595. The Public Health Services in the Island are at present in a transitional stage, the reorganisation first contemplated in 1931 having been held up by lack of funds. It is not surprising, therefore, that the present system should be defective in many respects. A general survey discloses the following weaknesses, which any new Government should seek to remedy:--

  (1) An overlapping of services in St. John's.
  (2) The absence of a preventative Public Health Service.
  (3) The lack of adequate medical facilities in the Outports.
  (4) The decline in the number of nursing centres in the Outports.

Nameless Cove, n.d. Photographer unknown. From the album of photographs furnished to the Newfoundland Royal Commission, August 1933. Courtesy of the Centre for Newfoundland Studies Archives (Coll-207), Memorial University of Newfoundland Library, St. John's, Newfoundland. (45 kb)

  As regards the first of these defects, we understand that the Government already have in view plans of reorganisation which will enable better service to be rendered to the community at less cost than that at present incurred. We consider that the execution of these plans should be put in hand without delay.

  596. The second defect is less easy to overcome since, as a result of a lack not merely of funds but of trained personnel, the institution of a Preventative Public Health Service can only be accomplished step by step, the staff being built up gradually after training abroad. Plans should be worked out with this object in view, and should be put into force by stages as the personnel is available. The existing Medical Officers of Health, of whom there are 12, conduct private practices in addition to their official duties. These officers, if funds were available to employ them on a whole-time basis, would doubtless form a valuable nucleus for a Preventative Public Health Service.

  597. Meanwhile, there are other directions in which the means of medical advice available to the people can be improved. The shortage of doctors in the outports is most marked. Many doctors have practices extending over 50-100 miles of coast; travelling facilities, except by schooner, are limited, and in the winter months many places are ice-bound and scarcely accessible even from the land. On one stretch of the south coast, from Hermitage to Port-aux-Basques, there is no doctor or nurse for 150 miles. On this part of the coast the inhabitants, who number 6,500, have little hope of obtaining medical aid in the case of accident or sudden emergency.

  598. The procedure now adopted in the outports in cases of applications for free medical assistance is that a person, acting on behalf of the patient, should get in touch with the nearest doctor, who may be many miles distant, explain the circumstances to him, and assist in some cases in conveying him to the settlement where the patient lies. The doctor then gives treatment and advice and finally makes out an account for his services which the patient, or a person acting in his behalf, takes to the nearest Relieving Officer, adding to it any incidental expenses incurred. The latter then submits the account, with an affidavit relating to the applicant's circumstances, to the Department of Public Welfare. The Department, after scrutinising the account, either pays it in full or decides what proportion of it should be borne by public funds, and what proportion the applicant is capable of bearing himself. The doctor's fee is normally calculated on a prescribed scale.

  599. This system may perhaps be the best that can at present be devised, but it can hardly be doubted that in the more remote localities a regular system of inspection by Government Health Officers would be more effective. As has been indicated, the number of doctors has decreased by 36, or about 25 per cent., since 1911, one of the difficulties being that, owing to the conditions of poverty in which most of the people live, a doctor, however much in demand, cannot always be assured of obtaining a livelihood from his practice. The Government have endeavoured to meet this difficulty by appointing doctors to magisterial posts in various parts of the Island on conditions which enable them to conduct a medical practice in addition to fulfilling their duties as magistrates. This arrangement has worked well, and is being extended.

  600. Patients who are certified by doctors to require hospital treatment are conveyed to the nearest hospital, often 100-200 miles away, and while in hospital, unless their means are such that they can afford to pay the whole or part of the expenses, are given free treatment. The twelve hospitals in the Island, of which six are in St. John's, are generally well-equipped and managed, but in view of the distances which patients have to travel there is room in many parts of the coast for the establishment of small hospitals of the "Cottage Hospital" type. Much useful work could also be done by means of travelling clinics.

  601. The present system under which "Nonia" nurses are appointed in the outports is based on the salutary doctrine of self-help, that is to say, while the Government makes an annual grant towards the expenses of the Nursing Association, which in turn contributes towards the salary of each nurse, the greater part of a nurses emoluments is expected to be provided by the people of the settlement or district in which she lives and works. The procedure is that a settlement or district requiring the services of a nurse is requested to form a local committee, which undertakes to collect a specified annual amount towards the nurse's salary. On receipt of this assurance, steps are taken by the Association to engage a nurse and appoint her to the district concerned, the remainder of the emolument being provided from the funds of the Association. The nurses engaged by the Association are recruited from the United Kingdom, through the good offices of the Overseas Nursing Association in London; their engagements are usually for two years at a time.

  602. As originally conceived, the plan underlying the activities of the Association was two-fold, (1) the provision of badly-needed nursing facilities; (2) the development of home industries. It was recognised that many places where nurses were most needed would be too poor to make a contribution to a nurse's salary: in such cases it was hoped that by encouraging and providing facilities for the development of home industries, such as spinning and weaving, the people's earnings could be so improved that they would be able to support a nurse out of the returns from these industries.

  603. Unfortunately, the plan has not, in practice, operated in this manner. The places to which nurses have been appointed have not taken to home industries; those which have taken to home industries have not desired the appointment of a nurse. The result has been that in those places where a nurse has been appointed there has been no increase in the earning power of the people, which would assist them in contributing towards her salary; on the contrary, their earning power has shown a progressive decline consequential on the depression of the fishing industry, until to-day the number of nursing centres in the Island has been reduced from 25 to four. Bearing in mind the conditions of distress in which many of the people are now living, it would be altogether too much to expect that they should be able to make a direct contribution towards the salary of a nurse.

  604. It will thus be seen that, on the present basis, the system works paradoxically. That is to say, in proportion as the living conditions of the people deteriorate and they become the more likely to fall victims to illness, the less becomes their prospect of obtaining the services of a nurse. When their conditions improve and they can afford to contribute towards a nurse's salary, the hour of their greatest need will be past.

  605. We have already indicated elsewhere our serious apprehension that the health of the people, formerly good, is in many parts of the Island being seriously undermined by the conditions which they are now called upon to endure after four successive years of adversity. Urgent action is needed if the process is to be checked, and we trust that the subject will engage the earnest attention of the new Government.

  606. In saying this, we are far from seeking to belittle the work done by the Association since it was first established over 10 years ago. On the contrary, we have nothing but admiration for the untiring energy and devotion with which a small band of voluntary workers, principally in St. John's, have sought, by all the means in their power, to further the interests of their less fortunate compatriots in the outports. We would hope that the industrial side of the Association will be kept in being. There exists a very real need for the promotion of home industries on the lines of those carried out, e.g., in Scotland, and in this, and in voluntary aid in the provision of clothing, so urgently required in many parts of the Island, we feel sure that there will be a wide scope for the charitable activities of those who have rendered such devoted service to the cause of the Nursing Association.

  607. There is one further aspect of the Public Health organisation to which we wish to refer. The present Child Welfare Service is another service which is managed by voluntary effort with Government assistance, and we trust that it will also receive the attention of the new Government.

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