;
D ép artem en t de l ’H ygiène a u M inistère de l ’In térieu r, R om e;
Service de S an té et de l ’Hygiène, B ruxelles ;
Ministère de la S an té P ublique, L isbon;
Colonial Office, L ondon ;
C entral S a n ita ry B oard, K hartoum .

T he C om m ittee decided n o t to lim it its enquiry to th e consideration of answ ers receive

from official sources. In fact, it a ttac h es g re ater value to intelligence which it will o b tain
from p riv a te correspondence an d th e stu d y of sources of reference. T he C hairm an a n d Dr. Bag-
shaw e have been steadily collecting inform ation, on th e basis of which th e y are now undertaking
fu rth e r official enquiry. T h eir labours have n o t y e t reached a stag e which w ould allow them to
su b m it an in terim rep o rt to th e H ealth Com m ittee.

V. S e r v i c e of E p id e m io l o g ic a l I n t e l l ig e n c e and P u b l ic H e a l t h S t a t is t ic s .

I h a d th e ho nour to circulate to all th e m em bers of th e C om m ittee a note, inform ing them

of th e ap p o in tm en t of Mr. E d g a r S ydenstricker an d of th e pro gram m e of w ork sketched for the
service du ring th e first p a r t of 1923. I h ad hoped th a t th e new Chief of th e Service would be able
to develop his plans before th e C om m ittee m eeting, b u t u n fo rtu n a te ly he was prev en ted a t the
last m om ent from sailing in tim e to enable him to a tte n d the session. H e is not expected to arrive
in G eneva before J a n u a ry 20th.
I t is, I th in k, now agreed th a t th e first efforts in th e developm ent of th e Service must be
m ore or less te n ta tiv e an d experim ental. I believe I am rig h t in sta tin g th a t th e I n t e r n a t i o n a l
H e alth B oard wa,s in terested in co-operating in establishing th is Epidem iological Intelligent
 — 4i —

Service on a sound basis. T he p eriod of five years during which th e contribution of the Board will
be continued, m ay, it is hoped, be sufficiently long to dem onstrate to Governm ents th a t the work
is n o t only useful b u t indispensable, so th a t funds will be found for its continuance and further
development. If it is to be of real use to th e B oard and to th e Council, it is necessary th a t the
H ealth Com mittee should be given g re at la titu d e in carrying out the new undertaking. I t m ust
not be forgotten, however, t h a t th e R esolution of th e Council referred to in the first p art of this
report emphasises th e p oin t th a t th e funds provided by th e In tern ational H ealth Board should
be used for th e pu rpose for w hich th e y were contribu ted, i.e., to aid the H ealth Organisation in
developing th e services in question. The segregation of funds provided for in the agreement
cannot be objected to as a m a tte r of book-keeping. I t is obvious th a t the funds provided by the
Board and th e cred its provided in th e b u d g et of th e League will both be used for purposes which
c o n trib u te directly to w ards establishing th e Service. Serious difficulties would arise if the B oard’s
funds were used fo r scientific investigations while th e League’s credits were employed for the
service of supplying epidem iological intelligence to public health adm inistrations.

V I. I n t e r c h a n g e o f P u b l ic . H e a l t h P e r s o n n e l .

M. Velghe will present to th e C om m ittee his views on the results of the first experim ent in
interchange and will also m ake proposals which will form the basis for discussion and for the
decisions of th e Com m ittee.
May I say here t h a t th e first experim ent has proved successful ? The m embers will be able
to judge from re p o rts a n d conferences given during th e interchange, b o th in Belgium and Italy,
of the n um b er of problem s d ealt w ith an d of the very expert m anner in which the subject was
treated. I t is a p a rtic u la rly hopeful sign th a t one of th e addresses was given b y Surgeon-General
Cumming, w ho has declared his willingness to p articip ate in future interchanges b oth by suggesting
the organisation of a course in th e U n ited S tates and b y his decision to commission medical officers
of his service to ta k e p a r t in th e n e x t interchange held in Europe.
The In te rn a tio n a l H e a lth B o ard has tran sm itted its first q u arte rly contribution of 15,000
dollars in tim e for th e financing of th e first interchange. The to ta l expenditure am ounted to some
13.000 dollars. T he C om m ittee will rem em ber th a t the expenditure involved: (a) the paym ent
of subsistence allow ance of £1 a d ay to all the 23 m edical officers taking p a rt in the experim ent ;
(b) reim bursem ent of th e ir trav ellin g expenses (2nd-class fare during the day, 1st class and sleeping
accommodation d u rin g th e night) ; (c) lectu rers’ fees, hire of lecture-halls, etc. ; (d) railway and
motor expenses in organised to u rs of inspection; (e) adm inistrativ e expenses (interpreters, short -
hand-writers, d ocum entation, etc.).
The ra tio of ex p e n d itu re in cu rred an d subsistence allowance as com pared w ith th a t of item s
(6) to (c) m u st obviously v a ry in th e countries visited. In addition to individual differences due
to local custom s, etc., th e distances to be travelled m ust be tak en into account. I t was difficult
in the first experim ent to lay down v ery fast rules, and th e question of expense incurred was
very largely left to th e sa n ita ry adm in istratio n s of th e tw o countries. The ratio m entioned above
was 33 % for B elgium an d 61 % for Ita ly , and for future estim ates, a m ean of 50 % m ight be
taken as an a p p ro x im a te basis.
The d aily allow ance of 20 /—w as found am ple in th e three countries visited (Belgium, Italy
and Poland), while a supplem ent h a d to be granted for th e officer who went to H olland for his
practical course. If th e n ex t interch an ge were organised in England, it would be necessary,
according to th e advice of th e B ritish m edical officers, to increase th e allowance to 30 / - per day.
Calculated on this basis, th e expend iture for th e three m o n th s’ interchange, of which six weeks
would be ta k e n in E n g lan d a n d six weeks on th e Continent, would to ta l between 20,000 and
28.000 dollars if th e n u m b er of m edical officers tak ing p a rt varied between 25 and 34.
It was generally agreed b v th e first b atch of medical officers, as well as b y th e Belgian and
Italian sa n ita ry ad m in istratio n s, t h a t it would not be practicable to exceed th a t num ber.
The n e x t in terch an g e can n o t s ta r t before th e la tte r p a rt of F ebruary, and thus, to the balance
°f some 2,000 dollars rem aining, 7,500 dollars should be added as “econom y’ for the first six
"eeks of 1923. This, to g eth er w ith th e q u arte rly sum of 15,000 dollars, would cover the estim ated
expenses of th e second interchange.
In conform ity w ith th e C om m ittee’s recom m endation, I have un dertaken to s ta rt negotiations
at once w ith a view to fu tu re experim ents. The G erm an H ealth A dm inistration would be ready
to organise a n in terch an g e in th e la te spring. The A ustrian H ealth D epartm ent is prepared to
organise an in terch an g e on a four-to six-weeks basis a t the end of F eb ru ary or the beginning oi
March of this year. I am p a rtic u la rly grateful to Sir George B uchanan for his offer to ask the
Society of M edical Officers of H e alth of E nglan d if th ey would be prepared to take in h an d the
organisation of each interch an g e a n d I am v ery glad indeed to be able to inform the Committee
that I was in v ite d b y Sir George to explain to Delegates on th e Council in London the plans tor
such an interchange, in E ngland . The rep resentative of this society atten d ed the closing conference
°1 the first interchange, a n d we discussed w ith him very fully all the plans for the second in ter­
change. I t m ay be arran g ed in th e early spring . A fter six weeks spent in England, a similar
Period would be ta k e n in one of th e tw o C entral E uropean countries.
It m ay n o t be practicab le to arrange a second interchange in E urope during the coming
year. The A ssem bly h as insisted on m aking th e system applicable to as great a num ber of countries
as Possible, a n d we h a v e ta k e n steps to get in to touch w ith the South Am erican States.
 — 42 —

A letter has been addressed b y th e Secretary-G eneral to th e following S tates :

A rgentine P arag u ay
B olivia P eru
Brazil U ruguay
Chile Venezuela
Colom bia
enquiring w hether their G overnm ents are interested in th e schem e (A ppendix 2).
I have addressed a letter, A ppendix 3 to th e Public H e alth A dm inistrations of th e following
countries, asking them to inform th e H ealth Com m ittee w h ether th e y w ould be willing to partici­
p a te in such an exchange :
A u stria Ita ly
B elgium N orw ay
C anada Poland
Czechoslovakia R oum ania
D enm ark Russia
F in lan d K ingdom of th e Serbs, C roats an d Slovenes
F rance Sweden
Greece U nited S tates
H u n g a ry
If all th e in v ita tio n s were accepted, th e num ber of m edical officers w ould be tw enty-seven.
T he C om m ittee m ay wish to accept th e in v itatio n of Surgeon-General Cumming, and it may
be possible to arrange th e th ird collective interchanges in America.
E xchanges for individual s tu d y an d for special objects could b e financed from th e remaindei
of th e credit a t th e disposal of th e Com m ittee.
A credit ot 50,000 francs o u t of th e general b u dget of the H e alth C om m ittee of th e League may
b e draw n up on for the purposes of th e interchange. I t is im p o rta n t to em phasise th e tem porary
n a tu re of th e co n trib u tio n m ade b y th e In tern atio n al H e alth Board, which decided to aid the Health
C om m ittee during th e first stages of its u ndertaking.
T h e C om m ittee, howevei .(should n o t assum e th a t th e B oard will renew its contribution auto­
m atically. I believe I am rig h t in sta tin g t h a t th e B oard is interested in th is proposal as a
m eans of creating in tern a tio n a l und erstan d in g a n d goodwill as a basis for effective co-operation
in m ain tain ing th e Service of Epidem iological Intelligence of th e H e alth O rganisaton. I f I am
n o t m istaken, its view wras t h a t th e interchange w ould be valuable also as a m eans of educating
s a n ita ry personnel for each of th e countries tak ing p a rt, b u t it can n o t be expected th a tth e B oard’s
co n trib u tio n will be continued indefinitely.
I t is desirable th a t th e m oney found for the interchange should be considered as g ran ts supple­
m entin g th e credit at th e disposal of th e various h ealth adm inistratio ns for th is purpose, or at |
least of the League funds in th e estim ates of th e H e alth O rganisation.

V II. F a r - E a s t e r n C o m m iss io n o f E p i d e m i o l o g i c a l E n q u i r y

A special sub-com m ittee drew u p th e instructions for th e Commission and m ade proposals to
th e C hairm an of th e H ealth C om m ittee for the nom ination of its personnel. D r. N orm an White
was u ltim a te ly appoin ted to th is Commission. Dr. N orm an W hite atte n d e d th e League of Red
Cross Societies Conference in B an gkok a n d is at present engaged in a n enquiry a t Singapore. The
Surgeon-General of the U n ited S tates P ublic H e alth Service is com m issioning one of his expert
officers so fa r as possible to follow th e sam e itin e rary as Dr. N orm an W hite an d collaborate with
him , b u t while Dr. N orm an W h ite will re p o rt to y o u r Com m ittee, th e A m erican officer will
present his observations to his san itary adm inistration.

V III. T h e S u b -C o m m itte e s f o r T r a n s p o r t b y W a t e r a n d M ix e d S u b -C o m m itte e

o f t h e H e a l t h a n d O p iu m S e c t i o n s

T he special sub-com m ittees appointed to stu d y th e requirem ents for th e legitim ate c o n su m p ­
tion of opium an d for h ealth regulations for w aterw ays will m eet in a few days a n d m ay p r e s e n t an
interim rep ort before th e end of th is session to th e Com m ittee. A ny decision arising out of the
recom m endations m ay have to b e referred to the n ex t session of th e Com mittee.

IX . C ourse fo r P u b lic H e a lth P er so n n e l and th e E sta b lis h m e n t of

A n t i- E p id e m ic M u se u m s

T he C om m ittee w i l l be glad to learn t h a t th e san itary courses which were to be o rg a n ise d 1

accordance w ith th e recom m endation of th e W arsaw E uropean S an ita ry C o n f e r e n c e h a v e bee
held in W arsaw , Moscow an d K harkow . 67 m edical officers a tte n d e d th e courses in W a r s a '
w hich began on N ovem ber 20th an d closed a t th e end of December. In ad dition to le c tu r e -
 — 43 —

drawn from th e Polish public h e a lth services, th ree foreign experts gave the benefit of their expe­
rience. Professor C antacuzène lectu red on th e epidemiology of diseases prevalent in R oum ania
C olonel Liston gave a d em o n stra tio n of his m ethod of delousing b y the use of cyanide acid, while
Professor Abel explained th e m eth o d s of anti-epidem ic cam paign p ra c tis e d in Germany.’ P ro­
fessor Abel rep eated his course of lectures in Moscow a n d K harkow . The courses in Moscow, which
are continuing are of longer d u ratio n . A t th e course a t K harkow , where 65 medical officers attended,
it was found necessary to provide th e officers w ith parcels of food in order to enable them to take
full advantage of th e arrangem ent.
Work is still being carried on to w ard s the establishm ent of th e anti-epidemic museums, b u t
the arrangem ents have n o t y e t reach ed a final stage. Of th e £5,000 which were placed a t the
disposal of th e C om m ittee for th e purpose, £1,816 h as been spent, leaving a balance of £3,184 for
the repetition of th e courses a n d th e establishm ent of th e m useum s

X. S er o l o g ic a l Co n f e r e n c e s

The C om m ittee is aw are th a t, a t th e in v itatio n of th e Chairman, the Sub-Committee on

D iphtheria an d T eta n u s held a m eeting in Geneva from Septem ber 25th to 27th. The Chairman
is reporting fully to th e C om m ittee on th e result of th is very successful meeting.
He is also giving a detailed account of the Second In tern atio n al Conference on the S tandardi­
sation of S era a n d Serological Tests, w hich was convened b y him on behalf of the Committee and
held a t the P a s te u r In s titu te in P a ris from N ovem ber 20th to 26th.
The research in stitu tes engaged a t y o u r in v itatio n in investigations on the standardisation of
sera and th e sero-diagnosis of syphilis presented to th e P aris Conference very full reports em body­
ing their experim ental enquiries. The th irty -th ree very technical reports represent a m ost
valuable scientific co n tribution, a n d it is clearly in th e interests of the H ealth Organisation th a t
they should be m ade easily accessible to the various scientific institutions and research workers
throughout th e world. T his question was discussed inform ally in Paris by your Chairm an and
myself w ith th e delegates, an d it w as generally agreed th a t th e best m ethod for obtaining the object
in view w ould b e to secure th e pub lication of th e reports in the stan d ard technical periodicals
published in English, F ren ch an d G erm an.
The editors o f th e Annales de l'Institut Pasteur expressed their willingness to circulate to
their usual subscribers, free o f charge, a special supplem ent in th e form of a bulletin of th e same
size and in th e sam e form as th e ir periodical. The subscribing laboratories would thus be able
to have th e su pplem ent b o u n d u p a t th e end of th e year w ith the periodical.
The ed ito rs of th e sta n d a rd G erm an m o n th ly Zeitschrift für Immunitatsforschung have
expressed th e ir willingness to do th e sam e w ith regard to their periodical.
The Medical R esearch Council of G reat B ritain has expressed its readiness to publish
the reports in a special b u lletin w hich m ight be m ade the first of a new series in anticipation of
further research rep o rts of th e H e alth O rganisation to be published through the same channel.
The editors of th e tw o periodicals (French and German) would expect the H ealth Committee
to provide th em w ith th e su pp lem ent itself, i.e., to p a y the cost of printing copies sufficient for
their ordinary circulation. T he e stim ated expenditure for th e F rench edition would am ount to
between 3,600 a n d 4,500 Swiss francs. The volum e would consist of 400 pages and would be
printed in 2,500 copies. The co -t of th e G erm an publication would am o unt to approxim ately
2400 Swiss francs. T he only charge to be m et in respect of th e English bulletin would be th a t
of the copies w hich th e C om m ittee desire for free distribution and which the Secretariat would
utilise for official purposes. T he p rin tin g would be done b y th e Oxford U niversity Press and it
would be p u b h sh ed b y th e G overnm ent S tationery Office. I have not as yet any estim ate, b u t
the cost of th e English edition, if p rin te d in France, would am ou nt to roughly 4,800 Swiss francs.
In other words, th e to ta l cost of th e publication in three languages, in 2,500 copies, would am ount
to 11,400 Swiss francs. Of course th e cost would be less if the distribution were reduced.
I t is clear t h a t th e cost of th e publication m u st b e m et b y the H ealth Budget. The question
°f the m eth o d of p u blication being a v ery technical one, th e Council will probably not desire to
take a decision before hearing th e opinion of th e Com m ittee on the m atter.
There is a question of principle involved : nam ely, the free distribution of a League docum ent
paid for o u t of League funds as a supplem ent to a p riv ate periodical. W hatever the decision of
the Committee, I am sure y o u will wish it to be m ade clear th a t th e bulletins are League publi­
cations. T his could be secured b y h av ing th e docum ents published in regular League form but
printed by th e p rin ters of th e respective periodicals and d istributed free of charge to their own
subscribers. In a n y case each bulletin should contain some heading such as Supplem ent on
Scientific R esearch W ork carried o u t for th e League of N a tio n s”. The Committee m ay perhaps
desire to call for fu rth e r ex p lan atio n s from m e when discussing th e Chairm an s report.

XI. E p i d e m i c Co m m i s s i o n .

(1) The m em bers of th e C om m ittee are aw are of th e fact th a t no further contributions have
^een received from a n y of th e G overnm ents. T he only contribution received for the Epidemic
Commission is t h a t of th e Czechoslovakian G overnm ent am ounting to 173,000 Swiss francs, lh e
 — 44 —

B ritish G overnm ent h as prom ised to contrib ute half th e am o u n t co n trib u ted b y th e C zech oslov a­
kian G overnm ent. This is a salient fact as regards the possibilities of th e w ork of the Com m ission.
The H ealth C om m ittee has recom m ended th a t the Commission should <ontinue its w o rk , in
agreem ent w ith th e G overnm ents of L atvia, Poland an d R ou m an ia on th e one side an d w ith the
public h ealth au th o rities of Soviet Russia an d the U kraine on th e other, p ay in g special a tte n tio n
to the needs of th e b order area betw een R ussia and her w estern neighbours, a n d the problem
of the s a n ita ry control over rep atriatio n should be considered w ith p artic u la r care.
The Commission was only able to carry out p a rt of th is work. T he two Epidem ic Commissioners
in Moscow a n d K harkow continued to supply very valuable inform ation an d to develop their co­
operation w ith th e public h ealth authorities. The Commissioner resident in W arsaw continued
his tours of inspection of san itary institu tio n s in the frontier zone of P olan d for- th e establishment
of which th e Commission has co-operated.
The Epidem ic Commission has further assisted in the organisation of th e san itary courses
in W arsaw, Moscow an d K harkow .
As the Chief Epidem ic Commissioner was leaving on a mission of en quiry in the F a r East,
a m eeting of the Commission was convened in W arsaw on the 13th O ctober a t which arrangements
were m ade for the continuation of th e work. A t th a t m om ent th e funds a t th e disposal of t h e Epi­
demic Commission am oun ted to £30,864. The Commission will rem em ber t h a t th is sum repre­
sented the rem ainder of th e co ntribution of £50,000 given b y th e F rench G overnm ent and ear­
m arked for Poland. The balance of th e com m itm ent of th e Commission for P oland in connection
w ith the expenditure of this F rench contrib utio n am ounted a t th a t d ate to £16,479. I t was con­
sidered th a t a sum of approxim ately £5,000 would be sufficient to cover all th e administrative
expenses for a period of 12 m onths. In expectation of the p ay m e n t b y th e Czechoslovakian Govern­
m ent, which has since been realised, it was decided to offer im m ediate assistance to th e L atv ian
G overnm ent to th e ex te n t of £10,000 and to purchase im m ediately m aterial for R ussian Ukraine
to the value of £5,000. F o r th is la tte r purchase it was necessary to draw tem p o rarily upon the
balance of th e funds con trib u ted for other purposes. This was facilitated b y th e fact th a t these
credits were being p aid in instalm ents during a period of six m onths.

(2) L atvia. The C om m ittee, a t its last session, approved th e proposal t h a t th e assistance
given to th e L atv ia n G overnm ent should consist of the in stalm en t of q u aran tin e statio n s in Dvinsk
(Daugavpils), and th a t it would sup ply th e existing sta tio n a t Rezekne. This schem e involved,
however, an ex penditure of £35,000, and fu rth e r consideration of th a t schem e in th e presence
of two delegates of th e L atv ia n G overnm ent indicated th a t a sum of a t least £ 18,000 would be
necessary to com plete th e p a rt of th e scheme essential for th e w orking of th e statio n a t Dvinsk
on a reduced th ough possibly ad eq u ate scale. The Commission has enquired of th e Latvian
G overnm ent w hether it would be p repared to supplem ent the proposed co n trib u tio n of £ 1 0 ,00 0 ,
th e sum required for the realisation of th e Dvinsk schem e in a modified form.
The L atv ia n G overnm ent has s ta te d th a t it cannot e n te rtain th is proposal a n d has suggested
th a t th e contribution of the Commission should be devoted to th e establishm en t of a maritime
q u aran tin e statio n a t Libau. T he Commission has accepted this proposal an d th e L atv ian s have
sent two experts to inspect the arrangem ents a t H am burg an d B rem en as a prelim inary step to
w orking out th e plans for Libau. P a r t of their expenses will be charged to th e contribution of
th e Commission.
I t is expected th a t detailed proposals for th e L ibau sta tio n will be su b m itte d a t an early date.

(3) Greece. On October 2nd wre received a telegraphic request from Dr. Nansen,
H igh Commissioner of th e League of N ations for Refugees in C onstantinople, for th e services of
one or two epidemic commissioners in connection w ith the sa n ita ry control of th e movement
of refugees from Asia Minor to C onstantinople. As h undreds of tho usands of refugees w ere on
th e road, th e H igh Commissioner feared t h a t epidemics m ight spread. The E pidem ic Commis­
sioner resident in W arsaw was accordingly placed a t th e disposal of D r. N ansen a n d arrived
a t C onstantinople early in November.
W hen it was ascertained th a t th e refugees were concentrating in Greece, a n d th a t the field
of action of th e H igh Com m issariat did n o t extend as far as Asia Minor, th e E pidem ic Commis­
sioner proceeded to inspect th e various collections and encam pm ents of th e refugees b o th in Greece
a n d Asia Minor I h ad th e honour to circulate to th e m em bers of th e C om m ittee one of th e Epidemic
Com missioner’s earlier reports.
A few weeks later Dr. N ansen asked for the services of a second com m issioner, and our
representative in Moscow was requested to go a t once to Greece.
The service of these two commissioners were lent to Dr. N ansen a n d th e y were n o t acting
in Greek territo ry under th e Epidem ic commission a t t h a t tim e.
Since then, Dr. N ansen has com m unicated w ith th e Secretary-G eneral an d offered to transfer
to th e Epidem ic Commission th e funds still a t his disposal for th e relief of Greek refugees in order
t h a t th e Commission m ight continue to assist th e Greek G overnm ent in th e s a n ita ry control
of th e refugees. The situation of th e refugees has been sum m arised in Epidemiological Report
No. 34 on th e basis of th e inform ation received from our representatives a n d enquiries from
Am erican an d other sources. The Com m ittee will rem em ber th a t a t th a t tim e th e epidemic situa­
tio n in th e refugee cam ps was fairly satisfactory. A lthough there was g reat d anger of th e o u tb re a k
of infectious diseases, no o utbreak occurred in an y of th e cam ps. T he H igh C om m issariat offered
a gran t of £5,000 in addition to covering th e adm inistration expenses including th e salaries of
th e Commissioners.
N egotiations were im m ediately begun b o th w ith th e Greek au th o rities a n d w ith th e A m e n c a n
R ed Cross acting in Greece. I t is obvious th a t the Epidem ic Commission could n o t sta rt work
 until requested to do so b y th e Greek G overnm ent, which has, in fact, asked for technical assistance
The only useful w ork w hich th e Commission could do would be of a preventive nature. Having
o b ta in ed the sanction of th e C hairm an of the C om m ittee to the extension of th e work of the Com­
mission, I requested o u r tw o com m issioners to come to G eneva for consultation, and after full
c o n s id e ra tio n of th e re le v a n t facts an d of th e views of the Greek Government, we have come to
the conclusion t h a t th e assistance m ight usefully be given in three directions :

(a) By the im m ediate su pply of barracks, m obile b ath s and m otor ambulances, the sum of
f 3,500 being utilised for this purpose.
’ (b) By the organisation of general vaccination of the refugees against smallpox, cholera
typhoid, p a raty p h o id , and, in places, ag am st dysentery and plague. I t has been estim ated th at a
sum of £ 1,500 m ig h t be sufficient for th e purpose ;
(c) By acting in an advisory ca p acity to th e Greek authorities as regards the sanitation of
camps and th e o rganisation of em ergency anti-epidem ic measures.
To m ake th e v accination effective involved th e num erous units which will have to be appointed
in order to vaccinate som e 600,000 refugees th ro u g h o u t the whole territory of Greece and the main
islands. F ull d etails concerning th e proposed operations are given in the annexed memorandum
(Appendix 4). The annexed m in utes (Appendix 5) sum m arise the general conclusions arrived at
the Conference.
Since his re tu rn to A thens, one of th e commissioners has reported the o utbreak of smallpox-
on a large scale in several refugee cam ps an d has requested an im m ediate despatch of lymph vaccine,
while fu rth e r telegraphic inform ation has reached us of the outbreak of typh us in several camps, on
the m ainland a n d on th e islands. T he re tu rn of the second commissioner has been requested, as
wel1 as the earliest possible d esp a tc h of sa n ita ry m aterial.

X II . — - E p i d e m i c S i t u a t i o n in E astern E uro pe,

In the territo rie s of R ussia a n d th e U kraine, the epidemic outlook still continues to be very
grave. The to ta l figures for ty p h u s since th e beginning of the year 1922 am ount to 1,334,869 while
the figures for relapsing fever h ave totalled for the same period to 1,349,370. I t will be noted,
therefore, t h a t th e in te n sity of th e incidence has in no way dim inished as com pared w ith the pre­
vious year (497,333 cases of ty p h u s an d 560,013 cases of relapsing fever were notified in the same
period of 1921). D uring th e period from A ugust 1st to N ovem ber 10th, 126,625 cases of relapsing
fever were notified a n d 54,059 of ty p h u s. The relapsing fever is specially prevalent in South-
East Russia.
In addition, m alaria has m ade its appearance this year in a tropical form and has spread in a
very alarm ing m ann er. I t ap pears to have originated in T urkestan and to have been spread
over R ussia by th e p ea san ts who fled from T u rk e sta n during the famine of 1921 and who then
returned to th e ir hom es du ring th e early spring and sum m er of 1922.
It is n o t necessary to go into th e details of the situation, as during the last four m onths no
appreciable change h as occurred.
I t is becom ing u n fo rtu n a te ly clear th a t fam ine conditions will again prevail in a large terri­
tory situ ated m ore to th e e a st th a n th e fam ine zone of 1921, involving a population of about
8,000,000. The A m erican Relief O rganisations, who decided in the sum m er to concentrate their
work on h ea lth w ork, have now decided to continue th e famine relief as the m ost im portant factor
in the whole situ atio n . T he m edical b ran ch of th e American Relief A dm inistration in Russia desires
this year to co n c en tra te on furnishing lab o rato ry supplies, the m aintenance of a large num ber of
epidemic hospitals a n d th e d istrib u to n of food supplies to the medical profession. This program m e
will involve th e ex p e n d itu re of several m illion dollars. I t is not unlikely th a t the am ount of assist­
ance given b y th e m will be considerably increased and th a t very large consignments of drugs will
continue to be supplied, p artic u la rly in view of th e danger of m alaria.
It is obvious t h a t th e assistance offered b y the Epidem ic Commission in sanitary m aterial to
the Russian sa n ita ry au th o rities h as been very insignificant and it m ay n ot be possible to continue
it even on th is v ery m o dest scale. I t should "be realised th a t this p a rt of the work of the Commis­
sion has p ra ctically come to an end, and th a t th e Commission should concentrate its efforts on the
epidemiological enquiries co nd ucted by experts, public h ealth statistics and further co-operation
between public h e a lth services.
Steps h ave b een ta k e n in pu rsuance of th e instructions of th e H ealth Committee to assist the
Russian h ea lth a u th o rities in th e proposed enquiries on the spread of typhus, and the Committee
May perhaps desire m e to give fu rth e r details when discussing th e question of the epidemiological
services.

X III. A ccounts of the E p id e m ic Co m m is s io n .

The C om m ittee will rem em ber t h a t th e accounts of th e Commission were fully audited in
July last and th e a u d ito rs ’ s ta te m e n t was incorporated in th e Second A nnual R eport of the E pi­
demic Commission. In view of th e d e p a rtu re of th e Chief Epidem ic Commissioner for the F ar East,
Lhe accounts h av e been re-au d ited an d th e sta te m e n t of the auditors is annexed (Appendix ).
The present financial s itu a tio n of th e Epidem ic Commission m ay be sum m arised as fol ows,
 — 46 —

(1) T he balance of fun ds a t th e disposal of the Epidem ic Commission is approxi­

m ately ............................................................................................................................. £ I 7,6oo
A gainst th is sum there are com m itm ents to th e Polish G overnm ent, nam ely . . . t o , 500

L eaving a n e t balance o f ........................................................................................................... £ 7-100

or Swiss francs i 73,95o
To th is m u st be ad ded the Czechoslovak co ntrib utio n o f ............................... ^3,535
M aking a to ta l available o f ............................... ..................................................... 347485
In view of th e p ay m e n t of this contribution th e B ritish G overnm ent is
prepared to m ake a g ra n t representing one-half of th is am ount, nam ely 86,767

Making a to ta l o f ....................................................................................................... 434.252

(2) T he Epidem ic Commission is pledged to the L atv ian G overnm ent to m ake a
con tribu tion for th e establishm ent of a m aritim e q u aran tin e statio n of
£10,000, or .................................................................................................................... 245,000

Leaving a balance available of ............................................................................ 189.252

(3) T he B udget of th e H e alth O rganisation allows a co ntrib utio n to th e Epidem ic
Commission o f ..................................................... ......................................................... 50,000

M aking th e to ta l sum s likely to be a v a i l a b l e ................................................. 239.252

(4) Purchases for R ussia m ade on account of the Czechoslovak co ntribution am oun­
ted to ............................................................................................................................. 98,00c

Leaving a balance o f .................................................................................................. 141.252

(5) T he salaries of the three commissioners represent, for six m onths, Sw.Fr. 36,750
The Chief Epidem ic Commissioner ........................................ 18,375
S ecretariat staff and S ecretary ................................................. 32,000

M aking a to tal of 87,125

Leaving a balance of Swiss F rancs 54,127

 A ppendices to the Report of the Medical Director.

A P P E N D IX I TO A N NEX 3.

Letter from t h e P r e sid e n t of the Co u n c il to St a t e s M e m b e r s represented

at T h ir d A ssem b ly c o n c e r n in g t h e W ork of th e E p i d e m i c C o m m is s io n .

G e n e v a , Septem ber 15th, 1922.

Your Lordship,
Your L ordship is aw are of th e circum stances th a t led to the convocation of a European Inte-
national H e alth Conference in W arsaw in March of the present year and of the recommendations
and resolutions ad o p te d b y t h a t Conference. These recom m endations were taken into consideration
by the Econom ic Conference a t Genoa, which approved b oth th e principles of anti-epidemic
action enunciated b y th e W arsaw Conference an d the recom m endation th a t the Epidemic Com­
mission of th e League of N ations be en tru sted w ith th e d u ty of controlling and supervising the
expenditure of such n a tio n al subscriptions as m ight be contributed for the prosecution of the
anti-epidemic cam paign. T he G overnm ents represented at Genoa further undertook to approach
their respective p arliam en ts for th e financial assistance necessary to give practical effect to the
programme laid dow n b y th e ex p e rt Conference a t W arsaw.
Up to th e p resent no fu rth e r subscriptions to the funds of th e Epidem ic Commission have
been received as th e re su lt of th is recom m endation m ade b y the Genoa Conference. The British
Government, however, has o b tain ed parliam en tary sanction to a further contribution to the
Epidemic Commission of £ 1 0 0 ,0 0 0 provided th a t o ther G overnm ents interested together contribute
sums to tallin g £ 2 0 0 ,0 0 0 . T he Czechoslovak G overnm ent has prom ised a contribution of one
milhon crowns.
The Council of th e League of N ations, a t a recent session, considered th a t no useful purpose
would be served b y th e issue of an o th e r general appeal to Members of th e League, as the facts
regarding th e serious epidem ic situ atio n in E aste rn E urope were known to all. The Council there­
fore considered t h a t th e responsibility for the carrying out or otherwise of the program m e laid
down by th e In te rn a tio n a l H e alth Conference a t W arsaw m ust rest w ith the individual Govern­
ments. A t th e sam e tim e it w as th o u g h t well t h a t all delegations present a t the Assembly should
be acquainted w ith th e conditions governing th e B ritish offer of assistance referred to above, so
that endeavours m ig h t be m ade before th e close of th e Assembly to obtain promises of contri­
butions sufficient to enable im m ediate advan tage to be tak e n of the B ritish offer.
I t is in com pliance w ith th is decision of th e Counc il th a t I now address your Lordship with
the request th a t, if th e re be n o objection, you will kindly ascertain the extent of assistance th at
your G overnm ent is disposed to give. I need n o t here refer in detail to th e continued g ravity of
the epidemic situ atio n in th e countries of E aste rn Europe or to the urgency and m agnitude of
the task t h a t w aits to b e accom plished. These m atters have been dealt w ith fully in the reports
of t h e W arsaw Conference a n d of th e Epidem ic Commission and in the various publications
recently issued b y the H e alth Section of th e League of Nations. I t will suffice if I point o ut th at
an indefinite continuance of th e existing sta te of affairs will not only add enormously to th e sum
total of h u m a n m isery and suffering b u t will continue to be, as it is a t present, one of th e most
formidable obstacles to economic recu peration an d s ta b ih ty in th e countries concerned. I would
^so lay stress on th e considerable effort m ade b y the countries bordering on Russia to carry out,
with relatively little outside assistance, an effective anti-epidem ic campaign. W hen compared
with the resources of these countries, th is effort has been indeed rem arkable.
T rusting t h a t v o u r L ordship's G overnm ent will be in a position to respond generously to
this appeal,
I have th e honour, etc.
D. d a G a m a ,
President of the Council.
 - 48 -

A P P E N D IX II TO A N N E X 3.

I nterchange of P ublic H ealth P ersonnel .

Letter from the Secretary-General to the South American States.

G eneva , N ovem ber 7th, 1922.

Sir,
F u rth e r to the conveisations which I h a d w ith th e delegates of several L atin A m erican
S ta tes tow ards th e end of th e Assembly, I th in k it would be well to draw y o u r attentio n to a
passage in th e Resolution ad o p te d b y th e T h ird Assem bly a t its p len ary m eeting held on S e p tem b ei
15th referring to the interchange of public h ealth personnel of various countries which was
u n d erta k en under th e auspices of the H e alth Organisation.
A first experim ental interchange is being carried o u t in Europe. Some th irty officials belonging
to th e h e a lth services of various E u ropean countries m et a t Brussels, w here th ey atten d e d lecture
on Belgian legislation relative to h ealth problem s a n d on the details of th e administration of
th e Belgian public h ealth services. The officials tak in g p a rt in this interchange will finally be
a tta c h e d for a term of p ractical service to various h ea lth services, particu larly to t h a t of Italy.
A second and a th ird interchange will be organised early n ex t year, an d th e experience gained
in Belgium an d Ita ly will be ta k e n into account. These interchanges, approved in principle by
th e Assem bly, are intended to establish co n ta ct betw een th e h ea lth services of the various coun­
tries, to spread th e knowledge of th eir h ea lth legislation and to p erm it of th e creation of closer
relations an d a certain u n ity of m ethod am ong th e various h ealth services. The officials of the
h e a lth services appointed b y th e ir G overnm ents will be able to ta k e ad v an tag e of th e interchanges
to gain a knowledge of the m ethods applied in th e countries th e y visit, an d th ey will be able to
exchange th eir views on health problem s w ith th eir colleagues of o th er nationalities. In organising
these interchanges, the H e alth Organisation has been generously helped b y th e Rockefeller Foun­
dation, which has gran ted a su b stan tial contribu tion to th e b u d g et of the League of Nation,
for this purpose.
I t is extrem ely desirable t h a t the carrying-out of the program m e should not be limited to
E uro p ean countries solely. T he A ssem bly clearly pointed out th a t this was its desire. The dele­
gates of several n on-E uropean countries s ta te d how interested th e y w ould be to see some of their
own h e a lth services tak e p a r t in th e program m e of interchange of public health personnel.
M ay I therefore enquire w heth er it w ould be possible for y o u r G overnm ent to consider to
w h a t ex te n t the officials of its h ea lth service could tak e p a rt in th e forthcom ing meetings ?
I shall n o t fail to send you as soon as possible all available inform ation concerning t h e pro­
gram m e drawn up b y th e H e alth Section. Moreover, the decision of th e Assem bly leaves scope
for the m odification of details of the original program m e. Should it seem desirable to do so, it
would no dou b t be possible to organise, a p a rt from th e lectures an d term s of practical service
held in Europe, lectures followed b y term s of service in countries outside Europe. I t would be
of th e greatest value to us if we could h av e you r G overnm ent’s views on th is subject to s e r v e as
a guide in th e realisation of fu rth e r experim ents to be carried ou t n ex t year.
U n fo rtu n ately the credits a t th e disposal of the H e alth O rganisation of the League of Nations
render it difficult to charge to th e b u dget of th e O rganisation th e expenses of the sea voyages
of th e various m edical officers of health. According to th e present arrangem ents, the Health
O rganisation is prepared to refund the m edical officers’ second-class fares on railw ays for Conti­
n en tal travelling and to p a y th em a daily subsistance allowance of £1 for th e duration of the
lectures an d term of practical service.
I h ave the honour to be, etc.
S ecretary -G eneral.
 — 49 —

A P P E N D I X 3 TO A N N E X 3.

In terch a n g e o f P u b lic H e a lth P erson n el

(L e tte r from th e Medical D irector to th e H ealth Adm inistrations)

Geneva, Decem ber 16th, 1922.

Sir,
I have th e ho nour to inform you th a t th e H ealth Section of the League of Nations, w ith the
support of th e Rockefeller F o u n d atio n , organised, during th e m onths of October, November and
December 1922, a first experim ental interchange of public health personnel from several European
countries. This in terch an ge took place in Belgium an d Italy.
In each of these countries th e m edical officers atten d ed lectures and conferences on the system
of general a n d h e a lth legislation, on th e characteristics of their health, social an d political organi­
sations, on th e a ttitu d e of public opinion w ith regard to various health problem s which are being
worked out or are u n d er discussion in these countries, and on the details of adm inistrations of the
various public h e a lth services.
The m edical officers fu rth e r visited public h ealth and social welfare institutions, both State,
provincial, com m unal a n d private, afte r addresses on the subject by leading h ealth experts.
The m edical officers were finally atta c h e d for a term of practical service to the various health
services in order to gain in tim a te knowledge of th e working of the health organisation, the m ethod
of applying th e legal m easures an d regulations, and th e daily work of the medical h ealth officers
under whose guidance th e y h a d been placed.
In conform ity w ith th e decision of th e T h ird Assembly of the League of Nations, and under
the direction of th e H e alth C om m ittee, preparation s are in progress for a second experimental
interchange, w hich will p robably begin during th e m on th of F eb ruary 1923. This experim ent
will also last a b o u t th ree m o n th s — six to seven weeks will be spent in E ngland and six to seven
weeks in a C entral E u ro p ean cou n try . The C entral E uropean country has not yet been definitely
selected, b u t th e H e a lth C om m ittee will arrive a t a final decision on the subject a t its next meeting
in January 1923.
This second interch an g e of personnel will comprise :
(1) A prelim inary period of ten to fifteen days during which a series of conferences and lectures
will be given in order t h a t th e foreign m edical officers m ay have th e opportunity of learning the
principles of th e w orking of th e various h ealth services and their relations w ith the central and local
authorities an d public in s titu tio n s ;
(2) A period of four to five weeks devoted to practical service which th e medical officers, in
groups of five to eight, will a tte n d . T hey will sta y successively in urban, ru ral and industrial
areas, taking p a r t in th e daily w ork of th e m edical officers of health.
The n u m b er of foreign m edical officers of h ea lth invited to tak e p a rt in this second experim en­
tal interchange h as necessarily been lim ited to twenty-five, as the funds a t the disposal of the
Health O rganisation of th e League of N ations do not allow this figure to be exceeded. In view
°f the experience gained du ring th e first interchange and in view of the economic situation, the
Health Com m ittee an d those s a n ita ry adm inistrations concerned in the experim ent have decided
that the m edical officers tak in g p a rt in this interchange shall be entitled to a daily allowance of
20—for E ngland an d 3 0 — for C entral Europe. The travelling expenses (second-class railway fare,
with supplem ent for sleeping-car accom m odation for th e night, etc.) of th e officers concerned will
be refunded.
In order to derive real benefit from th eir course of study, the m edical officers of health should
have had several y ea rs’ technical experience of service w ith a public health adm inistration either
communal, provincial or S tate.
May I draw y o u r a tte n tio n to th e fact th a t the forthcom ing interchange is a further experi­
ment designed to supplem ent th e first, which was recently carried out in Belgium and Ita ly ? The
results of these experim ents will enable th e H ealth Com m ittee to arrange a series of interchanges
etween the m em bers of th e public h ea lth services; these system atic interchanges will be spread
0Ver a period of tw o and a-half years, beginning in Ju n e 1923.
I should be g ratefu l if you w ould kindly inform m e w hether you wish to select three medical
0tiicers from y o u r co u n try to ta k e p a r t in th e forthcom ing interchanges. In any case, I should
 — 50 —

be glad if you could com m unicate you r decision to m e before th e m eeting of th e H ealth Committ
on J a n u a ry 8th, 1923, a n d could le t m e h av e partic u la rs of th e c a n d id ates (according to the encln-"
form ). it£
I have th e honour, etc.
M e d ic a l D ir e c t o r .

A P P E N D IX IV TO A N N E X 3.

P r o v isio n a l E p id em ic C o m m iss io n

Record of the Meetings held on December 16th, 18th and 19th, 1922.

T he ac tu a l organisation of vaccination was th e subject of a searching discussion which thie

lig h t on th e various aspects of th e m a tte r and on th e obstacles to its fulfilm ent.
One im p o rta n t point was to determ ine which class of refugees should b e d ea lt with first,
w as decided to begin w ith :
(1) The m ore th ickly crow ded groups of refugees, b o th for p rophy lactic reasons and becaw
th e y offered o p p o rtu n ity for ra p id action and effective control ;
(2) The island refugees, w hom it would be easy to superintend, as form ing stationary group
A second an d a m ost im p o rta n t p o in t was to determ ine w h a t kinds of vaccination to emploi
it was decided th a t th e Commissioner of th e E pidem ic Commission should en d eav o u r to induce tl
H e a lth Section app o in ted b y th e Greek G overnm ent to organise this w ork to agree to the followii
vaccinations : Sm allpox, T yp h o id a n d P a ra ty p h o id , Cholera, which should be universal, ai
d y sen tery a n d plague vaccinations, which were to be em ployed to a m o re lim ited extent.

I.

Smallpox Vaccinations.

All refugees should be vaccinated ag ainst sm allpox. I t is extrem ely u n likely th a t the qua
titie s of J e n n e r’s vaccine p re p are d a t A thens will be ad eq u ate in view of th e im m ense number
refugees to be v accinated w ithin such a short period. L ev a d iti’s and N icolao’s smallpox vacci
m a y therefore have to be used. In th is case, only v ery sm all bodies of refugees should be selecte
in order to enable a careful an d conscientious observation to be tak en of th e resu lts obtained.

II.

Typhoid, Paratyphoid and Cholera Vaccination.

As these th ree vaccinations can be given b y em ploying poly v alen t vaccines, th e y may,
of being dealt w ith separately, be considered together.
In a n y case, it was acknow ledged th a t a biological te s t w as necessary w ith each vaccine,
order to ascertain its innocuousness before use. T he m eth o d s of ab so rp tion through the m®1
or of hypoderm ic injection w ould be em ployed according to circum stances.
I t w as agreed t h a t refugees betw een th e ages of 6 an d 60 should be given these vaccinatw

II I.

Dysentery Vaccinations.

I t m u st b e clearly u ndersto od t h a t d y sentery vaccination should n o t be carried out un1'

sally ; i t should be re stric ted chiefly to refugees living in d istricts in w hich dy sen tery is ende1
 — 5i —

in Salonika for instance. In these cases it is absolutely necessary, first, to m ake tests for th e pur­
pose of ascertaining th e ag e n t w hich caused th e infection an d then to employ the proper vaccine
Here again th e m eth o d s of ab so rp tio n b y th e m o uth or b y hypodermic injection m av be
employed. In cases in w hich it is decided to use hypoderm ic injection for dysentery vaccination
it has been found t h a t a s e x ta vaccine w ould be preferable to a purely bivalent dysentery vaccine’
as the former produce less-violent reaction s th a n vaccines of a smaller polyvalence

IV.

Plague Vaccination.

It was agreed t h a t th e plague vaccine should only be used in special circumstances as deter­
mined by events.

V.

T yp h u s Vaccination.

As this vaccine h as n o t y e t given sufficient proofs of efficacy, it appeared preferable not to

use it b u t to ensure t h a t refugees on m oving are deloused.

VI.

Vaccination Procedure.

The relations betw een th e Com missioner of the Epidem ic Commission and the Greek health
staff in charge of v ac cin atio n were defined in th e Protocol of December 18th, 1922, and it is not
necessary here to refer to th is question.
The n u m b er of G reek h e a lth officials was fixed in accordance with th e sub-division of Greek
territory into eleven te rrito ria l provinces, an d provision was m ade for the appointm ent of ten
vaccination staffs, each staff com prising a doctor and six m ale or female assistants.
I t was ag reed t h a t th e choice of th is staff would often depend upon local conditions, and
although it was im possible to draw u p a priori conditions for such selection, it was thought th a t
the principle of selection should be t h a t each assistan t should be able in case of need to become
head of a new staff form ed w ith locally recru ited personnel.
The principle for fixing th e ra te of rem un eration for such staff was laid down in the Protocol
of December 18th, 1922, b u t as it was agreed th a t th ey should form p a r t of the Greek health
services, it ap p eared only reasonable t h a t th ey should receive their pay from the Greek Govern­
ment, to w hich th e Com m issioner of th e E pidem ic Commission should, from tim e to time, forward
the contribution g ra n te d for th is purpose b y th e Commission.
It is of th e u tm o s t im portance th a t vaccination should be organised in such a m anner th at
a really scientific ex p erim en t can b e m ade for th e purpose of determ ining the preventive value
of the vaccine em ployed a n d of th e value of th e m ethod of absorption under clearly defined
conditions ; and, fu rth e r, t h a t a s tric t b u t simple control should exist. The services of Greek
and foreign specialists m ig h t, if th o u g h t necessary, be called upon to fix the conditions for
experiments.

V II.

Budget.

The estim ate for a b u d g e t of th is k in d can only be quite approxim ate. I t m ust be remem ­
bered, before all, t h a t th e E pidem ic Commission can only devote to this portion of its relief work
the sum of £1,500; accordingly, should th is sum prove inadequate, it would be necessary to ask
f°r financial help from th e Greek G overnm ent.
I t m ust be rem em b ered t h a t th e ra te of p ay m e n t for Greek officials employed in vaccinating
was to be fixed in agreem ent w ith th e Greek G overnm ent after arrangem ent w ith the representatives
of the Am erican R ed Cross.

If we e stim ate th e co n trib u tio n m ad e by th e Epidem ic Commission at:

^500 drachm as a m o n th for doctors,
600 drachm as a m o n th for assistants,
5o drachm as as a d aily trav e llin g allowance for doctors for 20 journeys a m onth,
3o drachm as as a d aily travelling allowance for assistants for 20 journeys a m on ,
£450 for p u rc h ase of m aterial.
 — 52 —

W e o b tain th e following rough estim ate :

Drachmas
io doctors for th ree m on ths a t 1 ,5 0 0 d rachm as a m o n th .......... 45,000
6 0 0 d a y s’ travelling allowance a t 5 0 drachm as a d a y ................... 30,000
6 0 assistants for th ree m o nths a t 6 0 0 d rachm as a m o n th .......... 108,000
3 , 6 0 0 d a y s’ travelling allowance at 3 0 d rach m as a d a y ................... 108,000

T o tal . . . 291,000
On D ecem ber 20th, 1 9 2 2 , th e £ sterling = 3 4 9 d rachm as

£
Therefore 2 9 1 ,0 0 0 drachm as 834
P urchase of m aterial . . . 450
In h an d ............................... 216

T o ta l £1,500
G e n e v a , Decem ber 2 1 s t , 1 9 2 2 .

A P P E N D IX V TO A N N E X 3.
P r o v isio n a l E p id e m ic Co m m issio n .

Record of Meetings held on December 1 4 th and 15th, 1 9 2 2 .

T he question on th e agenda dealt w ith th e action tak e n in Greece b y th e Epidem ic Commissioi

of th e League of N ations as an autonom ous unit, independent of th e action tak e n b y Dr. Nansen'
H igh Commissariat.
T he sum of £5,000 sterling was placed a t th e disposal of th e Commission for this purposeb
Dr. Nansen.
(1) T he inform ation supplied b y th e Commissioners, Dr. G authier and D r. H aigh, was to th
effect t h a t th e health situ ation is liable to become, a t any m om ent, worse, as a result of th
unsatisfacto ry san itary conditions.
(2) T he refugees are d istrib u ted over th e whole territo ry of C ontinental Greece and the Gree
islands, eith er in concentration cam ps or in public buildings in th e towns, or else placed a m o n g th
in h ab ita n ts of th e villages. These different circum stances increase th e difficulties of the problen
(3) T he m edical resources of th e co u n try itself are clearly inad eq u ate to cope w ith so sudde
an increase in th e num ber of in h ab itan ts and in th e causes of in san itary conditions. Faced wit
such a situation, th e A m erican R ed Cross is installing 5,000 beds an d sending staff whose dutt
will include th e inspection of its m aterial and th e intro duction of san itary m ethods into camp
I t will also b ea r a share of th e pay m en t of th e 1 6 7 G reek doctors already in charge of the medic:
service of th e refugees.
According to th e Greek authorities, sm allpox vaccination is already being carried out b y meat
of vaccine prepared in th e co u n try itself.
T he action to be tak e n b y th e Epidem ic Commission should therefore be th e following:
(1) The purchase of baraques, m otor am bulances and p ortable baths.
(2) The organisation a n d carrying out of vaccination.
(3) Technical advice, when requested b y the Greek Governm ent.

(1) The Purchase of Camps, Huts, Motor Ambulances and Mobile Baths.
M. Doxiades, M inister of P ubhc Relief, expressed to Dr. H aigh, when th e la tte r was pas®
th ro u g h A thens, his earnest desire t h a t th e Epidem ic Commission should purchase its stofl
because he considered th a t hospital accom m odation, rem oval of contagious cases to h osp ital a«
delousing were th e m ost u rg e n t questions to be solved. The Commissioners, therefore, deep
t h a t th e y wTould be well-advised to effect these purchases im m ediately u p to a sum of
provided th a t the Greek G overnm ent gave a w ritten agreem ent thereto. A telegram to this tw
was sent to M. Doxiades. The purchase of these stores would result in th e speady m a térialisât11
of th e Epidem ic Commission’s endeavours, and would dem o nstrate th e practical nature o t1
work.

(2) Organisation and Method of Vaccination.

A fter a close stu d y of th e h ealth situation, taking into account th e im portance of p r o p h ) ^
from an in ternatio nal point of view— p articularly because th e epidemic danger is a pefflianc
 — 53 —

l e —it was considered essential to organise th e vaccination of th e refugees with the least possible
lay.

[
The Epidemic Commission h av in g th u s assum ed responsibility, the Commissioners considered
their duty to point o u t to th e G reek G overnm ent th a t vaccination was essential in order to pre-
nt the possibility of th e o u tb rea k of epidemics which could not b u t be disastrous among these
nSe masses of refugees; and, fu rth er, t h a t it would be desirable to afford the refugees the benefit
of the most m odem m ethods of vaccination and to in stitu te comparison between the respective
Ialues of the various toxin s and th e m etho ds of adm inistering them .
In the course of conversations which M. Doxiades had w ith Dr. G authier and Dr. Haigh, the
jrmer agreed as to th e necessity of vaccinating the refugees ; the principle having thus been
ccepted, the Com missioners considered t h a t th e y should propose t o the Greek Government
îat the vaccination scheme should be organised on th e following lines:

(а) The Greek G overnm ent w ould place one of its health services in charge of the organisation
,r vaccinating refugees. In accordance w ith a desire expressed by M. Doxiades, the Epidemic
ommission would assist b y app ointing one of its Commissioners as an active member of this
;rvice, to be in charge of th e execution of the general order given by the service ; the methods
[putting the scheme in to practice would be adopted b y m utual agreement.
(б) The Epidem ic Commission was prepared to devote £1,500 sterling to the purchase of
ie necessary stores in Greece a n d abroad and also to contribute to a certain ex tent to the salaries
nd allowances to Greek officials em ployed in carrying out the vaccination.
The staff m ig ht include te n doctors an d sixty assistants. Their salaries would be fixed by
revious agreem ent w ith th e Greek G overnm ent and the American Red Cross, and, if necessary,
ith the Greek relief societies.
(c) The various p ractical details would be clearly and precisely determ ined by official corres-
ondence between th e Greek G overnm ent and the Epidem ic Commissioners.
It was understood t h a t th e vaccination scheme would be carried out within three months.

() Technical Consultations.

After an exchange of views betw een M. Doxiades and the Commissioners on th e subject of the
ery great im portance of th e h ealth problem as affecting the refugees, th e m inister expressed a
esire that th e Com missioners of th e Epidem ic Commission should assist him w ith technical advice
1the accom plishm ent of his task.
The action to be ta k e n b y th e Commissioners under this heading was considered w ith all
:quisite care, and it was decided t h a t one of the Commissioners should be placed at the disposal
[the Greek h ea lth services as a technical adviser for all m atters connected with health questions
Electing the refugees.
It was realised t h a t th is d u ty necessarily implied the holding of local enquiries into m atters
[health, b u t in this question, as in t h a t of vaccination, practical details would be settled b y means
f official correspondence betw een th e G overnm ents and th e Commissioners.

f) Allocation of Duties.

In view of th e tem p o ra ry ch aracter of th e Epidem ic Commission’s work and the urgent

ecessity of tak in g stronger m easures, it was realised th a t it would be b etter to divide the work,
ot by territorial districts b u t b y separate departm ents, in order to obtain u n ity of control in each
I these fields.
Dr. G authier w as en tru ste d w ith th e work of vaccination, his headquarters being fixed at
thens, so t h a t he m ight keep in touch w ith th e central Greek health authorities.
In view of th e difficulties an d slowness of com m unication between Athens and Salonika the
'0chief centres n ea r which th e m a jo rity of th e refugees were distributed—it was decided to apply
IIthe consent of th e Greek G overnm ent to th e appointm ent of an assistant doctor to Dr. Gauthier,
ith headquarters a t Salonika. .
The post of technical adviser to th e G overnm ent health services was allocated to Dr. Haigh.
As regards th e in tern al organisation of his services, Dr. Haigh expressed the view th a t there
as no need a t th e m om ent to ap p o in t an assistant doctor, b u t he considered th a t it would, perhaps,
edesirable, in view of th e in san itary condition of the camps, to suggest th a t th e Greek Govei n-
lent should enlist tem p o rarily th e services of a sanitary engineer.

(Signed) A. G a u th ie r .
W. E. H a i g h ,
L u d w ik R a jc h m a n ,
H. R u lo t.
Geneva, Decem ber 18th, 1922.
 — 54 —

A P P E N D I X VI TO A N N E X 3.

A c c o u n t s o f t h e E p id e m ic Co m m is s io n .

Chief Commissioner,
E pid em ic Commission,
League of N atio ns, L o n d o n , D ecem ber 7 th , 1922.
G eneva.

D e ar Sir,
I n pursu ance of in stru ctio n s, we h av e exam ined th e accounts of th e H e ad Office of the Com­
m ission for th e eleven m o n th s ended O ctober 31st, 1922, a n d th e accounts of th e W arsaw Office
an d Moscow Office for th e five m o n th s a n d ten m o n th s ended t h a t d a te respectively.
W e now presen t our re p o rt thereon, to g eth er w ith exh ibits as p er prefixed index.

Income and Expenditure Account.

E x h ib it "A ” sets o u t th e operation s of H ead Office for th e eleven m o n th s ended October 31st,
1922, in co rp o ratin g th e ex p e n d itu re p er W arsaw Office. As no b alance of th e accou nts of the latter
Office w as m ad e a t th e tim e of th e la s t a n n u a l accounts of H e a d Office, th e ex p e n d itu re through
t h a t source has been included a t th e to ta l figure to t h a t date, less th e am o u n t charged in Head
Office accounts to N ovem ber 30th, 1921, a n d which represented th e re m ittan c e m ade less balance
rem ain in g in h a n d a t t h a t d ate .
T h e co n trib u tio n s received d u ring th e period h ave a m o u n ted to £59,718. 7 . 11, consisting
of th e following:

£ 1. d.
Belgium (2nd c o n trib u tio n )........................................... 1,000. o . o
F ran ce ................................................................................ 50,000. o . 0
H olland (fl. 1 0 , 0 0 0 ) ......................................................... 8,718. 7 .1 1

£ 5 9 ,718 . 7 .1 1

I n ad d itio n to th e foregoing income, th ere has been credited a sum of £ 9 3 2 .1 4 . 5 interest

on b a n k deposits, m aking a to ta l incom e for th e period of £ 6 0 , 6 5 1 . 2 . 4 .
T he exp en ditu re m ay be sum m arised as follows:

P er H ead Office:
£ ». d.
Supplies to P o l a n d ........................................................ 3 ,0 5 7 .1 0 . 0
Supplies to R u s s i a ........................................................ 3 0 4 .1 5 . 6
A dm inistration E x p e n se s................................................. 5 ,3 9 4 .1 .2
P e r W arsaw O f f i c e ................................................................... 50 ,46 5.19 . 6

£59,222. 6 . 2

The to ta l incom e for the period has exceeded the ex penditure b y £ 1,4 2 8 .1 6 . 2, making, with
th e balance of £28,928.19. 8 b ro ug ht forw ard as a t N ovem ber 30th, a to ta l of £30,357.15.10 un­
expended. As against th is balance certain com m itm ents have been m ade as h erein after referred to.
T h e following is a su m m ary of th e incom e and ex pen ditu re of th e Commission from the
d a te of its inception to O ctober 31st, 1922.

INCOME : Per Wareaw Office Per Head Office Total

C o ntrib utio ns an d D onations :
£ 1. d. £ ». d. £
N a tio n a l C on tributions. . . . — 186,055.12. 3 186,055.12. 3
League of R ed Cross S o cieties. — 10,000. o . 0 10,000. 0 .0
P riv a te D o n a tio n s.......................... — 2 6 .1 6 . 0 26.16. 0
In te re s t on B an k D eposits . . . 5 .1 3 . 6 1,344. 6 . 4 i , 349-i 9,i°

£ 5 .1 3 - 6 £ 1 9 7 ,4 2 6 .1 4 . 7 £ i 97. 432- 8 ' 1

 — 55 —

Per Warsaw Office Per Head Office Total

E x p e n d it u r e :
£ S. d. £ S. d. £ s. d.
pplies and G ran ts to P oland 56,488.18. 7 86,308. 3. 4 142,797. 1.11
pplies to R u s s i a .................. 8,224. 2 - O 304.15- 6 8,528.17. 6
ministration E xp en ses. . . 3 ,4 2 1 .1 4 . 1 0 11,245.19.10 14,667.14. 8
xchange •. .................................... 805. 7.IO 805. 7.10
esearch W o r k ........................... 275-IO. 4 275.10. 4

£69,215.13. 7 £97,858.18. 8 £167,074.12.

Excess of Incom e over E x p e n d itu re .

£ 30,357 -1 5 - 1 0
The ad m in istratio n expenses are sub-divided as follows :
£ s. d.
Salaries . . 8,833. 6 . I I
T rav elling . 4,452.10. 2
M iscellaneous 1,381.17. 7

£14,667.14. 8

The percentage of to ta l a d m in istratio n expenses to total income is 7.43 % , whilst of this

rcentage 2.26 % rep rese n ts trav e llin g expenses due to the large area covered.
It will be seen t h a t £ 8 0 5 .7 .1 0 is included w ith expenditure in respect of exchange. Income
d E xpenditure A ccounts of W arsaw an d Moscow Offices have been converted a t the average
tes at which sterling h a s been exchanged, and balance-sheet item s as a t October 31st, 1922,
ve been converted a t th e ra te s q u o ted a t th a t date.
During th e period u n d e r review , settlem en t of insurance claims were m ade am ounting to
07.8.0 in respect of losses d u rin g th e prior period, an d this sum has been deducted from expen-
ure in the an n e x ed accounts. A re b a te obtained in respect of m otor spares has been similarly
ated.
Balance Sheet.

Exhibit “B ” sets o u t th e financial position as at O ctober 31st, 1922.

Cash a t b an k s h a s been verified b y b a n k certificates. The le tte r of credit for £6,000 in transit
Warsaw has been produced to us, a n d is accounted for in th e W arsaw accounts subsequently
date of balance sheet. T he b alance of £ 7 7 5 .1 2 .3 on letters of credit held a t Warsaw have
en verified b y inspectors.
Commitments. W e u n d e rsta n d t h a t th e F rench G overnm ent contribution of £50,000 was
ocated as follows:
£
B a r r a c k s ........................... 2,500
Mobile L a b o ra to ry . . 1,000
C y a n i d e ........................... 1,000
“R eserve” ...................... 2,500

7,000
Polish M inistry G ran ts 43,000

£50,000

The scheme a rran g e d for th e la tte r g ra n ts was calculated a t the ra te of 18,000 Polish marks
the £ and am o u n te d to P.M. 774,000,000 or £43,002. We understand th a t an arrangemen
' made in O ctober w hereby g ra n ts w ould in fu tu re be m ade in sterling and th a t paymen o
at date should be cred ited a t an average ra te of P.M. 23,583 to £. At th a t tim e t e pay
nts had to talled P.M. 644,404,664, equivalent to £27,323, leaving a balance of £15, 79 011
ding. Since t h a t d a te a sum of £ 7 1 9 .3 .0 (P.M. 42,000,000) was paid, m aking th e a ance ou
ding £14,959.17.0.
The o u tstan d in g co m m itm en ts as a t O ctober 31st, 1922, am ounting to £16,831.15.7’ com
'se the following:
ance of allocation of £43,002 to Polish M inistry, £ s. d. £ s-
as a b o v e ........................................................................................................ 14,959•I 7 -u
foie L aboratory A l l o c a t i o n .................................... 1,000.0.0
Less : A m ount expended p er H ead Office . .. 7 5 0 .0 .0 ^ Q Q

anide A l l o c a t i o n ............... 1,00 0.0.0

Less: A m ount expended p e r W arsaw Office
(G. M. 293,809) considered eq uivalent to . 2 0 0 .0 .0 g0 0_ o 0

Kacks Allocation ...................................................... 2,5 00 .0 .0

Less : A m ount expended per H ead Office .. 1 ,721.8.0 778.12.0

Carried f o r w a r d ......................................... £16,788. 9

 - 56 -

s. a,
Brought forw ard. £16,788.0,
9.0
M inistry of A pprovisation, Poland, h ospital screens P. M. 1,772,978
H ospital U n its for R ussia, estim ated balance . . . 1,000,000

P. M. 2,772,978 43. 6.
£16,831.15,
P. M.: 64,000 to £.

W ith regard to th e m obile lab o rato ry , we u n d ersta n d th a t fu rth e r sum s will require to '
expend ed for alteratio n s an d also tra n sp o rt, an d th e balance of £250 from th e allocation is there­
fore included as a com m itm ent.
T he ac tu al cost in sterling of cyanide already purchased was only £ 6 9 .4 .9 , owing to I
difference in ra te of exchange, b u t we u n d e rsta n d t h a t a t th e ra te a t which th e allocation was
ca lculated th is exp enditu re is to be considered th e equ ivalen t of £200, leaving a balance of {800
unexpended.
W e u n d ersta n d th a t, in add itio n to th e foregoing com m itm ents, a conditional offer of a grant
to th e L a tv ia n M inistry has been p u t forw ard, b u t no definite conclusion h a d been arrived at at the |
d a te of audit.
Warsaw Office.

In E x h ib it " C ” we have com bined th e E pidem ic A ccount a n d S an itatio n A ccount, Warsaw,

a n d Moscow Office Accounts. The accounts of each b ra n ch are d etailed in E x h ib it " D ” to “I”
inclusive. In com bining these accounts we have converted th e item s a t th e ra te s of exchange |
existing as a t O ctober 31st, 1922, resu lting in a loss of exchange of £ 6 5 8 .1 5 .6 .
E pidem ic Account. The expenditu re on th is account h as been m et b y advances from Sani-1
ta tio n A ccount, w ith th e exception of £1,000 re m itte d from H ead Office to N a tio n a l Bank für |
D eutschland, Berlin.
T he purchase of cyanide included in expenditure, n am ely G.M. 293,809 — £ 6 9 . 4 . 9 forms
p a rt of th e allocation of th e F ren ch G overnm ent co n trib u tio n of £50,000.
A dvances on account of salaries an d trav e llin g expenses com prise:

M. B irencw ajg — S a l a r y .................................... £40

Col. G au thier — Travelling, C onstantinople . £50
C h a u f f e u r ............................... P. M. 156,000

Sanitation Account. W e h av e not h a d produced to us th e a u d it re p o rt of th e P olish Govern-1

m en t Control D e p artm en t in respect of g ra n ts to, and expenditure by, N aczelny Nadzwyczajnv
K o m isarja t, an d we u n d ersta n d th a t no such rep o rt has been received since t h a t to March 31st,
1922, previously inspected b y us. W e have, however, inspected s ta te m e n ts from th e Komisarjat
d a te d N ovem ber 16th, 1922, showing th e ex penditure to have been as follows :

Old Scheme Grants Expenditure

P iotrk ow ........................................ P. M. 2,500,000 P. M. 1.425.000
Z a k o p a n e ........................................ 12,000,000 8,246,025
W l o d a w a ........................................ 1,500,000 1.450.000
S a n d o m i e r z .................................... 2,000,000 1.500.000
O kreg L w o w .................................... 16,295,320 16,295,320
S a n o k ................................................. 3,500,000
K a l i s z ................................................. 2,500,000 2.500.000

P. M. 40,295,320 P. M. 31,416,345
New Scheme
New H o s p i t a l s ............................... P. M. 3x3,604,664 P. M. 412,370,340
P o in ts étape d ’h i v e r .................. 117,000,000 117,000,000
P o in ts étape d ’é t é ...................... 10,000,000 17,000,000
In te rn m e n t C a m p s ...................... 14,800,000 14.800.000
B ath in g E stab lish m en ts . . . . 40,500,000 27.200.000
R e p a t r i a t i o n .................................... 190,500,000 179,300,000

P. M. 686,404,664 P. M. 760,670,340
(£28,042.3.0)

I t will be observed t h a t in th e case of g ra n ts u n d er th e new schem e, such g ra n ts had been

a n tic ip a te d b y expenditure to th e e x te n t of P. M. 74,265,676 as a t O ctober 31st, 1922.

Moscow Office.

T he accounts of th e Moscow Office for th e ten m o nths ended O cto b er 31st, 1922, have been
in co rp o rated w ith those of W arsaw Office.
 — 57 —

A sum of £7 cash p aid in a n d converted in to R ussian roubles in October has been

carried in suspense, as we h av e no p resen t inform ation regarding the source of this am ount
pending the absence of th e M edical D irector.

Generally.

Vouchers have been produced for all expenditure charged, and all income reported as received
has been duly accounted for.
We rep ort th a t we have o b tain ed all the inform ation a n d explanations we have required
and in our opinion th e a tta c h e d b alance sheet an d Incom e an d E xpenditure Account exhibit
a true and correct view of th e s ta te of th e affairs of th e Commission, and the operations for the
period, respectively, according to th e best of our inform ation and the explanations given us, and
as shown b y th e books of th e Commission. W e shall be glad to afford you an y fu rth e r inform ation
regarding th e acco u n ts should y o u so desire.
Y ours faithfully,
[Signed) R alph Sutton & Co.,
C hartered Accountants,
Auditors.
 - 58

A n n ex 4.

R eport on the F ar E astern Commission of E nquiry .

(Report by Professor Calmette.)

Geneva , J a n u a ry 8th, 1923.

As yo u are aware, Dr. M iyajim a, a t th e T h ird Session of th e H ealth C om m ittee, held in Paris,
in M ay 1922, presented a rep o rt on cholera a n d plague in th e F a r E ast. H e recom m ended that
a Commission of E n q u iry should be sent out to th e E a s t to investigate conditions in th e ports,
an d s a n ita ry regulations generally, w ith a view to controlling th e spread of epidemics.
The H e alth Com m ittee, afte r discussion, asked the Medical D irector to s tu d y th e question
an d the m a tte r was again tak en u p a t th e F o u rth Session, held in A ugust. T he following resolu­
tio n was th e n a d o p te d :

“The H e alth Com m ittee, h aving considered th e proposal? p u t forw ard b y D r. Miya­
jim a for th e despatch o f a sm all commission to the F a r E ast, to collect information
regarding th e incidence of epidemic diseases, especially those of in tern a tio n a l importance,
in im p o rta n t ports, an d th e m easures tak en to p re v en t th e transm ission of these diseases
to other ports, recom m ends in principle th e d espatch of a Commission.
“T he H e alth C om m ittee ap p o in ts a Sub-C om m ittee of three m em bers in order to
define :
“(a ) The details of th e enquiry, th e objects of w hich are defined above ; and
“( b) The prelim inary negotiations to be u n d erta k en , as well as to m ake recom­
m endations to the C hairm an of th e C om m ittee as regards th e ap p o in tm en t of the
Commissioners. ”

A Sub-C om m ittee was accordingly appointed, consisting of :

Sir George B uchanan,

Professor Calmette, and
D r. Miyajima .

The first m eeting, a tten d e d b y Sir George B u ch an an an d Dr. M iyajim a, w ith Dr. Norman
W hite, was held on A ugust 23rd, a t Geneva. T he Sub-C om m ittee considered th a t, in considera­
tio n of clim atic conditions, th e m ission should s ta rt not later th a n Decem ber. T he subjects of
enquiry, th e ro u te a n d the countries to be visited were discussed, as also th e steps to be taken
to o b tain th e concurrence of th e G overnm ents of th e countries in question. Sir George Buchanan
u n dertook, in consultation w ith Dr. C alm ette an d Dr. M iyajim a, to arrange for preliminary
inform ation concerning th e objects of th e mission to be furnished in certain instances in advance
of th e form al request from th e S ecretariat. I t w as also arranged t h a t preliminary
unofficial enquiries should be m ade b y m em bers of th e Sub-C om m ittee, in order to
ascertain w h a t experts m ig h t be available for n om ination to th e C hairm an as mem­
bers of th e Commission.
The m ain objects which th e Sub-C om m ittee decided to recom m end for special s tu d y by the
Commission were as follow :
1. E nquiries on th e transm ission of infectious diseases from p o rt to p o rt; th e measures
a d o p te d an d th e co-ordination already o b tain ed or which is considered desirable in in te r n a tio n a l
in terests ; th e relation also of an y such co-ordination w ith th e proposed revision of th e I n te r n a tio n a l
S a n ita ry Convention of 1912.
2. S tu d y of th e m aterial available from th e different countries which shows th e progress
of epidemics, so as to facilitate th e use of such m aterial b y th e cen tral h ea lth office ; th e desirab ility
of establishing a local epidemic intelligence centre for F a r E aste rn countries.
T he Sub-C om m ittee a d o p te d th e view th a t, alth o u g h th e re p o rt of th e Commission might
h av e v ery valuable results in relation to the application of th e In tern atio n al S an ita ry Conven­
tion in th e F a r E ast, and m ight lead to useful sup p lem en tary agreem ents u n d er t h a t Convention,
th e fa ct of th e Commission’s enquiries did no t, and should not, co n stitu te a n arg u m en t for post­
poning th e proposed In tern atio n al S an itary Conference to îevise t h a t Convention.
The Council of th e League of N ation, a t a m eeting held on Septem ber 2nd, approved the
proposal of th e despatch of a Commission of E n q u iry to th e F a r E ast, w ith th e suggestion th a t two
 ~ 59 —

or three experts, w ith special experience of in te rn a tio n a l public health agreements and tropical
diseases, should be appointed.
The Sub-Com m ittee held its second m eeting in Paris on Septem ber 27th, 1922. I t was
a tten d e d by all th re e m em bers and also b y Dr. R ajchm an, Dr. N orm an W hite and Dr. J itta .
The composition of th e Commission form ed th e chief subject of th e discussion. Representations
were made to th e Sub-C om m ittee b y th e Medical D irector and in a letter from the Secretary,
General to Sir George B u ch an an th a t, from th e p o in t of view of th e League, two conditions were
almost indispensable: first, t h a t one of th e commissioners should be an expert connected with the
Health Section, an d second, t h a t th e o th er commissioner should be a national of one of the smaller
European States. Stress was also laid on th e necessity of lim iting the Commission as m uch as
Possible in consideration of th e funds available.
The Sub-C om m ittee considered th a t these representations necessarily imposed a regrettable
limitation on th e choice of th e experts w hom th e y could suggest for nomination. In th e circum­
stances, they decided to recom m end th a t D r. J i t t a and Dr. N orm an W hite, two very experienced
and distinguished hygienists, should be appointed.
Dr. J i t t a prom ised to give his definite answ er as soon as he should have had time to consult
his Ministry.
A letter from th e P rince of Siam w as also read. In this letter he urged th at, as a preliminary,
the Commission should a tte n d th e B angkok Conference, which was to be held, under the auspices
of the League of R ed Cross Societies, a t th e end of November, and which would be discussing
questions of in tere st to th e League. I t was accordingly decided th a t a t least one of the members
of the Commission should tak e p a rt in th e Conference, an d Dr. N orm an W hite was asked to make
the necessary arran gem ents in order to be able to sail in tim e to be present a t it.
It was fu rth e r decided t h a t th e Commission should, subject to th e assent of the Governments
concerned, visit th e following places :

B om bay,
C alcutta,
Singapore,
B atav ia,
B angkok,
Saigon, H an oi a n d H aiphong,
H ong-K ong,
Form osa,
Shanghai,
Kobe, Y okoham a,
an d p erh ap s th e Philippines.

After th e m eeting of th e Com m ittee, D r. J i t t a inform ed th e m em bers th a t he was unfortunately

not able to join th e Commission as his M inistry could n o t gran t him sufficiently long leave.
Accordingly, a th ird m eeting of th e Sub-C om m ittee was held in Paris on October 26th. I t
was considered im possible to o b tain a t sh o rt notice th e assistance of other hygienists who would
comply w ith th e conditions w hich h ad been accepted a t th e last meeting, having regard to the very
imited time available. T he Sub-C om m ittee, therefore, did n o t suggest the nom ination of another
member in su b stitu tio n for Dr. J itta . I t w as ascertained t h a t Dr. N orm an W hite’s services could
ie made available a t once an d th a t he h a d provisionally m ade arrangem ents to proceed to the
"ar East in tim e for th e Conference a t B angkok to which reference has been made above.
In the circum stances, th e Sub-C om m ittee recom m ended th a t, w ithout prejudice to proposals
in a future y ea r fo r a m ore exten d ed mission, Dr. N orm an W hite should be entrusted, after
completing his visit to B angk ok, w ith th e d u ty of visiting the different countries which had been
ecided on in th e F a r E a st, a n d th a t, so far as practicable in th e circumstances, he should himself
obtain the inform ation a n d m ak e th e necessary visits on the lines of the m em orandum which had
been prepared to in dicate th e objects of th e mission.
The C om m ittee learned t h a t it was th e intention of th e Surgeon-General of th e United States
’ublic H ealth Service to ta k e ad v an tag e of th e F a r E astern Commission and to commission one
'fits experts to accom pany D r. N orm an W hite on th e to u r of inspection, or a t least for some p a rt
it. I t was considered th a t th is arrangem ent should be m u tually helpful.
Dr. N orm an W h ite left for th e F a r E a s t on N ovem ber 3rd, and interim communications have
®ce been forw arded b y him from B angk ok and from Singapore.
 — 6o —

Annex 5.

Letter from the Director of the North Manchuria Plague Prevention Service to the
Chairman of the Health Committee.

H a r b in , C h in e , S eptem ber 27th, 1922.

Sir,
Our G overnm ent has forw arded m e a copy of th e R ep o rt of th e H ealth C om m ittee of the
League of N ations, d ate d J a n u a ry 6th, 1922, which contains, am ong o th er things, th e following:

Para. 6.— The Jap an ese m em ber of th e C om m ittee drew a tte n tio n to th e very serious
problem of th e incessant prevalence of pneum onic plague in M anchuria a n d Siberia.
The H e a lth C om m ittee declared itself generally in favo ur of sending a Commission of
E n q u iry to M anchuria and Siberia, etc.

I beg leave to inform you t h a t th is sta te m e n t is n o t q u ite accurate, for, alth ough plague has
been rep o rted alm ost every year,either in th e bubonic or pneum onic form, in Siberia, which possesses
m a n y endem ic centres, Manchuria has only been visited b y plague on tw o occasions, namely :
O ctober 1910— A pril 1911, an d S eptem ber 1920— May 1921.
On b o th occasions, th e early cases h a d travelled from th e endem ic spots in Siberia. Manchuria
itself has no endem ic areas, a n d all bacteriological exam ination s of ra ts a n d m arm o ts living in
these regions h ave proved negative for plague.
L ast week, before seeing your R ep o rt, I sent your C hairm an a copy of our scientific Report,
in which you will find original investigations up on th is interesting problem .
W e shall be glad to show your rep resentativ es, w henever th ey come, o u r specim ens and offer
th em a n y inform ation th e y m ay need.
Y ours faithfully,
(Signed) Wu L ien T eh , M.D. (Cantab.),
D irector a n d Chief Medical Officer.
 Annex 6.

P r o p o se d C o- o p e r a t io n betw een the H e a l t h Se c t io n o f t h e L ea g u e of N a t io n s

and the I n t e r n a t io n a l S a n it a r y B u r e a u .

Letter from the Union Panamericana to the Medical Director.

O f ic in a Sa n it a r ia I n t e r n a c io n a l ,

W a s h i n g t o n , N ovem ber 22nd, 1922.

My dear D r. R ajch m an ,
I am sending to you b y th is m ail a copy of th e Proceedings of the Sixth In tern atio n al Confe­
rence, held a t M ontevideo, to g eth er w ith copies of the B ulletin of th e In tern atio n al S anitary Bureau,
which is being pu blished from th e offices of th e B ureau, situ ated a t th e PanA m erican Union at
W ashington.
I t has occurred to m e th a t it w ould be entirely possible and highly desirable to work out a
plan of co-operation betw een th e H e a lth Section of th e League of N ations and the International
Sanitary B ureau, w hich confines its activ ities to th e republics of th e Am erican Continent.
The w ork to be accom plished is so g reat th a t every effort should be m ade to avoid duplication
of effort, an d it has occurred to m e th a t, throu gh such co-operation, th e International S anitary
Bureau, established a t th e P anA m erican U nion, m ight serve as a clearing-house for inform ation
relating to th e coun tries of th e A m erican C ontinent.
I have n o t as y e t p resen ted th is to th e G overning B oard of th e In ternatio nal Sanitary Bureau,
as I am first anxious to secure y o ur views w ith reference to th e situation.
I beg to rem ain,
Very cordially yours,
(Signed) L. S. R o w e .
Dr. L udw ik R a j c h m a n ,
Director, H e alth Section,
League of N ations,
G eneva.
 — 62 —

Annexe 7.

I nterchange of P u b l ic H ealth P erso nnel.

R e fo r t by M . 0. Velghe.

In conform ity w ith th e decision ta k e n b y th e H e alth C om m ittee, th e first interchange of

public h e a lth personnel from v ario u s coun tries took place in B elgium d u rin g th e last quarter
of 1922.
T h e C om m ittee will no d o u b t wish for full info rm atio n on th is experim ent, especia’ly as it
decided to aw ait its resu lts before ta k in g an y definite decisions on th e o rg an isatio n o f future
experim ents. T his is m y reason for su b m ittin g th e p re se n t R ep o rt. I t w ould ce rtain ly have teen
preferable to e n tru s t th e d ra ftin g of th e R ep o rt to an o th e r m em ber. B u t it w as suggested th a t I
was b e s t qualified to give an acco u n t of a n ex perim ent in w hich I alone of all th e m em bers of the
C om m ittee h ad ta k e n p a r t from beginning to end. I consented th erefo re to u n d e rta k e this work,
b u t in te n d to lim it m yself to a s ta te m e n t of th e facts an d to a re p o rt of th e opinions o f the
p u b lic h e a lth officials who to o k p a r t in th e first experim ent.
I t opened on O ctober 8 th w ith a series of lectures an d v isits to h e a lth in stitu tio n s, hospital
estab lish m en ts an d p u blic h e a lth in stallatio n s.
T he first period of w ork lasted u n til N ovem ber 3rd, th e following w eek being devoted by all
th e re p rese n ta tiv e s to stu d y in g questions an d visitin g services o r estab lish m en ts w hich specially
in tere ste d them a n d w hich h a d n o t been included in th e general program m e o r h a d not, in their
opinion, been given sufficient prom inence.
T his course of stu d y an d in v estig atio n w as a tte n d e d b y tw en ty -on e officials, tw o Belgians,
one B ulgarian, four Italian s, five Poles, five R ussians, two Serb-C roat-Slovenes an d two Czecho­
slovaks.
A large n u m b er of officials from th e B elgian H e alth A d m in istratio n a n d c e r t a i n delegates from
th e A rm y H e alth Service and directors of h e a lth offices in the p rin cipal B elgian Communes also
a tte n d e d reg u larly th e lectures an d inspections.
O n N ovem ber 10th, th e h ea lth officers dispersed to th e vario us co u n tries in which they were
to undergo courses of p ra ctical in stru ctio n , th e m a jo rity of th em — one B elgian, one Bulgarian, five
Poles, one R ussian, one Serb-C roat-Slovene an d tw o Czechoslovaks— going to R om e, where they
w ere joined b y tw o A u strian s whose ap p o in tm en t b y th e ir G overnm ent h ad b een m ade somewhat
late. F o u r Italian s to o k a course in P oland, one B elgian in th e N eth erlan d s, one Serb-Croat-
Slovene an d four R ussians in Belgium .
B efore beginning th e ir p ra c tic a l course in Ita ly , th e officials ap p o in ted for a course in that
c o u n try a tte n d e d a series of lectures specially organised for th em b y o u r em inent colleague, Dr.
L utrario.
All m em bers ta k in g th e course were asked to send to th e H e alth S ection of th e L ea g u e 01
N ations, before com pleting th e p ra ctical course, a re p o rt in answ er to a q u estio n n aire dealing both
w ith th is course of p ra ctical in stru c tio n an d th e lectures an d visits.
These h ea lth officers finally m et a t G eneva on D ecem ber 17th an d 18th, to exchange views
on th e principle an d m eth ods of in terchang e of p u b lic h ea lth personnel.
W e give below a su m m ary containing th e conclusions of these re p o rts an d discussions.
General Remarks. — T he ob ject of th e interchange of public h e a lth perso nnel is to give persons
tak in g p a rt in such interchange som e insight in to th e h ea lth legislation an d in to th e organisation
of th e h ealth services in o th er countries, an d to give them an o p p o rtu n ity of learning how hean
questions have been solved in practice an d th e m ethods of applying G overnm ent regulations
Such interchanges, m oreover, help to estab lish closer relatio ns betw een public h ea lth o f f i c i a l s , w
inspire them w ith a com m on esprit du corps a n d a com m on ideal of progress an d the uni
catio n of h e a lth regulations.
O ur experience was decisive in all these respects. All officers ta k in g th e course agreed ■
layin g em phasis upon th e g re at a d v a n tag es arising from such interch ang es an d in s ta tin g how muC
benefit th e y h ad derived from th e first experim ent. ;
T hey were also unanim ous in s ta tin g th a t th e b est system was th a t of subdividing the cours
in to stages consisting of lectures, v isits a n d p ra ctical in stru ctio n , followed b y a final d iscu ssio n '
T hey all reg retted , n o t t h a t th e program m e of lectures an d inspections h a d been too long,
th a t it h ad n o t been possible to d ev ote m ore tim e to it; in view of th e g re a t nu m b er of subje
to b e d ea lt w ith, th ere was h a rd ly sufficient tim e for s tu d y a n d research.
 — 63 —

It was also recognised t h a t tw o m ain categories of m edical h ealth officers had a special interest
in such interchanges: general p ra ctitio n e rs an d specialists. Am ongst the la tte r we m ust d istin­
guish between d o ctors who w ork in h e a lth laboratories and h ealth officials whose duties are lim ited
to a single subject, such as th e cam paign ag ain st m alaria and tuberculosis, child welfare, protection
of workmen from professional diseases, etc.
The system of in terc h an g e will n a tu ra lly v ary according to th e category under consideration
W ith reg ard to in terch an g e of m edical h ealth officers who are general practitioners, it was
also agreed th a t, in o rder to o b ta in th e b e st results, i t was essential to employ the most homogeneous
system of grouping possible, an d it w as th o u g h t th a t officials taking th e course should, in order
to derive full benefit, possess som e experience an d hold or be likely to hold in th eir respective admini­
strations a position carry in g w ith it powers of in itia tiv e and direction, and affording an opportunity
of exercising m ore or less w ide influence.
Under these conditions, m oreover, officials of cen tral adm inistrations and those of the executive
services could b o th ta k e p a r t in such interchanges.
As th e G overnm ents w ere n o t supplied w ith ad equate inform ation regarding the m ethods on
which th e first experim en t w as to be conducted, those who sent delegates were unable to m ake a
selection w hich w ould have assured a n ad equately hom ogeneous grouping of the health officers
taking p a r t in th e experim ent.
I t was agreed th a t th e length of th e period of interchange could not be fixed in advance.
The courses for h e a lth officers who are general p ractition ers m ust necessarily be more comprehensive
than those in ten d ed for specialists, an d th e h ealth organisations in th e various countries differ
widely, th eir in stitu tio n s v a ry in n um ber, and all countries have not reached the same standard
of education in h ea lth questions.
Lectures.—A ccording to D r. L u tra rio ’s R eport, th e subjects dealt w ith a t the lectures were
to be the m ethods em ployed b y th e h ea lth services in Belgium, her general and health legislative
system, th e ch aracteristics of h er political, m unicipal and health organisations and the present
state of public opinion regarding th e various h ealth problem s now under investigation. I t was
also agreed t h a t a course should be given on in ternational prophylaxis.
In accordance w ith R esolution I I voted last A ugust, th e theoretical courses were lim ited to
a statem ent regarding ad m in istrativ e legislation and organisation.
T w enty-six lectures w ere given in Belgium upon the following subjects :

In te rn a tio n a l H e alth P rophylaxis ;

B elgian H e a lth O rganisation;
G ov ernm ent H e alth Insp ection ;
D isinfection in B elgium ;
O rganisation a n d M ethods of th e G hent H ealth B ureau ;
P o p u la r H e a lth P ro p ag an d a ;
R eform of N ursing S isters’ an d M idwives’ Courses ;
W orking-Class H ouses in B elgium ;
W orking-Class H ouses an d G arden Cities in Belgium ;
R eco nstru ction of th e D ev astated Areas ;
W aterw orks S ystem ;
C am paign ag ainst Tuberculosis in Belgium ;
P rov incial A nti-T uberculosis Service in E astern Flanders;
P ro p h y lax is ag ainst V enereal Diseases, together w ith propaganda films;
V enereal Diseases, illu stra ted w ith lan tern slides;
C ancer C am paign;
N atio n al Child W elfare W ork;
M edical Inspection of Schools an d Physical T raining;
Professional R esearch W ork;
S pa T herm o-M ineral W aters;
M edical Insp ectio n of L abour in Belgium ;
P roph ylaxis ag ain st A nkylostom iasis;
R elatio ns betw een th e G overnm ent H ealth Service and the A rm y H ealth Service ;
S a n ita ry O rganisation in th e U nited S tates of America. ^

Those p resen t were of opinion th a t, w ith th e exception of one, all th e lectures were practical
and com pletely fulfilled th e ir object.
No one com plained t h a t th ere were too m any. C ertain h ealth officers even regretted th a t it
had not been possible to to u c h u p o n certain other subjects as well.
A sum m ary of these lectures w as afterw ards d istribu ted to th e audience. I t would have been
better to d istrib u te th e sum m ary before th e lecture, thus m aking it easier for those taking part,
and especially for those w ith an insufficient knowledge of th e language, to follow the lecture,
to ask questions upon p o in ts n o t fully dealt w ith or to s ta rt a discussion on such subjects.
This d isad v an ta g e m ay have been m itig ated to a certain ex te n t b y th e fact th at, having
been for several weeks in to u ch w ith Belgian h ealth inspectors, these officials had opportunities
f°r obtaining from th e form er a n y sup plem entary inform ation they desired.

Inspections.— F ifty -six visits were m ade to the following in stitu tio n s and establishm ents.

D isem b ark atio n from a vessel a t A ntw erp ;

Q u aran tin e s ta tio n on th e Scheldt at Dool;
 — 64 —

H o stel for em igrants ;

D elousing sta tio n of th e R ed S ta r Line Shipping C om pany;
S ta te vaccin ation office a t C ureghem ;
G overnm ent disinfection establishm ent in th e province of E a ste rn Flanders;
L ab o rato ry of th e Public H e alth D e p artm en t of th e M inistry of th e In terio r and of
H e alth ;
G overnm ent h ea lth inspection lab o ra to ry a t B ruges;
Social h ea lth dispensary a t R oulers ;
G hent H e alth Office;
O stend H e alth Office, w ith bacteriological lab o ra to ry an d disinfection station;
Provincial an aly tical establishm ent of E a ste rn F lan d ers ;
P rovin cial h ea lth and bacteriological in s titu te of N am u r;
H e alth in s titu te of th e province of H a in a u lt an d H e alth M useum a t Mons;
H e alth in s titu te of G hent U n iv ersity an d H e alth M useum ;
E d ith Cavell p riv ate nursing school a t B russels ;
P riv a te nursing school of St. Cam illa a t B russels;
P rovincial nursing school a t C harleroi ;
N urses' hom e a t G hent ;
B ruges m a te rn ity hom e;
B a ta v ia G arden C ity a t R oulers ;
Ligy Cité a t Y pres;
K a lfv aart Cité a t Y pres;
C atchm ent in stallatio n of th e w aters of th e B ocq;
F ilterin g R eservoir of th e V ial system a t O stend ;
A utom atic pum ping statio n for th e resid uary w aters a t O stend;
“Lizzie M assily” san atorium a t W estm ael-lez-A nvers ;
A n ti-tuberculosis dispensary a t G hent ;
Sanatorium a t M ont-sur-M euse ;
M en’s and w om en’s san ato ria a t H airé;
Men’s san ato riu m a t B orgoum ont ;
W om en’s san ato riu m a t M aguée ;
St. Idesbald sanatoriu m a t H o uthen-lez-F um es ;
A nti-venereal dispensary of th e “C entral-K linick” a t A ntw erp ;
P ro stitu te s' hosp ital a t Liège ;
Cancer in stitu te a t Brussels ;
M aternity hom e a t A ntw erp ;
School for th e m en tally deficient a t R ix en sart ;
C onvalescent hom e for children a t S toum ont ;
M others’ an d in fa n ts’ w elfare cen tre a t Liège ;
“Le N id ” a t Ixelles ;
T he “C entrale Ju m o i” dairy a t Gozée;
O pen-air sanatoriu m for children a t M arcinel es;
School show er b a th s a t Schaerbeek ;
School sw im m ing b a th a t Schaerbeek ;
School clinic a t Schaerbeek ;
Open-air school a t Schaerbeek ;
School canteen a t Schaerbeek ;
M edical service for G hent schools ;
Model secondary school ;
C ripples’ school ;
B ath s in stitu te a t Spa;
C atchm ent of th e "M arie-H enriette” spring a t Spa;
C atchm ent of th e “L a R eine” spring a t Spa;
D ispensary for parasitical skin diseases ;
A n ti-ankylostom iatic dispensary ;
L abour U niversity.

All these visits provided practical lessons th e usefulness of w hich th e m edical h ealth officers
fully appreciated. In all cases th e y were preceded or accom panied b y a lecture explaining the
w orking of th e organisation in question, in order to p o in t o u t its in d iv id u al features.
One foreign delegate was of opinion t h a t certain instances of overlapping m ight have been
avoided, such as visits to hospitals or com m unal h ea lth offices, an d t h a t it w ould have been better
to h av e devoted th e tim e th u s gained to th e inspection of in d u strial establishm ents.
As h as already been said, it was found possible to satisfy, to a ce rtain ex te n t, th e p a rtied 3
desire th u s expressed b y m eans of individual visits organised a fte r th e collective visits of th e de e
gates. To have acted otherw ise— t o have conducted all th e delegates th ro u g h th e innum era e
bran ches of th e P ublic H e alth Service— w ould have required m uch longer tim e. H o w e v e r, t !-
observation m akes clear th e necessity of ta k in g in to account, in organising exchanges, th e characte
of th e occupation and th e degree of specialisation of th e h ea lth officers tak in g p a rt therein.
Course of Practical Instruction. — A t th e beginning of th is re p o rt we po in ted o u t th a t, in °r^e_
to com plete th e ir course of p ractical in stru ctio n , h ea lth officers were sent to various countn
an d th e y h av e everyw here been m ost cordially received. , is
In his well-considered an d lucid re p o rt, M. L u tra rio h as alread y p o in ted o u t that 1
system of subdivision gave rise to ce rtain difficulties, an d his opinion w as sh ared b y severs
 *5 -

our colleagues a t th e A ugust session. The object of th e prelim inary lectures was to introduce the
foreign health officers to th e legislation an d political and h ealth organisation of the country in
question, and also to th e m e n ta lity , observances and custom s of th e p o p u la tio n .
T h o se who to o k p a r t in th e B russels exchange recognised th e necessity f o r these prelim inary
lectures and em phasized th is im p o rtan ce — lectures, visits and practical course f o r m a logical
whole. In order to u n d e rs ta n d th e w orking an d results of th e h ealth organisation o f any country
we are told it is essential to know, first of all, th e elem ents of th e general geography, physical geo­
graphy, and even eth n o g ra p h y of th e co u n try visited ; secondly, the political legislation and adm i­
n istrativ e organisation resu ltin g therefrom , th e social legislation, w ith th e public and private orga­
nisations which h av e d eveloped a s a re su lt of its application, an d health legislation, th e organisation,
both governm ental, provincial, d e p a rtm en tal, com m unal or m unicipal; and lastly, th e m ethods
employed for app lying in te rn a tio n a l h ea lth conventions.
If this is so, th e p ra ctical stage of th e course of in stru ctio n can only be profitable if it takes
place in the co u n try in w hich th e lectures a n d inspections have been organised; this has been deci­
sively shown b y th e first experim ent. B u t, as was pointed out during our last session, in order to be
able to organise a course of p ra ctical in stru ctio n u nder these conditions, it will be necessary to
limit the num ber of stu d e n ts to a s tric t m axim um of tw enty-five or th irty .
The h ealth officers w ere unanim o usly of opinion th a t th e practical course is th e m ost essential
part of the exp erim en t, an d t h a t i t m u st b e regarded as of g reater im portance th an lectures and
inspections, th e only ob ject of w hich is to prepare for th is practical course and to render it easier
and more profitable.
Should th is p ra ctical course ta k e place individually or collectively ? Opinions on this point
vary, and it w ould a p p e a r p referab le to leave it to the organisers to decide according to circum-
tances. I t has been recognised, how ever, th a t a practical course organised on collective lines m ay
preferable to a n in d iv id u a l one, provided it is lim ited to a very sm all num ber of students.
Moreover, a sm all n u m b er w ould b e desirable in respect of visits of inspection, and even, to a
certain extent, lectures also, as th ese would th en become more intim ate in character and would
more readily afford an o p p o rtu n ity for questions and discussions.
Moreover, th ere was a general agreem ent th a t the course of practical instruction should be
completed in various d istricts of a different ch aracter — urban, rural, industrial, seafaring, etc.

Conclusions. — i. T he first ex perim ent in interchanges betw een th e h ealth personnel of

various countries w as a com plete success. A p a rt from certain m atters of detail, th e chief of
hich is, u n d o ub tedly , th e co n cen tratio n of lectures, visits of inspection an d a practical course
n one and th e sam e c o u n try , th is first experim ent m ay serve as a m odel for fu ture organised
xchanges.
But it is im p o rta n t t h a t th e organisers should n o t be ham pered b y being confined within
duly narrow a n d rigid lim its. The diverse ch aracter of th e h ealth organisations of th e various
ountries should re n d er it possible to ad o p t w hatev er m ethods m ight be considered desirable.
It is indeed only b y experim enting w ith new m ethods th a t it will become possible to appraise
eir merits an d fu rth e r th e progress of th e in stitu tio n .
2. The prog ram m e of fu tu re experim ents will have to be m ade known in sufficient tim e to
able the h ea lth ad m in istratio n s in v ited to ta k e p a rt therein to m ake a suitable selection from
“ong their officials. T he m ore hom ogeneous th e grouping of th e h ealth officers appointed, the
ore fruitful will b e th e results.
In this connection, th e C om m ittee would do well to decide th a t tw o of the four experim ents
o be organised in 1923 should be allo tted to general practitioners an d th a t two should be reserved
or specialists ; one of th ese la tte r should be allo tted to assistants in h ealth laboratories and the
ther specialists in one p a rtic u la r disease, such as m alaria. The average period for th e la tte r two
experiments w ould b e six weeks.
3. The actio n ta k e n b y th e R ockefeller F oundation was inspired by a desire to s ta rt th e new
institution in o rder th a t, w hen its usefulness h ad been fully dem onstrated by facts, th e League
f Nations should b e able to ensure its continuance. A credit of 100,000 francs for th e purpose of
hering th e o rg anisation of closer relations betw een th e health services of the world was applied
or, for this purp ose (R esolution III ad o p ted a t th e m eeting held on A ugust 17th, 1922). In
rder to afford th e R ockefeller F o u n d atio n guarantees of perm anence, th e League of Nations
hould a t once, u n d e rta k e to b ea r p a r t of th e expenses involved b y th e interchange of health
rsonnel, an d it w ould be desirable for th is share to be successively increased in th e following
ears, in order to cover th e whole of th e expenses when th e assistance given b y th e Rockefeller
oundation com es to an end.

5
 — 66 —

Annex 8.

IN T E R C H A N G E O F PU B L IC H E A L T H P E R S O N N E L IN ITA LY .

(N ovem ber n t h to D ecem ber 16th, 1922.)

B y D r. L u t r a r i o

I.

T he first experim ental interchange of public h ea lth personnel in Italy , w hich took place
from N ovem ber n t h to D ecem ber 16th, 1922, m ay be divided in to four periods.
T he first was sp en t in Rom e, an d was d ev o ted to a series of lectures designed to give a general
idea of th e Ita lia n organisation of public h ea lth an d th e m anner in w hich certain problem s relating
to public h ea lth h ad been solved in Ita ly , an d to excursions for the purpose of examining tit
op eration of th e various h e a lth in stitu tio n s.
T he second period, sp en t outside Rom e, w as devoted to th e exam ination of h e a lth institutions
w hich are of exceptional im portance in th e field of public health .
T he th ird period was m ore specially d ev o ted to a detailed consideration of th e manner in
w hich th e principles of Ita lia n h ea lth legislation are ap plied in th e provinces an d th e communes.
T h e fo u rth period, w hich was a very sh o rt one, was sp en t a t Milan, w here th e visitors met
before th e ir d ep a rtu re fo r G eneva.

First Period. — Rome, November n t h to 22nd.

T he visitors were in v ite d on N ovem ber n t h to th e Office of P ublic H ealth b y th e Director-
G eneral of P ublic H ealth, who m ade a general s ta te m e n t of th e program m e of w ork which had
been plan n ed ; th e program m e w as approved b y th e visitors, by th e D irector of th e H ealth Section
of th e S ecretariat of th e L eague of N ations an d b y th e Medical D irector of th e Rockefeller
F o u n datio n.
T he first w orking day, N ovem ber 12th, w as dev o ted to a visit to H a d ria n ’s Villa, near Tivoli,
where th e im posing rem ains still m ake it possible to visualise w h a t was know n in im perial Roman
tim es as th e P a la tiu m ; special a tte n tio n w as given to ce rtain constru ctio nal featu res : mortars,
for instance, th e various b uildin g m aterials, an d th e arrangem ent of th e room s, including the
prem ises specially devo ted to physical culture, th e "pœ cile”, b ath s, etc.
O n th e m orning of N ovem ber 13th, P rofessor D evoto, D irector of th e Clinic for Professional
an d O ccupational Diseases in M ilan, lectured, (in th e M icrographical and B acteriological Laboratory
of th e Office of P ublic H ealth ), on th e "H ealth P rotectio n of L abou r".
In th e afternoon a visit w as p aid to th e F o ru m an d th e P alatin e, w here th ere are the most
ancient existing exam ples of sew erage an d su b te rra n e a n d rains (some of w hich are still in working
order), and of o th e r s a n ita ry works, such as dam p-proof courses, various system s of tom bs, dispo­
sition of corpses, etc.
On N ovem ber 14th, Professor G asparini, H e a lth Officer of th e c ity of F lorence, delivered 1
lecture to th e visitors on th e supervision of m ineral springs and bath s, w hich abound in Italy,
an d w hich are su b ject to special provisions u n d er recen t law s an d regulations.
In th e afternoon, a visit was paid, first to th e Museo N azionale (B aths of Diocletian) ana
th en to th e m agnificent B ath s of C aracalla. T h e visitors were th u s able to form a n idea of the
variou s system s of m edical an d surgical th era p eu tics an d of physical cu ltu re used b y the ancient
R om ans, who a tta c h e d g re at im portance to these m atters.
On N ovem ber 15th, Professor Di V estea, D irector of th e H ealth In s titu te of th e University
of Pisa, lectured on p ro phylactics again st tuberculosis, w ith special reference to th e propaganda
w hich should be m ade b y th e S ta te an d b y o th e r public or p riv ate in stitu tio n s an d individuals
Such pro pagand a is clearly necessary in o rd er to encourage th e public to co m b at the disease
F inally, th e lecturer gave d etails of th e m eth o d s w hich he h ad form erly recom m ended a n d wh'c
are a t present ad o p ted in Ita ly , if n o t com pletely, a t least in p a rt.
In th e afternoon, a visit was paid to th e Ita lia n R ed Cross Sanatorium , “Cesare B attis» >
bui'.t on th e M onteverde Hill.
A fterw ards a visit was paid to the new general hospital, “L a V icto ire”, w hich is being c011
stru c te d through the good offices of th e Pio In s titu te di S. Spirito ed Ospedali R iuniti di K°®3
W hen com pleted, th e h o sp ital will be able to accom m odate 1,500 patients.
On N ovem ber 16th, th e M a'ariological School of N ettu n o was visited an d Professor Gos'j1
D irector of the M icrographical an d B acteriological L ab o rato ry of th e Office of Public Hea* 1
m ade first a sta te m e n t on p rop aganda as th e best au x iliary of th e cam paign against
T he lecture was given, as sta te d above, in th e a p a rtm e n ts of th e M alariological School,
in stitu tio n is entirely Italian . I t was founded b y th e Office of P ublic H ealth in order to tra
 — 67 —

the best efforts of th e c o u n try to th e ap plication of th e various m inor measures recognised as most
effective in the cam p aig n ag ain st m alaria, the u tility of w hich is now accepted w ithout question
particularly as a necessary com plem ent to th e m ore im p o rtan t measures of prevention.
The lecture w as followed b y a d em o n stratio n of th e various m ethods used and of their appli­
cation in practice.
On returning, a v isit was p aid to th e M ilitary H ealth Cam p a t Anzio, established along the
seashore in th e m id st of a p ine forest, consisting of m ovable structures for the accommodation of
tuberculous soldiers.
On N ovem ber 17th, th e m orning w as sp en t in visiting th e “Preventorium E . M ariani”,
administered b y th e Ita lia n R ed Cross. T his in stitu tio n receives infants bom from tuberculous
parents im m ediately a fte r th e ir b irth . T he infants have th e advantages of treatm ent in sur­
roundings free from a n y tu berculo us infection, an d th ey rem ain there u n til th e age of three years.
The visit to th e in s titu te w as m ad e u n d e r th e guidance of Professor Valagussa, who delivered
a lecture sta tin g his view s on la te n t tuberculosis in infants.
In the afternoo n a v isit w as p aid to th e In s titu te of Puériculture a t St. Gregorio al Celio.
The fo u n d atio n of th is in stitu tio n w as due to th e initiative of the Office of Public H ealth,
which continues to afford i t effective su p p o rt. I t aim s a t spreading the observance of health rules
in the feeding of in fan ts, e ith er b y th e ir m others o r foster-m others or by artificial foods, a t educating
young girls for th e profession of children ’s nurses, and a t inculcating into young teachers in country
schools the ru d im en ts of child welfare.
In order to c a rry o u t th is huge task , th e in stitu tio n has special sections devoted to foster-
children, to w eaned children, to nu rsing classes, etc.
On N ovem ber 18th, in th e m orning, S enator Sanarelli, D irector of th e H ealth In stitu te of the
University of R om e, lectu red on “F resh Views on P athogeny an d the Prophylaxis_of Infectious
Diseases of th e In te stin e s
In th e aftern o o n a v isit w as p a id to th e tw o in stitu tio n s specially devoted to the care of chil­
dren, i.e., th e A nti-M alarial S an ato riu m of G ro tta F e rra ta an d th e Anti-Tuberculosis Sanatorium
of Ariccia. B o th are in th e A lb an hills, a n d th e first, w hich was founded b y p rivate in itiative and
is supported b y th e Office of P u b lic H ealth , receives m alarial children, who are given th e benefit
of the best an ti-m ala rial p ro p h y lax is an d receive an education designed to fit them m ore p a rti­
cularly for ag ric u ltu ral p u rsu its, since th e little p atien ts are nearly all th e children of peasants.
The A nti-T uberculosis S an ato riu m of Ariccia, w hich m ust be regarded as an am algam ation
of a charitab le in stitu tio n su p p o rted b y a R om an p atrician fam ily and th e adm irable initiative
of a political R o m an new spaper (the Giornale A’Italia), receives poor children who have tendencies to
tuberculosis, o r who are suffering from tuberculosis of th e bones or o th er form s of local tuberculosis.
On N ovem ber 19th, an excursion w as m ade to th e ancient tow n of Ostia which was the
Aemporium of rep ublican a n d im perial R om e, where the san itary installations of th e ancient
Romans, a n d p a rtic u la rly th e plan of th e city; and th e lead pipes for supplying the town with
drinking w ater, th e drains, public lavatories, dom estic architecture, m arkets, etc., can still be
examined.
On N ovem ber 20th, Professor A lessandrini, Professor of P arasitology at the U niversity of
Rome, lectu red in th e m orning on th e problem of th e prophylaxis of exanthem atic typh us in
relation to th e biology of lice, lay in g stress upon th e necessity of using m ethods in the cam paign
against verm in co m m en surate w ith th e m eans of defence w ith which these parasites are provided.
In th e afternoon th ere w as a p ra ctical dem onstration of m ethods in use in the cam paign against
vermin and even of p re v en tiv e m easures. Info rm ation was also given in regard to the emergency
and other m eth o d s ad o p te d b y th e Office of P ublic H ealth w hich enabled th a t office to equip
without d elay a com plete sa n ita ry sta tio n specially ad a p ted for th e prophylaxis against typhus,
including delousing sections, disinfectin g sections, sections for m edical inspection, isolation of
p atien ts, etc., etc.
On N ovem ber 21st in th e m orning, th e D irector-G eneral of Public H ealth, Dr. L utrario,
explained th e organ isatio n of th e h ea lth services in Italy.
After explaining th e fu n d a m e n tal conception of th e Ita lia n health legislation (which is based
on the cen tralisation of th e v arious activities, w ithout, however, suppressing local initiative), the
Director-General exam ined th e m an n e r in which this conception h ad been p u t into effect b y the
original law of 1888 a n d b y sub seq u en t legislation which co n stitu ted an orga.nic whole, a t once
simple and com plex, elastic a n d powerful, conceived w ith a view to encouraging and supporting
local initiative a n d a t th e sam e tim e of co-ordinating, regulating an d directing these efforts to the
desired end.
The D irector-G eneral th e n proceeded to exam ine th e organisations an d the work of the Italian
Health A d m inistration. . . .
As regards its executive organs, these m ight be considered first as individual and collective
by reason of th e ir n a tu re a n d th e ir co nstitu tio n ; b ut, from th e point of view of their functions,
they might be grouped in four categories, th a t is to say, direction, action, consultation and scien 1 c
research.
In regard to th e ir functions, th e D irector-G eneral m ade a com plete survey, though necessarily
a brief one, of th e m a tte rs re g u la ted b y h ea lth legislation and p articu larly : , ,
. (a) th e various form s of m edical, surgical, obstetrical, pharm aceutical and nospi a ®a .
d is ta n c e ; (6) th e o rg an isatio n of th e services of prev ention against infectious diseases, (c)
various form s of sub vention an d co-ordination b y th e S tate, eith er in th e form of m oney or >
e use of th e S ta te p ro p h y lac tic equ ipm ent, o r b y th e provision of the services of a specia lse
Personnel in the case of epidem ic o u tb rea k s in th e kingdom ; or b y subsidies or loans a. in e
or the establishm ent of w orks of public h ea lth , th e installations for the supply of drinking wa ,
Aqueducts, etc.
 — 68 —

F inally, th e D irector-G eneral referred to th e m ore im p o rta n t w ork accom plished in the field
of public h ealth, such as u rb a n san itatio n , prev en tiv e m easures against m alaria, acqueducts
p ointin g o u t th e a d v a n tag es derived b y Ita ly from th ese m easures, w hich are confirm ed by bio­
m etrical statistic s.
On th e sam e day, in th e afternoon, th e D irector-G eneral show ed th e visitors the various
and com plete pro p h y lactic equipm ent of th e Office of P ublic H ealth . This dem onstration took
place in th e cen tral depot of prop hylactic equipm ent, a huge b uilding ex ten d in g over 6,000 square
m etres, to w hich are attac h ed w orkshops for th e rep airin g of m edical p lan t, etc.
On N ovem ber 22nd, Professor D ucrey, D irector of th e D erm atological Clinic, of th e University
of R om e, lectu red on th e prop hylaxis of venereal diseases, an d o u tlin ed th e fu n d am en tal features
of th is pro p h y lax is an d th e legal provisions an d regulations in force in Ita ly . F inally, a visit was
p aid to Professor D u crey ’s clinic an d th e o th er clinics a tta c h e d to th e Policlinico Umberto I,
In th e afternoon a rap id excursion was m ade to th e G arden C ity a t A niene, w hich is under
co n stru ctio n an d will be com posed of a nu m ber of sm all villas an d houses each accommodating
one fam ily.

Second Period. — Naples and Ferrara, November 23rd to December 3rd.

T he kindness displayed b y th e prefects of N aples an d F e rra ra an d b y th e m ayors, w ho extended

th e w arm est welcom e to th e ir guests an d d id every th ing in th e ir pow er to assist them , made the
excursions to N aples an d F e rra ra highly successful.
On N ovem ber 23rd, a fte r th e arriv al of th e p a rty in Naples, a v isit was p aid to the public
lab oratories of h e a lth and sa n ita ry surveillance, w hich consist of tw o sections, th e bacteriology
an d m icrography section an d th e ch em istry section.
N ovem ber 24th was devoted to visiting in stitu tio n s for th e p ro tectio n of ailing children with
tuberculous tendencies an d foundlings. These in stitu tio n s, w hich are situ a te d in some of the most
lovely sp o ts on th e B ay of N aples, are as follow :—
1. T h e “P a u s ilip o n ” In s titu te , consisting of (a) A h o sp ital for the various ran k s of medical
services, to w hich is attac h ed a h elio-therap eu tic statio n , founded b y th e Office of P ublic Health
The h o sp ital is provided w ith prem ises for th e segregation of persons suffering from contagious
diseases an d w ith disinfecting in stallatio ns, (b) T he “ Villa S antobono ” Preventorium , for
children w ith tuberculous tendencies; th e p a tie n ts receive d ietetie and m edical treatm ent and
also go th ro u g h courses of scientific physical culture.
2. T he “ Scugnizzi ” School a t M arechiaro, w hich provides a hom e for foundlings, orphans
an d th e children of tuberculous paren ts. These children are classified in various groups according
to th e ir special ap ititu d es (farm ers, fisherm en, etc.).
On th e sam e d ay a v isit w as also p aid to th e P ie d ig ro tta in stallatio n s — one of the m ost
im p o rta n t p o in ts in th e c ity ’s sewage system . These w orks are of g reat technical in terest, in view
of th e differences of level in th e city of N aples, w hich rises from sea level to a heig ht of 150
m etres.
T he Ita lia n Sero-vaccinogenous In stitu te , w hich is un der th e charge of Professor Bandi,
of th e U n iv ersity of N aples, was th en inspected.
In th e evening “ l ’O rdine dei Medici di N a p o li” held a reception, a t w hich th e president
explained th e aim s an d w ork of th a t body. The guests included th e prefect, th e m ay o r of Naples
an d th e vice-principal of th e U niversity.
N ovem ber 25th was sp en t in visiting th e m ore im p o rta n t of th e T orre A n n u n ziata Works,
w hich m an u fa ctu re m acaroni an d sim ilar p re p ara tio n s (pâtes alimentaires) an d g rin d wheat.
T he various system s used in th e m an u factu re of these cereal p ro d u c ts were exam ined and
also th e sa n ita ry an d p ro phylactic arrangem ents ag ain st th e spread of plague b y rats. These
arrangem ents h av e been in op eration for som e tim e an d h av e been found high ly effective, especially
a t T orre A n n u n ziata, w here, in view of th e large im p orts of co m (abo ut 260,000 q u in tals p er month),
t h e dang er of th e in tro d u ctio n an d dissem ination of plague has alw ays to be guarded against
In th e afternoo n a v isit was p aid to Pom peii, w here, as a t O stia, th e stu d e n ts h ad an oppor­
tu n ity of stu d y in g an ancient city recalling th e glories of im perial Rom e.
The program m e for N ovem ber 2 6th included : (a) A v isit to th e N aples R ed Cross Committee
S an atorium for tuberculous p a tie n ts a t S. G ennaro, n e a r Pozzuoli, situ a te d in a d istrict of the
g reatest b eau ty , w ith a m agnificent panoram ic view of th e sea;
(6) A v isit to the A gnano b ath s, w here th ere are m ineral b a th s of different kinds, therm
b aths, m ud b ath s, a sudatorium , carbonic-acid b a th s an d m assotherapeutic, hydrotherapeutic
and ra d io th e rap e u tic installatio n s ;
(c) A visit to th e Pozzuoli su lp hur deposits, w hich are of g reat in tere st as bein g of volcanic
origin;
(d) An inspection of th e sa n ita ry w ork carried o u t in th e low er p a rt of Pozzuoli, where ttie
soil has long been sinking ;
(e) A visit, a t C apodim onte, to th e g re at reservoirs of Serino d rink in g w ater, which supp*:
a p a rt of th e city of Naples.
On N ovem ber 27th a visit was p aid to th e sources of th e Sele, w here th ere are importa111
catch m en t w orks inten ded for supplying th e provinces of Foggia, B ari, Lecce and Potenza wit
w ater.
T he engineer who com pleted th e design for th e g re a t aq u ed u ct explained th e w o rk in g of the
whole catch m en t system . An account of th e various in stallation s, an d especially those connecte
w ith public h ealth , w as given b y th e h ead of th e A queduct P ublic H e alth Office.
 — 6g —

As a result of a m o to r-car m ishap, th e visitors h ad to spend the night at Contursi and Caposele
I and could not re tu rn u n til th e aftern o o n of th e following day.
a During th e foren oon of N ovem ber 29th, som e of th e p a rty inspected the M aritime H ealth
Service of the p o rt of N aples, a n d especially th e H e alth Office, th e S anitary S tation and the Em i­
gration Services.
In the afterno on th e w hole com pan y left for F errara.
On the afternoon of N ovem ber 30th, a t F errara, in a hall belonging to the " Consorzio
della Grande B onifica F e rra re se ” , th e U nder-D irector-G eneral of Public H ealth lectured on Italian
legislation dealing w ith th e m ore im p o rta n t im provem ent works, stressing its relations between
these works and s a n ita ry law, laws a n d regulations against m alaria, and the m iner im provem ent
works. In th e p ro v in ce of F e rra ra m ore th a n 100,000 hectares of ground have already been
dealt with. T his la n d is alm ost im m une from m alaria and supports a large agricultural popu­
lation. .
December 1st an d 2nd were sp en t in visiting territo ries subjected to this treatm ent, p arti­
cularly in exam ining th e work done a t B ondeno, P ilastresi, A rgenta, B erra, Jo lan d a di Savoia,
Codigoro, L agosanto an d Marozzo.

Third Period. — December <\th to 13th.

During th e period w hich th e visitors sp en t in the various places, the provincial medical officers,
acting in accordance w ith in stru ctio n s received from th e Office of Public H ealth, carried through
the program m e w hich h a d been laid down. T he provincial m edical officers m ade a special point
of supplying th e v isitors w ith inform ation regarding the working of the S tate health services in
the provinces, in o rd er t h a t th e foreign doctors m ight—so far as the lim ited period at their
disposal p erm itted — observe th e w orking of the provincial and com m unal health services.
Details of th e visits in each place are given in appendices 1 to 5.

Fourth Period. — M ilan, December 14th to 16th.

The visitors h a d been invited to m eet a t Milan before leaving for Geneva. On December 14th,
all were present a t th e Office of th e Provincial Medical H ealth Officer in Milan. On the following
day, at th eir own request, th e y visited th e chnic for professional and occupational diseases, of
which Prof. D evoto, th e D irector, gave a m ost interesting account. Finally, on Decem ber 16th,
the whole p a rty left for Geneva.

II.

P articulars reg ard ing th e doctors tak in g p a rt in th e first experim ental interchange of public
health officials.
(«) The following foreign officials w ent to Ita ly :

Austria : Dr. K aiser , D irecto r of th e Epidem iological Section of th e Central Public H ealth
Office, V ienna ;
D r. H aimel, D irector of th e Public H ealth Office in th e Province of G ratz ;
Belgium : D r. H olemans, G overnm ent Public H ealth Inspector, Ghent ;
Bulgaria : D r. Golosmanoff, D irector of th e Infectious Diseases B ranch in the D epartm ent
of P ublic H e a lth ;
Kingdom of the Serbs, Croats and Slovenes: Dr. K r a l je v ic , H ead of th e Bacteriological
S ta tio n a t T re n tin je ;
Czechoslovakia : D r. Bazant, M edical Officer to th e Public H ealth Office, Uzhorod (Czech
R u th en ia) ;
D r. F ügner , M inisterial S ecretary to the M inistry of Public H ealth, Prague ;
Poland : D r. T renkner , Chef de Service a t th e M inistry of Public H ealth ;
Dr. P olack, A cting H ead of the In ternatio nal Conventions B ureau a t the M inistry
of P ublic H e alth ;
D r. A damskj, D irector of th e Public H ealth D epartm ent a t the M inistry of Public
H ealth ;
Dr. Lebrun , E d ito r of Publications at th e M inistry of Public H ealth;
Dr. B ogucki, Chief P ublic H ealth Official in th e city of W arsaw ;

Russia : Dr. P y j o f f , A ssistant D irector of th e Epidem iological Section of th e Ukraine P u b l i c

H e alth C om m issariat.
The th irteen visitors included tw o A ustrians, two Czechoslovaks, one Belgian, one Bulgarian,
°ne Serb-Croat-Slovene, five Poles an d one Russian.
 — 70 —

(b) W ith the exception of Dr. Pyjoff, who arriv ed 48 hours la te owing to form alities at the
frontiers, th e oth er m em bers of th e p a rty reported on N ovem ber n t h a n d all rem ained in Italy
u n til D ecem ber 16th. D r. H eim el, how ever, who was to h av e gone to F lorence, left on December
8 th for G raz, being recalled on pressing public business.
M ention should also b e m ade of th e presence of Dr. R ajchm an, M edical D irecto r of the Health
Section of th e S ecretariat of th e L eague of N ations, who rem ained w ith th e p a r ty u n til N ovem ber
17th, an d of Professor G unn, of th e R ockefeller F o u n d atio n , who rem ained u n til N ovem ber
16th. D r. R u lo t, M em ber of th e H e alth Section of th e L eague of N ations, was w ith th e party from
N ovem ber 17th to D ecem ber 3rd, an d D r. P aro di from N ovem ber 13th to N ovem ber 30th.
(c) T he m ost cordial relation s w ere m ain tain ed th ro u g h o u t b etw een th e visitors and the Italian
public h ea lth auth orities, as well as betw een th e visitors them selves.
I t w ould therefore ap p e ar th a t th e organisers of th e interchange achieved th e ir object of
creating an esprit de corps an d establishing closer friendly relations, w hich, beginning w ith indivi­
duals, m ay lead to reciprocal confidence an d tru s t betw een th e public h ea lth adm inistrations of the
various countries.
(d) All th e h ea lth officers who were sen t to Ita ly show ed g reat keenness, b o th during lectures
an d w hen paying visits of inspection. T hey asked questions w ith th e object of obtaining a clear
idea of th e various organisations an d th eir functions. T hey freq u en tly to o k n o tes of the main
po in ts discussed in th e lectures, an d th e y all w orked enthusiastically d uring th eir visits to the
provincial public h ea lth services to w hich th e y were allocated .

III.

G eneral considerations reg ardin g th e organisation an d w orking of th e system of the inter­

change of personnel.
(a) Organisation of the course. — As alread y m entioned, th e foreign public h ea lth officials
arrived in Ita ly on N ovem ber n t h a n d rem ained u n til D ecem ber 16th, i.e., for a period of 35 days.
On th e ir arrival in Ita ly , a fte r com pleting th e first p a rt of th e ir course a t B russels, th e y had
no inform ation concerning th e organisation of th e h ea lth services in th e kindgom . Lectures had
therefore to be given to enable th em to form an idea of th e above-m entioned organisation, and to
help them in carrying o u t th e ir program m e of work.
N ine lectures were given in Ita ly an d th e y were spread over a period of tw elve days, i.e., a
th ird of th e period of th e v isito rs’ stay . I t proved im possible, how ever, to ta k e u p all the ques­
tions w hich h ad been placed on th e program m e, and a n um ber of these questions — some of
them , indeed, of v ita l im portance — were only d ea lt w ith in a cursory m anner.
A ccordingly, a t th e close of th e first period of th e sta y in Ita ly , i.e., w hen th e visitors had to
en ter th e field of p ra ctical application, th e ir know ledge of public h e a lth legislation a n d organisa­
tio n an d of th e g re at problem s of social h ea lth was insufficient for th e field of p ractical application.
M oreover, th e period of foreign stu d y , strictly so-called (from D ecem ber 4 th to 14th— barely ten
days), was q u ite inadequate.
I t w ould therefore ap p e ar t h a t th e carrying o u t of th e course in tw o periods and in two diffe­
re n t countries is n o t th e p lan b est a d a p te d to achieve th e results w hich i t is hoped to secure from
th e interchang e of personnel. Ju d g in g from th e experience w hich has ju s t been gained, it would
be b e tte r to com plete th e whole course of stu d y in a single co untry, so th a t, w hen th e theoretical
and p ra ctical studies are com pleted— it would be desirable th a t these should ta k e place a t the
c e n tral ad m in istratio n — th e allocations m ay be m ade w ithin th e general organisations of th e country
chosen.
T he ad v an tag es of such a system are clear, for th e officials of th e various S ta tes would be
enab led to o b ta in a know ledge of th e d etails of th e organ isation of th e v ario u s public health ser­
vices and, b y extending th e ir knowledge,(w ould co n trib u te to th e estab lish m en t of closer relations
betw een b o th individuals and betw een th e various services to w hich th e y belong. Reciprocal
confidence is th e basis of in te rn a tio n a l prophylaxis.
A n other p o in t has also been noted. T he shortness of th e period in Ita ly , an d th e necessity
of draw ing u p a sta te m e n t on th e public h ea lth organisation of th a t c o u n try in th e form of a
general sum m ary , subjected th e v isitors daily to an undue in tellectu al an d physical strain.
N a tu rally , th is system m akes objective first-h an d criticism im possible, and, m oreover, it leads
to a ra p id an d confusing succession of ideas, w hich m ilitates ag ain st a n y satisfacto ry study.
T aken as a whole, these conditions involve a dangerous degree of over-w ork, w hich m an y students
m ig ht n o t b e ab le to u n d ertak e.
(b) N um ber of visitors.— T he experience ju s t gained has clearly show n the necessity of making
th e nu m b er of each group of visitors as sm all as possible. T he n u m b er should n o t exceed ten or
tw elve. T he fact m u st n o t be overlooked th a t th e atten d a n ce of a crow d of visitors a t practical
dem o n stratio n s cannot b u t reduce th e value of these dem onstrations, w hich is inversely propor­
tio n al to th e num b er of persons present.
M oreover, w hen th e groups are sm all it is easier to m ake successive allocations w i t h i n the
o rg an isatio n of th e provincial public h ea lth services an d to ensure a m ore satisfacto ry distribu­
tion of effort.
 — 7i —

A P P E N D I X I TO A N N E X 8.

P rogramme at T urin .

I. Visit to th e M unicipal H e a lth B u reau — m etho d of work of the sanitary and prophylactic
i ervices, veterin ary services an d lab oratories.
II. P ro phylactic Service : ex am in atio n of th e notifications of cases of infectious disease.
Home disinfection.
Disinfections at the municipal disinfection station.
Transport of p a tie n ts suffering from contagious diseases to th e Amedeo H ospital, and visit to the
hospital.
Inspection of dairies, with relation to prophylaxis against typhoid fever.
Daily ex am in atio n of d rink in g w ater.
Laboratory research.
Tuberculosis: v isit to th e P rev e n to riu m : to th e San Luigi and Birago di Vische sanatoria;
[tothe prophylactic colon y; an d to th e heliotherap eu tic clinic ( “Casa del Sole”).
Syphilis : v isit to th e dispensaries for venereal diseases; survey ance of wet-nurses.
H ydrophobia: in s titu te for v accination against hydrophobia.
Smallpox: v accin atio n s a n d re-vaccinations.
D iphtheria : sero th e rap e u tic prophylaxis.
A nthrax : sero th e rap e u tic prophylaxis.
Scabies a n d pediculosis : v isit to th e special delousing section a t the disinfection station.
Schools : office procedure (exam ination, notifications, etc.). School inspections ; read-m ission of
children rem oved owing to contagious diseases ; show er-baths a t the P acchiotti school ; visit to the
Santorre S an taro sa school.
III. S a n ita ry services: surveyance of san itary professions — professional registration —
methods of w ork of th e services of th e “G ondotte m ediche e ostetriche” (medical and obstetric
administrations) — list of paupers.
First aid — p e rm a n e n t staff.
Office procedu re for conveying p a tie n ts to hospital — visits to the following hospitals : San
Giovanni, S an V ito, M aurixiano, M aria V itto ria, Inf. R egina M arghenta, M artini, Ricovero di
Mendicità an d Ospizio d i C arità.
Children’s d isp en sary .
Aqueduct a n d sew er, slaughter-house : v isit to th e in stallations of the Venaria, to th e springs
of the “P ian della m u ssa” an d V alsangone, to th e installations a t Mirafiori — Conference a t the
Office of P ublic W orks on th e proposed sewerage schem e — visit to the m ain sewer; visit to the
municipal slaughter-house an d th e c a ttle m ark et ; exam ination of a scheme for a new slaughter­
house.
Industrial estab lishm en ts : procedure for issuing work cards to women and boys. Regis­
tration of th e estab lish m en ts ; visit to th e chief establishm ents equipped w ith m edical rooms for
fot aid, m o to r am bulances, etc.
Laboratories a n d scientific in stitu tio n s ; visit to th e U niversity institutions and th e phyto-
pathological lab o ra to ry .
Health inspection a n d food sup ply. R eg istration ; surveyance of public buildings - procedure
for obtaining b u ild in g a n d residence perm its — police supervision ; supervision of food supply
- action of v ete rin ary surgeons an d "vigili” ; m arkets, sale of cereal products (substances alimen-
laires) ; railw ay w harves — chem ical la b o ra to ry — infringem ents an d notifications to legal au th o ­
rity.

A P P E N D IX II TO A N N EX 8.

P rogram m e at G enoa.

Visits and Inspections.

San M artino, G alliera, an d P am m ato n e H ospitals.

A nti-tuberculosis office.
Heliotherapeutic station.
Open-air schools.
Public sea-w ater baths.
 — 72 —

N ig h t refuge an d s a n ita ry estab lishm en t atta c h e d .

M unicipal disinfection statio n .
M otor service for schools an d sa n ita ry services attac h ed .
In c in e ra to r for household refuse.
M unicipal m o to r am bulances.
M unicipal schools for sufferers from trach o m a.
C em etery service.
S am p ierd aren a slaughter-house.
S am p ierd aren a H ospital.
N icolai a n d De F errari G ailiera aq u ed u cts (w ater-filtering ap p a ratu s).
C ity B acteriological an d Chem ical L ab o rato ry .
U n iv ersity H e a lth L ab o rato ry .
P o rt S a n ita ry s ta tio n an d san itary service.

A P P E N D IX III TO A N N E X 8.

P rogram m e at M il a n .

S ta te policy in resp ect of hygiene a n d public h e a lth in th e province.

P ro v in cial an d com m unal services in th e ca p ita l for th e p ro p h y lax is of contagious diseases,
M unicipal H e alth B u reau — H e a lth L ab o rato ry .
P erm an e n t vaccination service — anti-tu berculosis dispensaries — disinfection sta tio n s -
h ospitals for contagious diseases — cem etery an d M orgue — various ho spitals — Foundling
h ospital (Brefotrofio).
D rinking w ater — sew ers — m ark e t — food supply.
P ublic b ath s.
S upervision of schools — open-air schools ; asylum s an d schools for th e ab n o rm al — sanitary
services; am bulances — "C ondotte m ediche” — m edical, surgical an d o b stetric first-aid posts -
p h arm aceu tical services for th e poor — d istrib u tio n of m ilk.
"M aisons P op ulaires” — chnical convalescent in stitu te s — asylum s — m un icip al tuberculosii
chnic — visits to th e H e alth B u reau a t L egnano an d to th e m edical aid an d prop hylactic services
for w orkm en — “M aisons P o pulaires” — san ato riu m for consum ptives.
P ro p h y lax is ag ain st venereal diseases (visits to th e in stitu te s, dispensaries a n d th e hospital).
S ero -th erapeutic In s titu te of Milan.

A P P E N D IX IV TO A N N E X 8.

P ro g r a m m e at V e n ic e .

E x p lan a tio n of th e organisation an d w orking of th e P rovincial S an itary Office, the Port

S a n ita ry Office a n d th e M unicipal H e alth B ureau.
V isits to vessels on arriv al an d d u ring th eir sta y in th e p o rt (execution of m easures required
b y th e regulations in force, d estru ctio n of ra ts , prop hylaxis ag ain st plague).
V isits to establish m ents u n d er th e sa n ita ry surveyance of th e " S y lo s ” , to th e mill and
facto ry of th e " S tu c k y ” cereal p ro d u cts (pâtes alimentaires) an d th e S an M arco brewery.
V isits to th e p o rt s a n ita ry sta tio n s a t Lido, Alberoni, Chioggia an d Poveglia.
V isits to th e M unicipal H e alth B ureau an d th e chem ical an d bacteriological l a b o r a t o r i e s ,
an d inspection of th e hygienic and p ro p h y lactic services of th e C ity of Venice.
V isits to th e refrigerators a t L a Giudecca, Le Z atte re an d M archera.
V isits to th e C ity H o sp ital of Venice, th e U m b erto I. H osp ital for children, th e hospital
incurables, th e h o sp ital for infectious diseases a t the Islan d of L aG razia an d th e San M a r c o tuber­
culosis clinic.
V isits to th e Sailors’ H ostel, th e anti-tuberculosis dispensary and th e clinic for healthy an
tuberculous children.
V isit to th e new com m ercial po rt.
 — 73 —

Visits to the aq u e d u cts of Venice, M estre an d San D onà di Piave.

Insp ectio n of th e w orks ex ecuted as prevention against m alaria (bonifiazione) a t San Donà
di Piave (Bella M adonna), T o rre d i M osto, San Stino an d Caorle (Bocca Fossa).

A P P E N D IX V TO A N N EX 8.

P rogram m e a t F lo r en c e.

V isits and Inspections.

Disinfection s ta tio n of th e C ity of Florence a t th e m unicipal wash-houses. Organisation of

home disinfection service.
Mayer H o sp ital for C hildren — F oundling H ospital (Brephotrophe) and M aternity H ospital —
Assistance to m o th ers — Careggi S an ato riu m — Ita lia n R ed Cross Society’s H ospital for persons
with tu b ercu lar ten d en cy — Q ueen E lena S anatorium — School for trachom atous children —-
Open air school — A n ti-tu b ercu lo sis dispensary of th e “Société U m berto I ” .
In stallation s for th e su p p ly of drink in g w ater, reservoirs.
Installation for th e d estru c tio n of household refuse (Beccari system ).
“ Maison P op ulaire
Public b ath s.
F actory of “ Conserve alim en tari T orrigiani di Sesto F lo ren tin e’’ — W ool factory a t P rato —
Molteni chem ical works.
M unicipal H e alth L ab o rato ry .
General P atholo gical L a b o ra to ry a t Careggi.
Sewer an d a q u e d u ct a t Siena.
E stab lishm en t of th e " B agni di M ontecatini ” .
 — 76 —

being used in E ngland, ra ts in th e U n ited S tates. In b o th countries every b a tc h is officially tested

in th e P ublic H ealth D e p artm en t a t W ashington u n d er th e law governing th e inter-State traffic
in biological rem edies, an d und er th e Medical R esearch Council in E ngland, as a condition of the
licences issued b y th e B oard of T rade in connection w ith th e p a te n t.
In th e case of N eosalvarsan no sta te m e n t of control for to x icity or o th er properties h as been
m ade b y th e G erm an p aten tees. T he directions for m an u factu re in th e p a te n t specification arc
b y no m eans so full an d explicit as in th e case of S alvaisan, th e rem edy being m ade by a process
to som e e x te n t secret. I t h a s been found necessary, b o th in B ritain an d Am erica, to introduce
tests foi th e to x icity of th e various p ro d u cts which, m ore or less closely, represent Neosalvarsan
In ad d ition, i t h as been found th a t sm all variations can be introd uced in th e process of manufac­
tu re, which, while giving product;- of low to x icity, im pair the th erap eu tic potency. I t has therefore
been necessary to introduce tests for th era p eu tic potency. In b o th countries tests are now being
used w hich are based upon d eterm in atio n of th e dose needed to clear m ice or ra ts of a standard
infection w ith a strypanosom e ( T . equiperdum) in a sta n d a rd tim e. Mice are used in Britain, rats
in A m erica; th e stra in s of T. equiperdum are different, an d th e stip u la tio n s as to in tensity of infec­
tion an d tim e of com plete disappearance are n o t th e sam e.
O n all po in ts such as these, in tern a tio n a l agreem ent is highly desirable, and , so far as Britain
and A m erica are concerned, p ro b ab ly a tta in a b le w ith o u t difficulty. T he a ttitu d e of Germany,
in view of th e existence of unexpired p a te n ts for these rem edies, m ay create a difficulty in the
w ay of in tern atio n al agreem ent.

The authority for imposing standards.

W hile th e need for biological stan d ard s, an d th e desirability of m aking these international,
is as obvious in th e case of som e of th e rem edies here considered (e.g. p itu ita ry ex tra ct, insulin,
Salvarsan) as in th a t of the im m une sera, th e a u th o rity for th e ir im position w ould n o t necessarily,
in an y one co un try , be th e sam e. In th e U n ited S ta tes of Am erica, w here th e co n tro l of sera and
o th er bacteriological p roducts, a t least fo r “in ter-S tate traffic ”, is clearly established by law and
exercised b y th e F ederal P ublic H e alth Service, of substances m entioned in th is memorandum
only th e m em bers of th e S alvarsan group have been h eld to come w ithin th e purview of this control,
and even th ey ap pear to h av e been included b y a som ew hat ingeniously strain ed interpretation
of th e A ct. F or th e rest, m ethods of biological assay were in tro duced in to th e last edition of the
U n ited S ta tes Pharm acopoeia. In G reat B ritain th ere w ould p ro b ab ly be no difficulty in persuading
th e a u th o rity (Pharm acopoeia C om m ittee of th e G eneral M edical Council) responsible for the Phar­
macopoeia to in tro duce directions, in th e case of any of these rem edies w hich are included in the
Pharm acopoeia, to th e effect th a t th e indication “Physiologically s ta n d a rd ise d ” shall signify
th a t th e p re p ara tio n so labelled h a s been physiologically tested in accordance w ith th e interna­
tionally accepted m ethod an d ad ju sted to th e in tern a tio n a l stan d ard , w hen such methods and
sta n d a rd s exist. This p ro b ab ly represents the lim it w ithin w hich such stan d ard s could be made
effective in several countries. T he idea of a Pharm acopoeia h as been a code of directions for the
p re p ara tio n of w idely used rem edies, such th a t an y qualified p h arm acist should be able to follow
th e m ; an d it w ould certain ly be difficult, in th e case of w ell-established an d fam iliar drags like
digitalis, to m ake obligatory procedures w hich could only be followed b y th e m anufactu rer posses­
sing a w ell-equipped biological lab o rato ry , or h av in g easy access to such. To establish, however,
t h a t th e description "Physiologically stan d ard ised ”, w henever used, should h av e reference to a
definite an d in tern atio n ally accepted stan d ard , an d n o t as a t present, to som e unknow n standard
set u p b y th e m an u factu rer him self, w ould be a solid achievem ent.
I t was recently sta te d b y th e C hairm an of th e Pharm acopoeia C om m ittee (the President
of th e G eneral M edical Council) o f G reat B ritain , th a t h is C om m ittee h a d felt it impossible to
include certain rem edies in th e Pharm acopoeia, on account of th e facts th a t no m eth o d of measur­
ing th e ir a c tiv ity existed excep t a biological m ethod, an d th a t no a u th o rita tiv e ly prescribed
biological s ta n d a rd w as available.
I t should b e n o ted th a t a m easure of in tern atio n al agreem ent, w ith re g ard to some of the
drug s w ith w hich th is m em orandum is concerned, h as been reached b y an “In tern atio n al Confe­
rence respecting th e U nification of th e Formulae for P o te n t D rugs an d P re p a ra tio n s ” in the several
n a tio n a l Pharm acopoeias (1902). T he S ta tes p artic ip a tin g in th is conference m ade a series 0
reco m m endations com m only referred to as th e “In tern atio n al A greem ent”. T he various national
pharm acopoeias issued since th e d a te of th a t conference h av e ado pted m odifications which make
uniform th e proportions of drug to solvent used in preparin g th e tin ctu res of digitalis and strop»-
a n th u s, for exam ple. In view of th e ad m itted fact th a t, since no chem ical stan d ard s for these
p re p ara tio n s are available, th e appearence of u niform ity so obtained m ay be q u ite illusory, the
effort to o b tain in tern a tio n a l agreem ent on physiological m etho ds an d sta n d a rd would be an
obvious corollary an d p ra ctical developm ent of th is “In te rn a tio n a l A g reem en t”. I t is one, however
w hich th e Pharm acopoeia C om m ittees of th e several countries concerned are unlikely to prom oe
b y th e ir own action. T heir a ttitu d e w ould probably be sim ply one of readiness to adopt, by r«e'
rence, stan d ard s set up b y som e o th er in tern a tio n a l au th o rity . I t should be noted, f u r th e r , tna
several of th e rem edies above considered — p itu ita ry e x tra c t, insulin, S alvarsan — are a d m in is te r
b y p a re n te ra l injection, an d are on m uch th e sam e footing w ith reg ard to dang er from im perteC
sterility , abnorm al to x icity an d irreg u lar activ ity , as some of th e im m une sera and bacterial pr0
ducts. ,
My conclusion is th a t a n in tern a tio n a l conference, following som ew hat sim ilar lines to
In te rn a tio n a l Serological Conference, could do valuable w ork in th e direction of e s t a b l i s h ' .
 - 77 —

national stan d ard s for th is sm aller group of rem edies. I would suggest th a t the field of activity
f such a conference should be defined as “rem edial agents, other th an immune sera and bacterial
ducts, needing co n tro l or sta n d a rd isa tio n b y biological m ethod s’’. I would suggest th at,
nee the'field of ac tiv ity so defined is a com paratively sm all one, the membership of such a confe-
nce should be correspondingly sm all — n o t m ore th a n three from each country participating.
( it should be decided to call such a conference, it w ould be useful to have in m ind the fact th a t
ie In te rn a tio n a l Physiological Congress is to m eet in E dinburgh during the last week of July,
2, if a conference on sta n d a rd isa tio n were arranged in convenient relation to th a t Congress —
the middle of J u ly or early in A ugust — the difficulty and expense of arranging for adequate
■ ( p r e s e n t a t i o n from A m erica w ould p ro b ab ly be very small. Since the biological standardisation
)f drugs originated in th e U n ited S tates, an d has been m ore system atically studied and advocated
here than in o th er countries, th is w ould be a n im p o rtan t consideration.
 Annex 10.

Study o f Malaria i n I taly .

(Telegram addressed to Dr. L utrario .)

R ome, J a n u a ry n th , 1923.

A pprove proposed m eeting in Ita ly of m alaria experts.

F inzi .

Annex 11.

R eport on the D iscussions of the Mixed Opium S ub -Committee b y D r . H . C arrière.

A t th e last session of th e H e alth C om m ittee, held in A ugust 1922, it was decided to replace
th e Opium Sub-C om m ittee of th e H e alth C om m ittee b y a M ixed S ub-C om m ittee to be compos
of m em bers of th e H ealth C om m ittee an d of th e A dvisory C om m ittee on Opium . The duty oi
th is M ixed C om m ittee was to m ain tain c o n ta c t betw een th e tw o organisations, to avoid overlapped
an d to consider th e im p o rta n t questions of a m edical n a tu re w hich w ould be subm itted to it
b y th o se organisations.

B y virtue of this decision, the Mixed Committee was composed as follows: F o r the Health
Committee: M. Chodzko (replacing Dr. Miyajima, at present in Japan), Dr. S a n t o l i q u i d 0'
Dr. C a r rière . F o r the Advisory Opium Committee: Dr. A n selm in o , Mr. Campbell.

Y ou will doubtless rem em ber t h a t th e O pium S ub-C om m ittee of th e H e alth C om m ittee ha<
been’en tru ste d w ith th e d u ty of exam ining th e results of an en q u iry w hich h a d been undertake!
in respect of a certain nu m b er of S ta tes w ith a view to eliciting th e ir leg itim ate requirement
in opium , opium derivatives and o th er narco tic drugs. Sm all coun tries w ere selected for t®-
enquiry, it being considered t h a t th e y w ould be m ost suitable for th e purposes of investigati°r-
an d th a t an average m ight be stru ck from th e figures o b tain ed an d a basis furnished there 5
for subsequent regulations. U n fo rtu n ately , th is hope has n o t been realised, and, w ith few excep
tions, th e results of th e enquiry h av e been, in fact, som ew hat inconclusive. A s u m m a r y o ft
resu lts of th is enquiry was published in th e M inutes of th e H e a lth C om m ittee’s session held1-
P aris in M ay 1922, an d th ere appears to be no necessity for rep eatin g it here. 1
This being so, th e A dvisory O pium C om m ittee th o u g h t it necessary to proceed to a
generalj|enquiry in respect of all th e S ta tes signatories of th e H ague C onvention and other Mem .
of th e League of N ations, an d th e questionnaires were sen t o u t in M ay 1922. The resu lts of1
 — 79 —

further investigation h av e been exam ined by th e Mixed Sub-Com m ittee, and the present report
is designed as a s ta te m e n t of th e S ub-C om m ittee’s conclusions. T h e Sub-Com m ittee’s d u t i e s
were clearly defined in th e following term s of reference: QUtleS

1. To exam ine in th e lig ht of previous enquiries conducted by th e H ealth Committee of the

figures furnished in rep ly to a circu lar le tte r sent to all th e S tates signatory to the Convention
and to other S ta tes M em bers of th e League of N ations, asking th em to state th e to tal quantity
of opium and of its d eriv ativ es considered necessary each year for th e needs of home consumption
2. To in v estigate w ith a view to evolving a satisfactory m ethod of determ ining the quantities
of opium, d erivatives of opium an d o th e r noxious drugs required each year for the needs of the
home consum ption of th e various countries.

In regard to th e first item on th is agenda, th e M ixed Sub-Com m ittee, after considering the
figures supplied to it, w as once m ore convinced th a t th e results of the enquiry were n o t such as to
lead to definite conclusions. T he Sub-C om m ittee had, it is true, figures supplied by eight countries,
that is, South A frica, C anada, China, Czechoslovakia, F inland, Italy , Luxem burg and Norway!
(It should be rem em bered in th is connection th a t D enm ark, Sweden and Switzerland had already,
at the tim e of th e H e a lth an d O pium Sub-C om m ittees’ enquiry, supplied details which, in their
view, rendered it unnecessary for th em to ta k e p a rt in th e new enquiry.) B u t the difference between
the two m ethods of enq uiry m ade com parison very difficult and definite conclusions still more
difficult. C ertain S ta tes had , in fact, applied d irectly to chem ists, doctors and hospitals to dis­
cover the q u a n titie s of narcotics used b y them . O thers had only deducted th e exports from the
imports an d h ad ad d ed to th e figure th u s obtained the figure for production and had given the
result as representing th e q u a n tity necessary for th e legitim ate requirem ents of the country.
The faultiness of th is la st m eth o d is obvious, in th a t it gives, in fact, only th e quantities consumed
within th e co u n try , w ith o u t giving a n y precise indication of how far th is consum ption is for legi­
timate purposes. N evertheless, th e results of th e new enquiry, as those of the previous enquiry,
reveal com m on factors, which, if th e y are n o t m erely accidental, lead to th e supposition th a t it
should be possible to arrive b y a carefully chosen m ethod a t useful results and establish w ith
sufficient accuracy an average w hich could be equitably applied to all countries and serve as a
basis for regulations. The ta sk of th e M ixed Sub-Com m ittee has been to endeavour to determ ine
such a m ethod.
However, a p re lim in ary question arose w hich it was necessary to solve, because the principle—
or at any ra te th e m eans of ca rry in g o u t th e m ethods of enquiry— depended upon th e solution
arrived at. W h a t w as m ea n t b y “leg itim ate req uirem ents” ? The discussion on this point was
very lively an d revealed all th e differences of opinion which are m et w ith in circles interested in
the opium question.
The M ixed C om m ittee th e n considered th e opinion which h ad already been p u t forward in
the same sense as t h a t of th e H ealth C om m ittee, nam ely, th a t all consum ption of narcotic drugs
other th an for m edical purposes does n o t necessarily co n stitu te an abuse, th a t in certain countries
—e.g. in In d ia —opiu m is a stim u la n t w hich is indispensable for certain labouring classes of the
population, an d th a t th is facto r m u st be tak e n into account in defining th e requirem ents known as
"legitimate” . T he m edical m em bers of th e Sub-C om m ittee replied to this argum ent th a t, in their
view, the only leg itim ate requ irem ents were m edical requirem ents, th a t it was not desirable to
legalise a form of consu m ption wrhich m u st be regarded, in an y case, as an abuse the suppression of
which should ra th e r b e aim ed a t ; th is w as th e point of view w hich was finally accepted, though not
until Mr. Cam pbell— w ho h ad defended th e opposite point of view—h ad m ade a form al reservation.
H aving estab lished th is point, nam ely, th a t legitim ate requirem ents are exclusively medical
requirements, w hich term should no d o u b t include the em ploym ent of opium and its derivatives
for scientific purposes, th e Sub-C om m ittee was able to proceed to the consideration of th e m ethods
enquiry.
H aving reg ard to th e resu lts of previous enquiries, the Sub-Com m ittee was of opinion th a t it
would be im possible to ad o p t a single m ethod, th a t m ethods which m ight suit the organisation and
customs of one c o u n try m ig h t n o t b e applicable to another, and th a t it was therefore necessary
|° consider th e possibility of em ploying various m ethods. In addition to th e necessity, imposed
Jy force of circum stances, of em ploying various m ethods, it should also be pointed out th a t it wou
e desirable to co n d u ct p arallel enquiries in one and th e sam e country, since a com parison of t e
results of such enquiries w ould give th em g reater exactness and certainty. A fter a discussion, t e
•‘ixed C om m ittee agreed u po n th e following m ethods :

(1) To utilise th e s ta tistic s relatin g to im ports, production and exports, as has already been
done in certain co untries. . ,
We have alre ad y po in ted o u t th a t th is m ethod is unreliable, b u t at least it m akes î possi e
’° work o ut very roughly th e to ta l consum ption of a country, and, as we shall see later, 1 is o
Poetical im portance to determ ine th is to ta l. . ,
(2). To m ake enquiries, as has been done already, from hospitals, chem ists an oc ors
dépense m edicines, an d no d o u b t also from dentists and v eterinary surgeons li the^replies
? tained in this w ay w ere reliable, th is m etho d would no dou bt be th e one calcula e 0 gi
est results ; it will b e for th e a u th o rity carrying o u t th e enquiry to see as far as possi e a
4nswers are reliable. . . , - h .
(3) T he th ird m eth o d is based upon principles which, if we are correctly inform ed n
;‘ot yet been applied. I t consists of : first, ascertaining the general incidence of ■
n a country by reference to the statistics compiled by health insurance fun s, a
 — 8o —

b y ascertaining, b y enquiries from a lim ited nu m b er of general hospitals, th e average consumption

of narco tic drugs p er p a tie n t a n d p er year. By m u ltiply in g th e first to ta l b y th e second it would
seem possible to o b tain — v ery roughly it is tru e — th e to ta l leg itim ate requirem ents.
T h is m eth o d is interestin g, b u t it is open to certain criticism s. T hus, it is no d o u b t true that the
m o rb id ity of persons in sured in h e a lth insurance fund s is higher th a n t h a t of non-insured persons
for th e sim ple reason t h a t as in sured persons do n o t h av e to p ay th e d o cto r, th e y call him in more
freq u en tly th a n do uninsured persons. B u t th a t is a facto r of w hich s ta tistic ia n s can gauge the
value, an d of w hich th e y can tak e acco unt in th e ir calculations. On th e o th e r h an d , it is equally
tru e th a t in a general hospital, narcotic drugs are n o t used for all th e p a tie n ts, so th a t the figure
o b tain ed b y dividing th e to ta l an n u al consum ption of th e h o sp ital b y th e n u m b er of patients
w ould be to o low. W e shall th u s h av e tw o sources of error, b u t it m ay b e assum ed t h a t they will
co m pen sate each other u p to a certain point.
I t is, m oreover, evident t h a t th is m etho d of en quiry can only b e ad o p te d in countries where
th e h e a lth insurance funds are m ore o r less officially organised.
F in a lly , it w as p o in ted o u t in th e M ixed Sub-C om m ittee th a t as soon as th e system of import
an d ex p o rt licences recom m ended b y th e A dvisory C om m ittee on O pium is b ro u g h t into general
ap p licatio n , to g eth er w ith th e supervision w hich it entails, we shall possess ex a ct statistics which
will n o d o u b t ren d er all o th er m ethods of en quiry superfluous, b u t th is condition is n ot yet ful­
filled.
B efore leaving th e question of m ethods of enquiry, we w ould like to say a few words about
th e first of th e m ethods referred to. W e p o in ted o u t th a t th is m ethod, being b ased on imports,
p ro d u c tio n an d exports, could only give th e to ta l consum ption of th e co u n try , b u t if parallel
enquiries w ere carried o u t, it w ould be possible, b y com paring th e re su lts given b y th e first method
w ith th o se o b tain ed b y th e second or th ird m ethods, to determ ine, w ith in c e rta in lim its, the extest
of th e illeg itim ate consum ption.
Such w ere th e results of th e discussions of th e M ixed Sub-C om m ittee, an d it appeared that,
w hen th ese p o in ts h ad been settled , its ta s k was com pleted. H ow ever, H is E xcellency M onsieur
Chodzko th o u g h t th a t it was n o t sufficient to m ake enquiries an d to accu m ulate m ore or less
reliable figures, b u t th a t it w as m ore im p o rta n t to lay dow n th e principles fo r a programme of
ac tio n in th e cam paign ag ain st th e abuse of n arco tic drugs. H e th o u g h t it was especially desirable
t h a t a n agreem ent should be reached regarding th e system of control, w hich h e th o u g h t should he
v ery s tric t, to w hich th e p ro d u ctio n of th ese drugs should be subjected.
T h e M ixed S ub-C om m ittee considered, how ever, t h a t such proposals should n o t b e submitted
to it, ra th e r to th e H e a lth C om m ittee an d to th e A dvisory C om m ittee on O pium . I t will therefore
be for D r C hodzko, if he th in k s fit, to ex p lain to th e H e a lth C om m ittee, d u rin g th e discussion which
will ta k e place on th e p re sen t re p o rt, th e views w hich he h a d in ten d ed to m a in ta in before the Mixed
S ub-C om m ittee. If these proposals are accepted b y th e C om m ittee, th e y can be communicated,
to g e th e r w ith his reasoned sta te m e n t, to th e Council of th e L eague of N ation s, w hich will commu­
n ica te th em , if it th in k s fit, to th e A dvisory C om m ittee on Opium .
As reg ard s th e enquiries them selves, if th e H e alth C om m ittee approves th e proposals of the
M ixed S ub-C om m ittee, it will be th e d u ty of th e la tte r to c a rry th e m o u t in th e m eth o d which it
th in k s b e st calcu lated to fu rn ish conclusive results.
 Annex 1 2 .

Report of t h e S u b -C o m m it t e e on P u b l ic H ealth Measures in the N ear E ast in

R e l a t io n t o t h e N ew T u r k ish P eace T reaty.

Geneva, J a n u a ry 9th, 1923.

The convocation of th e P eace C onference at L ausanne signified th at the representatives of

he Allied Pow ers an d T u rk ey w ould be called upon to discuss the settlem ent of several public
lealth questions of im p o rtan ce in relatio n to q uaran tin e and th e prevention of the spread of
ipidemic diseases in th e N ear E ast. C ertain of these questions had already been closely studied
nthe early p a r t of 1922 b y th e N ear E a st H ealth Commission of th e League. The report of th is
Commission co n tain ed , it will be rem em bered, recom m endations on the essential principles on
iction which sho uld be ta k e n in th e S tra its and also in o th er ports of the N ear E ast which before
he war were u n d e r th e ju risd ictio n of th e Superior B oard of H ealth of Constantinople. In illus-
ration of th ese principles, th e Com m ission h ad suggested certain new articles for insertion in the
îext In tern atio n al S a n ita ry C onvention relating to th e san itary defence of the S traits and of
he Mecca P ilgrim age.
In these circu m stances, th e C hairm an of the H ealth C om m ittee decided to request Monsieur
t'elghe and S ir George B u ch an an to form , u n d er his chairm anship, a Sub-Committee, (1) with the
luties of p reparing a m em orandum on th e ex pert opinion subm itted to the League on these ques­
tions, and (2) to b e a t th e disposal of th e Council for an y advice which the Council m ight desire
t to give on th e m a tte rs dealt w ith in th e m em orandum .
The S ub-C om m ittee accordingly prepared , on N ovem ber 4 th , a m em orandum (C. H. 45),
opies of w hich h av e been circulated to all m em bers of the H ealth Committee.
Since th is was done no fu rth e r app lication has been m ade to the Sub-Comm ittee for advice
rod consequently no m eetings h av e been held.
Sir George B u ch an an has inform ed th e Sub-C om m ittee th a t, in the capacity of a B ritish
^legate, he a tte n d e d a m eeting of a technical Sub-Commission of th e Peace Conference at L au­
sanne on J a n u a ry 5 th last. The q u estion of th e public h ealth clauses to be inserted in th e T reaty
#as then u n d er consideration, an d it was evident th a t th e recom m endations of the N ear E ast
Commission w ere being ta k e n b y b o th sides as an im p o rtan t and au th o ritativ e guide to the technical
pestions a t issue. N o decision h a s so fa r been arrived a t, b u t it should be observed th a t no ob-
ection was m ad e b y the delegates, including the Turks, to th e principle th a t im p o rtan t public
salth bodies of an in te rn a tio n a l ch aracter, such as are suggested for the control of th e S traits
wd for th e M ecca Pilgrim age, should be placed in official relation with the League of Nations
hganisation a n d w ith the. Office in te rn a tio n a l d ’H ygiène publique — for exam ple in the m anner
toposed b y th e N ear E a st Com mission in A rticle 154 of th e annex to its report.
 *— $2 —■

Annex 13.

P il g r im a g e s to t h e H oly P laces.

(N ote b y D r. L utrario .)

M in ist r y of th e I n t e r io r
R ome, N ovem ber 27th, 1922.

D ear Sir,
I h av e received th e N ote co ntaining th e technical opinion regarding th e h e a lth measures to
be ta k e n in th e N ear E a st w hich was d ra fted b y th e Sub-C om m ittee com posed of Professor Madsen,
Sir George B uchanan and M. Velghe. T he N ote concluded w ith th e recom m endations adopted
by th e C om m ittee of th e In te rn a tio n a l H e a lth Office a t th e last session in O ctober of this year.
I th in k th a t, in ord er to o b tain a b e tte r idea of th e g re at im portan ce of th e th ree recommendations
p u t forw ard a t th e end of th e N ote, it w ould p erh ap s be useful to ad d , for y o u r information, a
su m m ary of the discussion w hich to ok place w ith reg ard to th e th ree recom m endations.
I do n o t th in k th a t I should give a su m m ary of th e discussion w hich to o k place on this subject,
p artic u la rly in th e C om m ittee which was e n tru ste d b y th e C om m ittee of th e H e alth Office to
exam ine th e d ra ft am end m ent to C h ap ter I I an d th e following ch a p ters of th e In te rn a tio n a l
C onvention of 1912. As you are aw are, th is d ra ft am endm ent h ad been considered an d w a s pro­
posed b y th e C om m ittee, w hich, h av in g been au th o rised an d delegated b y th e L eague of Nations,
proceeded in F eb ru a ry last to th e N ear E ast.
I th in k th a t I m u st confine m yself to th a t p a rt of th e discussion w hich concerns me, parti­
cu larly as regards th e second an d th ird recom m endations.
In th is connection I th in k it desirable to tra n sm it to you a n o te (A ppendix) summarising my
views on th e pilgrim ages — views m ost of w hich I expressed rep eated ly to th e P aris C om m ittee.
T his n o te sufficiently explains th e p u rp o rt of th e second an d th ird recom m endations.
I should like, how ever, to give y ou som e fu rth e r explanation.
As regards th e second reco m m end atio n, I laid g reat stress on th e necessity of establishing
on all th e m ain lines of railw ay in th e E ast, q u a ra n tin e sta tio n s to deal w ith th e h ea lth o f pilgrims.
This m a tte r is of p rim ary im portance. T he ten d en cy is for th e pilgrim s to ab an d o n the old sea
routes a n d to tra v e l b y rail, wiiich is m uch m ore ra p id an d econom ical. T his tendency, with regard
to w hich I have definite inform atio n, clearly indicates th e desirab ility of giving fresh scope to
th is p a r t of th e C onvention. W e m u st devote m uch m ore a tte n tio n to th e railw ays th a n h a s been
done in th e C onvention a t p resen t in force.
As regards th e th ird recom m endation, w hich I w arm ly supp orted, I should like to point out
one in a d v e rte n t inaccu racy w hich has crep t in to th e published te x t.
T he te x t reads as follows :

“A co-o rdinating b ody of an in te rn a tio n a l c h a rac ter should be form ed with the
d u ty of co-ordinating th e w ork of th e several sa n ita ry au th o rities, etc .”
U pon th e m otion of M. B arrère and m yself, th is te x t was am ended as follows :

“T he C om m ittee ad o p ts th e following recom m endations :

" ( 1) .........................
“ (2) .................................................................
“ (3) T h a t a co-ordinating body of an in te rn a tio n a l ch a rac ter should be e n tru ste d with the dan
of co-ordinating th e w ork of th e several sa n ita ry au th o rities executing th e m easures, etc.”
T he am endm ent th u s in tro d u ced is n o t u n im p o rtan t. I t corrects th e im pression given b)
th e original te x t th a t th e “fo rm atio n ” of a new in te rn a tio n a l body was contem plated, w h i c h would
h av e been absurd.
T he second wording, on th e o th er h an d , w ith o u t claim ing to m ake an y suggestions to the
Peace Conference, im plies th a t it is h ard ly necessary to “form ” a new organisation for t h i s work
I t suggests th e idea w hich I expressed m ore definitely in th e special note a tta c h e d h e r e t o . W
m y hum b le opinion, one of th e alread y existing organisations m ight be used as a c o - o r d i n a t i n g
bo dy of in tern a tio n a l c h a ra c te r— th e H ealth C om m ittee of th e L eague of N ations, for in s t a n c e ,
in collaboration (or, if you prefer, in consultation) w ith th e C om m ittee of th e Office i n t e r n a t i o n a l
d ’H ygiène publique.
 ~ 83 -

This solution w ould be calcu lated to give satisfaction to all, and would ensure firm and com
letent action w ith a view to cen tralisin g an d co-ordinating prophylactic activities in a territorv
vhich issov ast a n d co n tain s such a larg e nu m b er of S tates. y
The following local in te rn a tio n a l organisations should be invited to collaborate in this co-
,rdinating action:

(a) T he E g y p tia n Q u a ra n tin e B oard for persons com ing from Africa.
(b) T he C onstantin ople Inter-A llied C om m ittee (either in its p resent form or w ith suitable
m odifications) for persons com ing from Asia and Europe.
(c) A H e d ja z C om m ittee consisting of delegates of the two organisations of E gypt and
C onstantin ople, in o rd e r to regu late questions of h ealth (if possible) on the spot
in th e H oly Places, in collaboration w ith the local authorities of the new regim e’
Believe me, etc.
„ . , (Signed) A. L u t r a r i o .
)r. Ludwik R ajch m an ,
Medical D ire cto r of th e H e alth S ection
of th e L eague of N ations, Geneva.

A P P E N D IX TO A N N EX 13.

P il g r im a g e .

I have stu d ied th is problem , w hich is now, as always, of vital im portance, n ot only for the
lediterranean cou ntries b u t fo r th e w hole of Europe.
This problem h as assum ed g re ater im portance in view of :
(a) The d e n sity a n d e x te n t of th e traffic, increased b y 250 million M usulmans ;
(b) The e x te n t of th e te rrito ry from w hich th e pilgrim s are draw n and which embraces
ibout one q u a rte r of th e old co n tin en t, w here th e m ost dangerous countries and regions are situated,
lermanent centres of th e w orst infections (Gulgia, Chinese K assar, Mongolia, T artary, India) ;
(c) The d iv ersity of th e pilgrim s, who are draw n from widely differing social classes, and
ire generally careless as reg ard s m a tte rs of h ealth ;
(d) The s ta te of sa n ita ry neglect of th e H oly Places. D rinking w ater has been provided,
Bdthis is a g re a t im prov em ent ; b u t th e drainage conditions still rem ain m ost prim itive (tem porary
sewers by th e side of th e roads) ; a d e a rth of prophylactic installations and isolation hospitals ;
(e) The m an y different directions tak en by th e currents of m igration in order to reach th eir
festination,
(f) The different seasons of th e y ea r during which th e pilgrim age takes place (the Musulman
unar year, in w hich th e tw o ritu a l m o nths D ulkam ia an d Dalheggia begin eleven days earlier
wry year) ;
(g) Religious fan aticism w hich h as led several S tates to g ran t freedom of pilgrim age w ithout
•ayrestrictions as reg ard s th e s ta te of h ea lth and economic circum stances of th e pilgrims (suggested
ratnot im posed b y th e C onvention in force).
These p oints m ake clear all th e vario us factors w hich affect this great social problem .
There are, how ever, fu rth e r reasons for its im portance from the prophylactic point of view :
i. The te n d e n cy to ab an d o n th e old routes an d to utilise m ore rap id m eans of communi-
ïtion.
In the first place, th e com pletion of th e Trans-Siberian route, which has brought a strong
jwent of pilgrim s from C hina (Gulgia an d T artary , regions inhabited b y 30 million fanatical
'lusulmans). These pilgrim s proceed to Y arkich in R ussia and thence to Sam ara, reaching the
’«ck Sea in a few days. (In th e territo rie s traversed cholera is endem ic and widespread.)
Since th e com pletion of th e K akand-T ashkend-O rem burg railw ay, th e pilgrim s from Northern
1(iia, A fghanistan an d B o k h ara prefer to ta k e these railw ays, which bring them to the Black Sea
^ a few days. H avin g reached th e B lack Sea, th e pilgrim s have tw o routes b y which to proceed
0 *he Hedjaz— b y la n d o r b y sea.
The form er, t h a t is to say, th e line of railw ay C o n s ta n t in o p l e - K o n ia - A d a n a - A le n - D a m a s c u s ,
always be chosen b y preference to th e sea ro u tes as soon as it is in full working order.
> Other pilgrim s, again, from th e B alkans, go by sea to B eirut and reach th e Holy Places via
^ascus, T eb u k a n d M edina. ,
■ This m ode of trav e l, w hich is becom ing m ore an d m ore general, very greatly shortens the
i°urney and is g rad u ally reducing th e length of tim e spent on th e journey, which in itself constituted
Attain p ro p h y lactic p ro tectio n , b o th on th e outw ard and on th e re tu rn journey.
 — 84 —

2. T he political changes w hich have ta k e n place in th e territo rie s from w hich the pilgriau
are d raw n an d th e neighbouring regions.
T he C onstantinople S uperior B oard of H ealth jw as abolished on O ctober 14th, 1914 by a
Im p erial Decree and w as superseded b y a M usulm an fro n tier board. A fter th e A rm istice, the
M usulm an board was superseded b y an Inter-A llied M ilitary B o ard of H e alth , an d q u ite recently
as th e re su lt of th e very serious h ea lth conditions of th e co untries bordering on th e Black Sea
th e pro p h y lactic service for th e defence of W estern E urope was e n tru ste d to an “ Inter-Allied
S a n ita ry C om m ission” (M arch 1922).
On th e o th er hand, th e T re a ty of Sevres set u p th e Com m ission of th e S traits, w hich exercises
a u th o rity over th e D ardanelles an d th e B osphorus, and, in ad d itio n , th e P ilgrim ages Quarantine
C om mission, w hich is placed u n d er th e a u th o rity of the L eague of N ations an d on w h ic h those
Allied Pow ers were to b e rep resen ted w hich are concerned w ith th e s a n ita ry con trol of pilgrimages
U nd er th e T re aty of Sevres, I do n o t know w h at special p a rt will be played by th e Egyptian
Q u aran tin e B oard as regards pilgrim ages. I am also unable to s ta te w hether th e H edjaz Admin­
istratio n , w hich was set up b y th e O tto m an G overnm ent, will be retained. P erh a p s it came to
a n en d w hen th e in d ep en d en t K ingdom of th e H edjaz was proclaim ed.
T he foregoing facts will show th a t, having regard to th e g re at v a rie ty of th ese national or
in tern a tio n a l organisations, b o th old an d new, th e powers of w hich do n ot a p p e a r to be clearly
defined, it will be a m a tte r of extrem e difficulty a t th e presen t tim e to bring a b o u t th a t unity of
s a n ita ry control w hich is indispensable in th e case of traffic on so v a st a scale— a u n ity which
ap p ears to m e to be of suprem e im p ortance in th e interests of public health.
3. O th er difficulties again are traceab le to th e dam age inflicted on sa n ita ry station s by tie
war.
Several of these sta tio n s are no longer in a position to c a rry on th e ir work. An attempt
has been m ade to re-establish th e posts a t C avak an d C ianak a t th e expense of th e A llies, but
th is is n o t enough. T he g re at m a jo rity of th e o th er statio n s are destroyed.
In ad d ition to all these difficulties, m ention m u st be m ade of th e in ad eq u acy of the existing
regulations. These ap p ly p rincipally to sea routes, alth o u g h it w ould ap p e ar th a t th e land route
(i.e. b y rail) is beginning to supersede th e sea route, especially as reg ard s pilgrim s com ing from the
m ore dangerous areas.
T he O tto m an A dm inistration endeavoured to rem edy th is s ta te of affairs an d issued special
reg ulation s to p re v en t th e in tro d u ctio n of infectious diseases in to th e H edjaz w ith the arrival
of th e pilgrim s a n d to g u ard ag ain st th e infection being spread on th e ir re tu rn .
W ith th is object in view, sa n ita ry sta tio n s were fully equipped a t Sinope, Surmeno, Cavak
an d T heodosia (in R ussia) for pilgrim s arriv in g a t p o rts on th e B lack Sea; a t Clazomene, Beirut
an d Jaffa for pilgrim s com ing from th e M editerranean area, an d a t T u b u k for th e Medina-Tubuk-
D am ascus-B eirut railw ay.
Thus it will be seen t h a t since th e w ar th e dangers h av e considerably increased, w h ile the
m eans for ensuring p ro tec tio n ag ainst epidem ics h ave been reduced.
In considering th e m easures th a t oug ht to be ta k e n to m eet th e situ atio n , a tte n tio n should be
given to th e question of th e organisations required an d th e ir duties.
W ith reference to th e organisations them selves, regard m u st be h a d to th e huge volume of
th e traffic draw n from an area covering a g re at p o rtio n of th e Old W orld— a traffic w hich, for histori­
cal, racial an d also political reasons, ca n n o t be checked. T he persons ta k in g p a rt in this move­
m en t belong to n atio n s w ith w idely differing n atio n al characteristics, b u t aJl are united by the
sam e sen tim en ts of religious fanaticism .
U n ity of control is essential if th e m easures required are to be effective, i.e. th e action musl
be uniform, guided by the same principles, carried out by the same means, must not allow itself to i<
diverted from its object, must be continuous and free from weakness.
On th is condition alone w ould it be possible to p re v en t th e resu lts of th e prophylactic work
from being im perilled.
I am of opinion t h a t it will be very difficult to achieve th is u n ity b y em ploying any of the
existing organisations or an y of those w hich existed in th e p ast, such as

1. T he Inter-A llied S an itary Commission of Control,

2. T he S traits Commission,
3. T he Pilgrim ages Q u aran tin e Commission,
4. T he H edjaz A d m in istratio n ,
5. T he E g y p tian Q u aran tin e B oard.

I t does n o t ap p ear to m e t h a t th e functions an d pow ers of these organisations (or of some 0

th em a t least) are of such a n a tu re as to ensure th a t th e re su lts alre ad y achieved should not
j eopardised b y in d ep en d en t actio n on th e p a rt of these bodies u n su p p o rted b y th e action of otne
organisations. ,
I am also of opinion t h a t n o t one of these organisations, actin g alone, w ould posses»
requ isite a u th o rity an d pow er to contro l th e whole of th e traffic.
Again, I do n o t believe th a t th e pow er of controlling th e w hole traffic can be e n t r u s t e d 0
single S tate. Such a S ta te w ould only exercise a u th o rity on its ow n te rrito ry , w hereas the en1'
p lan ou ght to be conceived as an organic w hole and be carried o u t in all th e co u n trie s throng
w hich th e pilgrim traffic passes.
T his “u n ite d fro n t” can only be achieved b y m eans of an o rg anisation of g reat autho
th o ro u g h ly qualified, in v ested w ith considerable pow ers an d provided w ith am ple re s o u rc e s .
 - 85 -

It may b e asked w hether th e T re a ty of Sèvres m akes m ention of any such organisation.

In my opinion, th e co m p e te n t b o d y w hich ought to be vested with full authority to discharge
these duties is th e H e alth C om m ittee of th e League of N ations, acting on the advice of the Office
nternational a t P aris.
In order th a t th is s a n ita ry co n tro l should be re ality an d not a mere name, executive organisa­
tions would have to be set up on th e spot which, as regards pilgrimages, would act on behalf of
the central body.
What should b e th e n a tu re of these organisations ?
Where should th e y be placed?
What powers should th e y possess ?
These subordinate organisations should number three and should be established at C onstanti­
nople, Alexandria and in the H e d ja z respectively — the three strategical points, as it were.
The Pilgrim ages Q u a ran tin e C o-ordination Commission referred to in the T reaty of Sèvres
might act as th e C o n stantinop le o rg anisation or sub-com m ittee.
This sub-com m ittee w ould b e called upon to deal w ith the whole of the traffic using the Black
Sea route or th e railw ays in Asia M inor, an d it w ould be authorised to supervise th e working of all
quarantine statio n s th ro u g h o u t th is region.
The E g y p tian Q u a ran tin e B oard m ight serve as th e Alexandria organisation. Its powers would
extend to all traffic passin g along th e A frican shore of th e R ed Sea, and it would also supervise the
;anitary statio n s in this area.
As regards th e H ed jaz, it w ould n o t p erhaps be necessary to set up a special sub-com m ittee.
The duties m ight be ad e q u ately perform ed b y a delegation of the Constantinople and Alexandria
;ommittees, w hich w'ould proceed to th e H edjaz in the pilgrim age season and co-operate with the
ocal governm ent.
I shall n o t discuss th e details of th e service.
Regard should, how ever, be h ad in th e Convention more particularly to the following points :
1. The new d irectio n ta k e n b y traffic, which tends to follow th e land route ra th e r than the
n route ;
2. The d esirab ility of m aking every possible effort from th e point of view of public health,
itthe places from w hich.the pilgrim s come, and during the journey or the voyage, as th e case m ay
i to ensure th e m ain ten an ce of satisfac to ry san itary conditions am ong these m oving masses of
mmanity, an d to enable pilgrim s to reach th eir destination w ithout occasioning outbreaks oi
ipidemics on th e w ay.
In this m an n e r it w ould be possible to safeguard th e H ediaz and to enable pilgrim s to visit
ind reside in th e H oly P laces a n d to re tu rn to th eir hom es w ithout any risk of epidemics breaking
rat.
In a m em orandum w hich I in te n d to su b m it to the P resident, I have set out m y observations
aid suggestions in g re a te r detail. These observations and suggestions I lay before the Com m ittee
or its consideration.
 Annex 14.

R eport on the R ecent W ork and P resent P osition of the E pidemic C om m ission
By Sir George B uchanan.

Geneva , J a n u a ry n t h , 1923.

1. The general w ork of th e Commission has been v ery fully described a t successive session,
by th e Medical D irector an d b y th e Chief E pidem ic Com m issioner, D r. N orm an W hite. At the
last session in A ugust, D r. W hite gave an account of th e p resent position of th e special f u n d s of the
Commission and of th e ex p en d itu re on its w ork w hich h a d been incurred to date. A t the present
session th e Medical D irector has given in his re p o rt a s ta te m e n t of th e fu rth e r w ork of the Commis­
sion since A ugust last, to g eth er w ith a sum m ary of th e m ain item s of expen diture from k
E pidem ic Commission F un d. T he la tte r h as also been th e su b ject of a n au d ited account appended
to th e D irector's report.
2. I t will be convenient to lim it th e present n o te to a brief review of th e present position
of th e Epidem ic Com m ission; in p articu lar, of w h at m em bers it consists, w h at are its resources
and w h a t duties lie before it.
3. P resen t c o n stitu tio n of th e Commission. — The Com mission, whose w ork is under the
general direction of th e M edical D irector an d th e H ealth O rganisation, consists of :

Dr. Norman White, th e Chief E pidem ic Com missioner, (now seconded for th e F a r East
E nquiry) ;
Dr. Gauthier, who has been actin g as Com m issioner since 1921 (now in Greece);
Dr. Haigh, w ho h as been a c tin g as Com m issioner since J a n u a ry 1922. (now in Greece);
Dr. Pantaleoni, who has been acting as Com m issioner since S eptem ber 1922 (now ii
Moscow) ;
to g eth er w ith a B usiness M anager (w ith h ea d q u arte rs in W arsaw ) an d a clerical staff.
4. R esources of th e Com mission. — These have h ith e rto been supplied entirely from thf
special funds an d m aterial o b tain ed b y th e League foom th e different G overnm ents w h ic h havi
u n d ertak en to c o n trib u te to its w ork, to g eth er w ith w h a t h as been supplied b y the League 0
R ed Cross Societies. Follow ing th e recom m endationsof th e H e alth C om m ittee a t its l a s t session
how ever, a sum of 50,000 (fifty thousand) gold francs h as been m ad e available from t h e genera
bu dget of th e League to w ard s t h a t section of th e work of th e Com m ission w hich consists o f obtain
ing inform ation regarding epidem ics for th e purposes of th e H e alth O rganisation, in m a k in g tin
necessary epidem iological enquiries, and ta k in g m easures to co-ordinate th e w ork of p u b li c healtl
au th o rities in different countries w ith a view to com bating risks of th e spread of epidemic disease
to w hich such coun tries are liable as a re su lt of th eir intercom m unications.
5. The special fu n d here in question appears now to be practically exhausted. O f the sun
still unexpended, som e £ 1 2 ,0 0 0 is required for work to w hich th e Com mission is alread y c o m m it te d
an d approxim ately £ 5 ,0 0 0 is a t present available for purchase of o th er m aterial an d general p®
poses. The p ro b ab ility th a t an y considerable am o u n t of ad d itio n al m oney or m aterial w illI1
added to th e fund, as a resu lt of th e m ore recent enquiries m ade b y th e League, is extremely small
I t is well, therefore, as a m a tte r of p ractical business, to face th e situ a tio n w hich has arisen. Ad®
tion al w ork requiring m ore m oney, how ever desirable, can not be proceeded w ith, while the tat
th a t th is special fund will so soon be ex h a u ste d m akes it p ru d e n t th a t as soon as th e c i r c u m s t a n c e
p erm it, a d ate should be fixed for closing th e fund and presenting a final su m m ary of expenditure
This should be accom panied b y a resum é of th e w ork accom plished b y th e C o m m i s s i o n e r s aJj
a list of reports an d accounts alread y presented. I t is un d ersto o d t h a t th is could c o n v e n i e n t * ,
be done on Dr. N orm an W h ite’s re tu rn , a fte r some final arrangem en ts have been m ade in P°^arl
This final docum ent should be com m unicated to th e G overnm ents concerned for th eir informât!0
Those G overnm ents w hich have c o n trib u ted m ay be assured t h a t th e whole expenditure has bee
wisely and econom ically directed, and t h a t th e benefit secured for th e P ublic H ealth o f Europe
b y th eir m eans, has been really great.
6. The enforced conclusion of th e work of th e Com m ission u n d er th is fund calls for a ^
observations. I t m arks th e term in atio n of some th ree y ea rs’ effort w hich has m ainly been dev°
to stren gthening th e sa n ita ry defences of S ta tes on th e w estern borders of R ussia, together "
 - 87 -

certain auxiliary arran g e m e n ts in R ussia itself. All th is w ork has h ad as a prim ary object the
p r e v e n tio n of th e w estw ard sp read of th e principal epidem ics which have been prevalent in Russia
and, more p articularly, it h as been directed to im proving th e control which could be exercised
over the im p o rtatio n of infection b y th e m asses of population leaving Russia and being repa­
tria te d from R ussia to P oland, L atv ia, L ith u an ia and o th er States.

(7) In th e review s w hich a t different tim es th e H ealth Com m ittee has m ade of the position
in Eastern E urope, g re a t stress h as been laid, an d rig h tly laid, on the im po rtant p art likely to be
played by th e in tro d u ctio n of infection en masse b y m eans of these great movem ents of popula­
tion. The E pidem ic Com m ission h as never been in a position to undertake out of its own funds
and m aterial m ore th a n a su b sid iary p a rt of th e organisation established in th e border States to
deal with this situ atio n ; b u t th is au x iliary action has been of th e greatest value, not m erely by the
material assistance w hich i t rep resen ts b u t perhaps still m ore by th e support which it has given
to the defensive org anisation in th e different countries concerned. F or this result much credit
is due to th e m an ner in w hich th e several Com m issioners have appreciated and utilised their oppor­
tunities, som etim es in circum stances of very considerable delicacy and difficulty, as well as to the
cordial welcome an d assistance w hich th e y have received from th e public health services with
which th ey were in co n tact. These observations apply not only to the border States b u t in a
very large an d im p o rta n t m an n er to th e work w hich has been done w ithin Russia itself in concert
with the Soviet public h e a lth au th orities.
(8) I t will n a tu ra lly be asked w h eth er th e conclusion of these activities, so far as th ey are
carried out b y th e aid of th e special fund, is likely to affect th e protection of Europe from invasion
by the epidem ics so severely p re v alen t in Russia. I t m ust be adm itted th a t the future in this
matter is v ery u n certain. T he C om m ittee can only conclude, from recent inform ation, th a t in
Soviet R ussia an d th e U kraine th e prevalence of typh us and relapsing fever continues this w inter
to be alm ost as serious as it w as a y ea r ago ; th a t a recrudescence of cholera m ay be expected in
various centres, while th e position as regards o th er diseases (notably smallpox, enteric fever and
dysentery), to w hich m u st now b e added m alaria rem ains of great grav ity according to th e stan ­
dards of o th er countries, an d also b y com parison w ith E uropean R ussia before the war. In regard
toextension to o th er countries, th ere is a t th e m om ent less cause for apprehension on account of the
recent dim inution in th e w estw ard m ovem ent of population from R ussia in the process of repa­
triation. As explained in m an y previous reports, th e m ost serious risk, in th is respect, has been
the im portation of infection on a g re at scale by m eans of arrival of masses of repatriated persons
in the border S tates. F o r political an d other reasons, however, this m ovem ent has lately almost
ceased. I t is und erstood, indeed, th a t th e R ussian d ep artm en t concerned with repatriation has
now been closed down. W hile th is consideration is of g reat im portance, the possibility of new
changes affecting th e m ovem ents of th e population, and th e possible result of freer com m uni­
cations of th e m ore o rd in ary k in d betw een R ussia and other countries, m ust not be forgotten.
It would b e w rong, in an y discussion of th is question, to fail to take account of the great influence
which m ust h av e been exercised b y th e various g reat works of relief and medical assistance in
these regions w hich h av e been u n d erta k en b y v o lu n tary agencies ; by th e American Relief Asso­
ciation on an enorm ous scale ; b y th e devotion of hum anitarians in so m any other countries.
(9) So long, therefore, as th is sta te of things continues, it is possible to hope th a t there is
less necessity th a n form erly for th e ty p e of work on which the Epidem ic Commission was prim arily
en gag ed, th e m ore so as th e public h ealth and epidemic services of several border States concerned
have in every w ay becom e m ore effective and m ore stabilised. In any case, as a practical m atter
it cannot be pursued.
(10) B y th is sta te m e n t, how ever, it is n o t im plied th a t all work which has been undertaken
hitherto b y th e E pidem ic Commission m ust cease. On the contrary, im p ortant duties, the under­
taking of w hich h as been approved b y th e Council and by the Assembly on the advice of the
Health C om m ittee, rem ain to b e carried out, an d can be carried out b y m eans of funds available
from the L eague’s own budget. These duties, in general term s, consist of obtaining epidemiological
facts in p artic u la r areas w hich are affected, in undertaking or organisang special observations or
enquiries in relatio n to th e spread of p artic u la r epidemic diseases, and in advising on the means by
which facts as to epidem ic prevalence could m ost effectively and accurately be obtained, for the
benefit of all n atio n s in th e progress of epidemics. W ork of th is kind has to a considerable extent
been carried o u t since th e last session of th e H ealth Com m ittee in R ussia successively by Dr.
Haigh and D r. P an taleo n i w ith v ery satisfacto ry results. From experience recently gained, th ere­
fore, it m ay be concluded t h a t th e continuance of Epidem ic Commissioners in some form or other
as part of th e H e a lth O rgansiation is of th e greatest practical value to th e health work of the
League so long as serious epidem ics recu r in countries which dem and or which welcome the assis­
tance which th e C om m issioners can give them .
n . T here is a n o th e r purp ose for w hich th e services of th e Epidem ic Commissioners m ay from
inte to tim e be used w ith th e g re atest possible advantage. Their experience, which is in mairy
respects exceptional, m ay on occasion be placed a t th e disposal of all Governm ents or pub ic
ealth organisations requiring th e ir counsel or assistance in emergency. An exam ple of the la er
Position has arisen since th e recent c a ta sti ophe to Greece and th e consequent flight of large num ers
0 Greek refugees from A n ato lia an d th e exchange of populations taking place in Thrace, n
connection w ith th e special arrangem en ts in augurated b y Dr. Nansen, a request was m ade tor e
services of m em bers of th e E pidem ic Commission to act as advisers on th e num erous and serious
. j I) questions w hich w ere d aily arising. In consequence of this, th e services of both Dr. Vau 1er
^ r- H aigh were len t to D r. N ansen, while a t th e sam e tim e the H ealth Organisation secure
 - 88 —

th e a d v a n ta g e of ob tain in g , th ro u g h these Com m issioners, in fo rm atio n as to th e principal sanitan

conditions an d epiden'ic risks likely to arise in connection w ith th is refugee m ovem ent. Recently
a sum of £5,000 h a s been h an d ed over b y D r. N ansen to th e Com m issioners to b e employed in th!
pu rchase of c e rta in essential m aterials in connection w ith th e p rev en tio n of epidemic disease
A ccording to th e p re sen t arrangem en t, th e C om m issioners h av e ceased to be ad visers to the Nansen
O rganisation an d are w orking in Greece b y th e direct req uest of th e G reek M inistry of Publjr
A ssistance in co n cert w ith th e G reek au th o rities. The funds a t th e ir disposal will be employed for
ce rta in special purposes, such as a vaccination cam paign, while th e ir experience of handling epi­
dem ics in em ergencies w ill be utilised in th e organisation of public h e a lth m easures in the
v ario us refugee centres.
12. I t seems ev id en t th a t arran g e m e n ts of th is kind afford a prospect of extrem e utility to
co untries in exceptional distress from circum stances of th is n atu re an d th a t such arrangem ents fall
en tirely w ithin th e purposes of an in te rn a tio n a l h ea lth organisation, p ro v id ed alw ays that the
au th o rities of th e coun tries affected are them selves willing an d anxious to o b ta in th e expert assis­
tan c e w hich th e H e alth O rganisation is in a position to lend.
13. I t m ay b e suggested th a t th e C om m ittee should a t its p resen t session ta k e note of the
p osition as above sta te d , while leaving to a subsequent session th e question of specific resolutions
regarding th e fu tu re of th is section of its work.
 - 8 9 -

Annex 15.

W A T E R W A Y S SU B C O M M ITTEE.

A. S p e e c h by M. C h o d z k o , C h a i r m a n .

J a n u a ry 5th, 1923.
After having read th is s h o rt n o te giving a brief account of th e W aterw ays Sub-Committee
of the H ealth C om m ittee, a n d its activities u p to th e present tim e, and the reports which have been
received on th e system of h e a lth regulations for w aterw ay traffic in force in various countries, I
think it desirable to p o in t o u t t h a t before a m odel program m e of health regulations for international
waterway traffic can be d ra w n up, we m u st reach an agreem ent on a certain num ber of general pro­
phylactic principles.
When these principles h a v e been decided upon, we m ust then m ake a statem ent of them and
give our reasons for ad o p tin g th em , and, if necessary, defend them before the Mixed Sub-Committee,
where we shall m eet th e m em bers delegated by th e T ransit Com m ittee of the League of Nations.
I therefore propose :
1. To determ ine in th e first place the infectious diseases in regard to which health surveil-
aice m ust be exercised, a n d in th e case of which, when an outbreak occurs :

(a) N otificatio n m u st be m u tu ally given b y the various health services of the rip a­
rian S ta tes;
(b) A d eq u ate hygienic m easures m u st be applied.

2. To decide a t once w h a t is to be th e n atu re of th e health surveillance and w hat health

measures are to be ta k e n as re g ard s th e crew an d passengers of vessels used for tran sport, b o th in
ordinary tim es an d in tim es of epidem ic.
I would suggest, for ex am p le:

(a) T he m edical ex am in atio n of persons, isolation of patients, observation of persons

suspected of in fectio n , surveillance of persons who h ave been exposed to contagion,
disinfection an d delousing of persons on board, vaccination, etc. ;
(b) Local ex a m in a tio n of vessels used for tran sp o rt, their disinfection, delousing,
an d th e e x te rm in a tio n of ra ts on board, disinfection and delousing of goods, etc. ;
(c) P rovisio n of drin k in g w ater;
(d) E v a c u a tio n a n d disinfection of faeces ;
(e) A d m in istrativ e m easures enabling surveillance to be easily and sim ply carried
out.

3- To specify an d ag ree upo n a nom enclature for the various agencies of health control
which will include :

D octors, a ssista n ts an d h ea lth station s;

Epidem iological sta tio n s w ith laboratories, disinfecting, delousing and rat-exterm m -
atin g statio n s;
M aterial, such as m o to r-b o ats, telephones, etc.,
Isolatio n h o sp itals.

It is im p o rta n t here to d ra w th e a tte n tio n of th e m em bers of th e Mixed Sub-Committee to the

necessity of these different agencies being in existence a t all tim es. In order to m eet the objection
which will certain ly be raised to th e enorm ous expenditure th us entailed in order to yield only
occasional results, th e G overn m ents m u st be advised to em ploy these various agencies for other
Purposes, so th a t th e y should b e re ad y to act w hen the need arises. F o r exam ple, in countries in
which there already exist bacteriological laboratories, disinfecting stations and isolation hospitals,
would be ad visable to m ake use of these w hen epidemics occur on navigable waterways, m
^operation w ith th e services of th e doctors in charge of the h ealth surveillance of waterways.
n countries in w hich these o rg an isatio n s do not exist in sufficient num bers, they should be es a
■shed as soon as possible, n o t m erely for th e supervision of h ealth m easures on rivers bu a so
01the perm anent needs of th e co u n try . In th is w ay these agencies would always possess a trainet
anc^ m aterial in w orking order, an d in case of epidem ics th ey would always be ready o u
e task allo tted to them .
 - go —

4. T here rem ains th e question of penalties.

I th in k th a t th is subject, which is n o t connected w ith h ea lth , should be left for examinat
b y th e m em bers ap p o in ted b y th e T ran sit C om m ittee who are co m petent to deal w ith this matter
I w ould ven tu re, how ever, to m ake one sm all suggestion, th e resu lt of m y ow n somewhat, limited
experience : in th e event of a dispute betw een th e h ea lth services of rip arian S tates, would it not
be advisable to propose th e m ediation of th e Mixed Sub-C om m ittee for In te rn a tio n a l Waterways !
I w ould p o in t as an exam ple to th e m ediation of the H e alth C om m ittee, w hich was accepted by
L a tv ia , Czechoslovakia an d R oum ania in th e event of an y disputes w hich m igh t arise between then
a n d P oland on th e subject of h ealth.

B. G enerel N ote.

G eneva, J a n u a ry 5 th , 1923.

I n view of th e fact th a t th e resolutions ad o p ted b y th e E u ro p ean H e alth Conference held at

W arsaw from M arch 20th-28th, 1922, were approved b y th e In te rn a tio n a l C onference at Genoa,
th e H ealth C om m ittee, to which th e Council of th e L eague of N ations h as e n tru ste d th e execution
of th e program m e draw n u p b y th e W arsaw Conference, exam ined, a t its recen t session held in
A ugust 1922, th e th ird section of th e first of these resolutions, w hich read s as follows :
“3. C om prehensive m easures should be in tro d u ced to deal w ith infectious diseases,
specially th e diseases now raging in th e E ast. These m easures should, in addition to
general provisions, co ntain special provisions dealing w ith :
"(a) F ro n tier traffic (including local fro n tie r traffic) ;
"(b) Traffic b y w ater. ”
P a ra g ra p h (6) of th is section was specially considered b y th e H e alth C om m ittee, in view of the
im portance of th e problem an d th e fact th a t A rticle 52 of th e revised P aris In te rn a tio n a l Health
C onvention of 1912 en tru sts to th e G overnm ents of rip arian S ta tes th e d u ty of m aking special
arran g em en ts for th e san itary regulation of w aterw ays.
I t was therefore th e task of th e H e alth C om m ittee of th e L eague of N ation s, in virtue of the
decision of th e Council already quoted, and w ith a view to facilitatin g th e w ork of th e Governments
of th e rip arian S ta tes of in tern atio n al w aterw ays, to in v estigate th e possibility of draw ing up the
ou tline of a general agreem ent on th is m a tte r.
F o r th is purpose th e H ealth C om m ittee, a t its session held in A ugust 1922, considered it
desirable th a t a M ixed Sub-C om m ittee should be set up, to b e com posed of representatives of the
T ra n sit C om m ittee an d th e H ealth C om m ittee. T he T ra n sit C om m ittee agreed, an d the Mixed
Sub-C om m ittee was com posed of MM. Chodzko, L u trario , an d C arrière, ap p o in ted b y the Health
C om m ittee, an d MM. B aldw in, Popesco an d S tievenard, ap p o in ted b y th e T ra n sit Committee.
In order to consider th e san itary aspect of th e questions to be su b m itte d to th e Mixed Sub­
co m m itte e, a p relim inary m eeting of th e m em bers ap p o in ted b y th e H e alth C om m ittee was held
on A ugust 22nd, 1922, in th e presence of a rep resen tativ e of th e S ecretariat of th e T ra n sit Committee,
A ccording to th e m inutes of th is m eeting, i t w as decided :

1. To consider th e general outline of a system of sa n ita ry regu lations which

be applied to all in tern atio n al w aterw ays ;
2. To enquire into th e following po in ts :
(a) P orts,
(b) Vessels an d th eir crews,
(c) Bills of h ealth,
(ct) E x am in atio n of vessels,
(e) O rganisations for sa n ita ry control ;
3. (a) To request certain ex p erts to draw u p a general re p o rt on th e sanitan'
regulation of w aterw ays an d p o rts in force in various countries ;
(b) To draw u p a d ra ft m odel system of regulations, after considerat
reports received.

In order to o b tain general repo rts on th e san itary regulation of w aterw ays an d p orts, the H ealth
Section of th e S ecretariat of th e League of N ations approached th e following:

The R eichsgesundheitsam t of G erm any,

The V olksgesundheitsam t of A ustria,
The P ublic H ealth Service of D enm ark,
The Chief H ealth C om m ittee of H olland,
The Office of th e Ita lia n D irector-G eneral of P ublic H ealth ,
The H ygienic Section of th e Serbian M inistry of P ublic H ealth ,
T he P ublic H ealth Service of th e U nited S tates.

D r. R ho, chief of th e S an itary Section of th e In te rn a tio n a l D anub e Commission, had ahead?

se n t a d ra ft schem e of regulations.
 — 9i —

The H ealth Section h a s received docum en ts from th e R eichsgesundheitsam t, the Volksgesund-

heitsamt, th e Ita lia n D irector-G eneral of P u b h c H ealth , and th e Serbian M inistry of Public H ealth.
A. The d ra ft reg ulation s for th e sa n ita ry p ro tectio n of D anube traffic, s e n t b y Dr. Rho
consist o f th e following sections :
1. General provisions re la tin g to th e h ea lth surveillance of t h e passengers and crews of
vessels used in tra n s p o rt an d to th e m easures to be applied, when necessary, to persons ruffering
from, or suspected of suffering from , diseases.
2. Special provisions re la tin g to

(«) Cholera, (b) plague, (c) ex anthem atic typhus.

3. Model form s, leaflets, etc.

B. The re p o rt of D r B reger, of th e G erm an R eichsgesundheitsam t, gives a description of the
customs and practises of w aterm en, to g e th e r w ith certain epidemiological considerations on cho­
lera. On th is basis he suggests a p lan o f cam paign which was approved and carried out in G erm any
in 1892-1893 on th e advice of R o b ert K och. H e dem onstrates th e sim plicity and effectiveness of
this plan.
C. Dr. H elly, D irecto r of th e V olksgesundheitsam t of th e A ustrian F ederal M inistry of Social
Economy, s ta te s t h a t he regards it as indispensable th a t th e traffic on international w aterw ays
should be subject to uniform regulations. T he d ra ft system of regulations draw n up by Dr. Rho
was, he says, exceedingly o p p ortun e, th o u g h he w ould like to m ake a few alterations in the m anner
in which th e problem is set forth.
H e draw s a tte n tio n to th e existence in A u stria of a system of san itary regulations for river
traffic w hich h as been in force since 1893 (Decree of Septem ber 30th, 1893, R. G. B. L. No. 148,
and the orders issued u n d er th is decree: No. Z. 1 /23 /406 of S eptem ber 30th, 1893; N o.Z 1/17/059
of November 18th, 1893, an d No. Z. 1 /8 0 /3 7 1 of N ovem ber 20th, 1893).
D. D r. L utrark); D irector-G eneral of P ublic H ealth in Italy , in the general report which
he sends, begins b y draw ing a tte n tio n to th e considerable p a rt played by w aterw ays in the dis­
semination of ce rtain infectious diseases a n d to th e absence of any in tern atio n al regulations dealing
with th e s a n ita ry aspect of th is serious question.
He th en p o in ts o u t th a t special s a n ita ry regulations for w ater-borne traffic have been draw n
up in Italy . These reg u latio n s conform to th e general principles laid down b y th e In tern ation al
Sanitary C onvention an d are based on ce rtain guiding principles:

(a) In sp e ctio n of th e hygienic and san itary conditions of vessels and persons carried
th ereo n before d ep a rtu re, an d issue of special h ealth papers for th e voyage ;
(b) In spection, a t in terv a ls of n o t less th a n 12 hours nor m ore th an 24 hours, of the
hygienic an d s a n ita ry conditions a t p orts of call, com pulsory and otherw ise, and a t the
place of destin atio n . E xecution, w hen required, of such san itary m easures as m ay be
considered necessary owing to circum stances ;
(c) O rgan isation of sta tio n s fo r th e isolation of persons suffering from, or suspected
of suffering from , infectious diseases, and for the m edical observation of patients.

E . D r. S t a m p a r , D irecto r of th e H ygienic Service of th e Serbian M inistry of Public H ealth,

points o u t t h a t in his c o u n try th e system of san itary regulations in force for traffic b y w ater is
the same as in A ustria.
He th en gives in his re p o rt th e nam es of th e bacteriological an d epidemiological stations and
isolation h o sp itals a t present in existence in Serbia. He states th a t th e G overnm ent has two
medical tra in s an d a m edical ship w ith lab o ra to ry an d disinfection station, and th a t each district
health section h as a m obile disinfection colum n provided w ith epidemiological specialists.

Conclusions.

The various ra p p o rte u rs all draw a tte n tio n to th e active p a rt played by w aterw ays in the
dissemination of ce rtain infectious diseases such as cholera, ex anthem atic typhus, plague, etc.
They lay stress on th e necessity of d raw in g up a model scheme of san itary regulations for traffic
Mi in tern atio n al w aterw ay s w ith a view to th e effective prevention of the propagation of
epidemics.
Some of them reg ard it as indispensable th a t a tte n tio n should be paid, in th e preparation
°f such a schem e, to ce rtain principles such as th e following: reciprocal notification of cases
°f certain specified infectious diseases, supervision and execution of m easures in such a way as
to avoid h indrances to traffic.
 — 92 ~

C. P roposal by D r. S t i e v e n a r d

(M em ber of the Advisory and Technical Committee for Communications and Transit.)

G eneva, J a n u a ry io th , 1923.

T he M ixed S ub-C om m ittee for T ra n sit an d H ealth,

C onsidering th a t a general p ro p h y lactic system can only resu lt from com m on an d co n ce rted
actio n on th e p a rt of all n atio n s ;
T h a t, in o rd er to be really effective, an d to check th e ravages caused b y epidem ic diseases
th e p ro p h y lac tic system ad o p te d m u st be such as to co -ord inate all efforts.
T h a t each c o u n try owes it to itself an d to th e whole w orld to co m b a t b y ev ery means in its
pow er a n y contagious disease w hich is discovered to ex ist w ith in its te rrito rie s;
C onsidering th a t, if each n atio n carries on th is cam paign w ith all th e energy of which it is
capable, if it em ploys all th e forces w hich th e c o n stan t progress of tech n ical science places at its
disposal, and if it u tilises th e resources offered to it b y th e in te rn a tio n a l h e a lth organisations, the
necessity for h e a lth defence on th e frontiers will be p ro p o rtio n a te ly reduced ;
A d m ittin g nevertheless th a t, on acco unt of th e v ary in g conditions of in tern a tio n a l traffic
an d th e existence of regions in w hich p ro p h y lactic p ro tectio n m ay b e difficult, if n o t impossible,
it is still necessary to m ake provision for situ atio n s ju stify in g m easures of h e a lth protection on
th e fro n tiers ;
C onsidering th a t it is therefore desirable to determ ine th e m eans of re stric tin g within the
low est possible lim it th e obstacles to com m unications caused b y th e p ro tec tiv e m easures ;
T h a t it is also d esirable to consider th e possibility th a t the ap plication b y a n y co u n try of mea­
sures of th is k in d on its frontiers m ight prejud ice th e in tere sts of in te rn a tio n a l com m erce and reduce
th e facility of com m unications:
Is of opinion t h a t th e H e alth C om m ittee an d th e C om m unications a n d T ra n sit Committee
of th e L eague of N ations should a c t in close a n d p erm a n en t co-operation in dealing w ith the above
problem s as a whole, since th e y concern b o th th ese bodies ;
A nd t h a t th e M ixed C om m ittee, com posed as it is of m em bers of b o th th ese Committees,
m ig h t form a p erm an en t organ of m ediation, as it is specially a d a p te d to find a p ra ctical solution
for an y difficulties arising betw een S ta te s in connection w ith th e app lication of m easures of health
defence w hich m ay affect in te rn a tio n a l com m unications and traffic.

D. N o t e f r o m t h e W a t e r w a y s S u b -C o m m i t t e e

(.submitted by Dr. Lutrario to the M ixed Sub-Committee for Transit and Health.)

G eneva, J a n u a ry n t h , 1923.

The W aterw ays S ub-C om m ittee of th e H e a lth C om m ittee, a t its m eetings held on J a n u a ry
5 th an d 6 th la st, unanim ously decided th a t in certain circum stances w aterw ays m ight prove to be
v ery ac tiv e ag en ts fo r th e spread of ce rta in infectious diseases, an d th a t th is fact was of special
in tere st as regards h ea lth p ro tectio n , p artic u la rly in th e case of those w aterw ay s w hich are great
in te rn a tio n a l arteries. I t therefore considers it necessary to lay dow n th e principles which should
form th e basis for th e p re p a ra tio n of a m odel program m e for th e regulation, from a h ea lth p o in t of
view, of traffic on in te rn a tio n a l w aterw ays. I t considers th a t th e sam e system of regulation m ight
also be em ployed on n atio n al w aterw ays.
A fter a n ex h au stiv e consideration of th e question, th e following resolutions were unani­
m ously ad o p te d :
1. T he W aterw ay s Sub-C om m ittee of th e H ealth C om m ittee considers th a t it is, in principl
in cu m b en t up on th e rip arian S ta te s of an in te rn a tio n a l w aterw ay to su p p ly each o th er regularly
an d un reserv ed ly w ith an y inform ation w hich th e y m ay possess on questions connected with infec­
tio u s diseases of an y kind.
T his ob lig ato ry declaration m ust include :

(а) N otification of first ap pearance of cholera, plague, an d yellow fever (in a c c o r d a n c e

w ith th e conditions of th e P aris In te rn a tio n a l H e alth C onvention of 1912) and of c a s e s 0
plague am ongst ra ts ;
(б) A ny developm ent in epidem ic form of ex a n th em atic ty p h u s, relapsing fever
sm allpox an d d y sen tery w hich has been du ly notified ;
(c) T he ap pearance of a n y infectious disease of an y kind w h atev er if it a s s u m e
an epidem ic ch aracter in d istricts in w hich th e disease does n o t generally appear, or in
w hich it does n o t usually ta k e an epidem ic form .
 — 93 —

2. The W aterw ays S ub-C om m ittee strong ly upholds th e principle laid down by the Paris
In te rn a tio n a l H e alth Conference of 1912 to th e effect th a t in th e campaign against infectious
diseases, interference w ith traffic an d com m ercial relations w ithin the country itself and w ith
neighbouring countries should, as fa r as possible, be avoided.
It considers, how ever, t h a t in th e case of cholera, plague, yellow fever, exanthem atic typhus,
r e la p s in g fever an d b acillary d y sen tery , th e ap plication of proper health measures should be com­
pulsory.
That in case of sm allpox it will suffice to advise th e G overnm ents to apply these measures.
3. The S ub-C om m ittee considers th e following conditions to be essential:

(a) T h a t th e h ea lth control service for w aterw ay traffic, both international and
national, should be carried o u t b y th e S ta te public health service.
(ii) T h a t th is control service should be com posed of th e following :
(а) D octors a n d assistants.
(б) H ealth statio n s, epidem iological stations, laboratories and disinfecting,
delousing an d ra t-ex term in a tin g statio n s ; m aterial such as medical aid boats, m otor­
bo ats, telephones, etc.
(c) Isolation hospitals.

The organisations an d installatio n s w hich already exist in th e various countries should be

drawn upon as fa r as possible b o th for staff and for prophylactic installations. W e do not think
that fresh official h ea lth services should b e created, b u t th a t th e organisations which already
exist should be u tilised b y ad a p tin g th em to cope w ith th e new duties.
The in stallatio n s should be organised on very simple lines and should consist, as far as possible,
of the m aterials available on th e spot.
The Sub-C om m ittee recognised, however, th a t though the m ethods of organisation m ay vary
in different countries, it is absolutely necessary th a t th is h ealth control service should be so orga­
nised as to be able to tak e action in an y circum stances which m ay arise.
4. W ith a view to th e sm ooth w orking of th e service, th e W aterw ays Sub-Com m ittee recom-
lends th a t a liaison organisation should be created betw een the health control services of the
nparian S tates of a n in tern a tio n a l w aterw ay, and th a t th is body should be composed of th e heads
of the various h e a lth services in question.
5. The W aterw ay s Sub-C om m ittee is of opinion th a t th e health control service for the traffic
on international, as well as on n ational, w aterw ays should be organised in norm al tim es and
should be b ro u g h t in to service w henever th ere is th e least call for its em ploym ent in co-ordination
with existing h e a lth services in ten d ed for o th er purposes.
6. As regards th e question of th e relations betw een the h ealth control service for the traffic
on international w aterw ays w ith each o th er an d w ith th e international river commissions and with
the Health C om m ittee of th e League of N ations, the W aterw ays Sub-Com m ittee of th e H ealth
Committee would observe th a t on th is p o in t it would be preferable th a t these questions and also
questions of penalties should be considered in concert w ith the m em bers appointed by th e T ransit
Committee. N evertheless, it v en tures to suggest th a t a proposal should be m ade to th e various
Governments to in sert in th e conventions an article providing for m ediation by the Mixed Sub­
committee for In te rn a tio n a l W aterw ays in th e event of any disputes which m ight arise between
the various h ea lth services of th e rip arian S tates.