COLLABORATION WITH THE GREEK GOVERNMENT IN THE SANITARY REORGANISATION OF GREECE

Transcription

1 L K B i m p [Distributed to the Council and the Members of th e League.] [C. H. 789.] Official N o.: C M. 63c III. Gen e v a, A pril LEAGUE OF NATIONS HEALTH ORGANISATION COLLABORATION WITH THE GREEK GOVERNMENT IN THE SANITARY REORGANISATION OF GREECE CONTENTS. I. Origin, Terms of Reference, and Composition of the Commission of the H ealth Com m ittee of the League of N ations appointed for this purpose, and Enquiries undertaken b y it a t the Request of th e G overnm ent of G reece... 2 II. General O b se rv a tio n s... 4 III. Recommendations regarding the Public H ealth S e r v i c e... 6 IV. Detailed Scheme for the R eorganisation of the S anitary A dm inistration : Central S an itary A d m in is tra tio n... 8 New T echnical Services a n d School of H ygiene (the A thens Centre)... 8 H ealth Services in th e Prefectures selected for the A pplication of the Scheme 11 H ealth Services for th e M etropolitan A rea of A thens and Piræus and for the C ity of S a lo n ic a...12 Scheme for the P erm anent Hellenic H ealth S e rv ic e B udget E stim a te s V. Special R ecom m endations as to : 1. H ospitals M alaria P re v e n tio n Tuberculosis P re v e n tio n L abour Conditions and Social Insurance (on th e basis of a R epo rt prepared b y Mr A. Tixier, Chief of th e Social Insurance Service of the International Labour Office) Q uarantine S e r v ic e VI. Annex Correspondence between th e Prim e M inister of the Greek Republic and the President of th e H ealth C o m m itte e...20 Pages

2 I. O R IG IN, TERM S O F R E F E R E N C E A N D COM PO SITIO N O F T H E COMMISSION OF T H E H E A L T H COM M ITTEE O F T H E LEA G U E O F NATIO N S, A N D T H E ENQUIRIES U N D E R T A K E N B Y IT AT T H E R E Q U E S T O F T H E G O V ERN M EN T O F GREECE. 1. T he U nder-secretary of S tate for H ealth of th e Greek G overnm ent having, in a letter to th e M edical D irector of th e League of N ations of O ctober 20th, 1928, requested the assistance of the H ealth O rganisation of the League of N ations in the san itary reorganisation of Greece, the H ealth Com m ittee, during its th irteen th session held a t Geneva from O ctober 25th to 30th, 1928, adopted the follwing resolution, S tated here in the form in w hich it w as adopted by the Council of the League of N ation s : The H ealth Com m ittee, H aving considered the letter addressed to it b y th e U nder-secretary of State for H ealth of Greece, asking for the collaboration of the League of Nations in the im prov em ent of th e h ea lth o rganisation of Greece : Declares its willingness to accede to this request subject to the approval of the C ouncil of th e League of N ations, an d Proposes th a t its P resident an d P erm anent V ice-president, together with Professor Léon B ernard and Sir George B uchanan an d th e C hairm an of the Malaria Commission, should hold them selves a t the disposal of th e Council of the League of N ations and of th e Greek authorities to give assistance, if so desired, in the matter of carrying out enquiries, and in giving the Greek H ealth A dm inistration such advice as the situ atio n m ay dem and. 2. This resolution was tran sm itted to th e M inister for Foreign Affairs of Greece by the Secretary-G eneral of the League of N ations in a le tte r dated N ovem ber 2nd, In his reply of N ovem ber 23rd, the M inister expressed th e lively satisfaction of his G overnm ent in regard to th e resolution of the H ealth Com m ittee. A t the sam e tim e, th e M inister indicated that his G overnm ent would be represented during the discussion of th e question before the Council by the U nder-secretary of S tate for H ealth, assisted b y a Chief of Section of the same d epartm ent. 3. T he Council, a t its sittin g of D ecem ber 13th, 1928, during its fifty-third session, having noted from the report of M. Quinones de Leôn th a t th e realisation of a far-reaching programme of in tern al developm ent appeared to be th e principal concern of th e Greek G overnm ent, and that the problem of the public h ealth was of v ital im portance in th e economic reconstruction of that co u n try, declared its readiness to accep t th e req u est of th e G reek G overnm ent for co-operation. The U nder-secretary of S tate for H ealth, having been invited to sit a t th e Council table as the representative of Greece, stated th a t the collaboration of the H ealth O rganisation w ith his own D ep artm en t during th e epidem ic of dengue had led to th e present request of his Governm ent. He em phasised the unprecedented difficulties of a public h ealth ch aracter w ith which the Greek G overnm ent had been confronted during the preceding fifteen years, difficulties which explained w hy no definite h ealth policy had been adopted or applied before the recent political an d econom ic stab ilisatio n of Greece. Greece had requested the assistance o f the League o f N ations in order that the Health Organisation might make a technical study o f the plan established by the Greek Government. The advice to be given, preceded where necessary by appropriate surveys carried out by the Health Organisation, would form a happy consummation of the studies already made by the Greek authorities and would materially assist in their application. Moreover, the representative of Greece asked the Council to invite the Health Organisation o f the League o f N ations to make a v a ila b le for his country such facilities fo r the training o f technical staff as m ight be found necessary for the application o f the scheme which the Greek Government would ultimately adopt. The Council adopted the following resolution : The Council : Notes w ith satisfaction th a t the G reek G overnm ent, in its desire to increase the value of the contribution w hich it can m ake to th e general im provem ent of health conditions, has invoked th e assistance of th e H e a lth O rg anisation of th e League ; Approves the proposal of the H ealth Com m ittee relative to the c o lla b o ra tio n of the H ealth O rganisation of the League of N ations in th e reorganisation of public health in Greece, in accordance w ith th e request o f th e Greek G overnm ent; And invites the H ealth Com m ittee, in the light of th e discussions before the Council, to p u t a t the disposal of the Greek G overnm ent th e various technical possibilities of collaboration of th e Com m ittee, including those of its technical Commissions, in order to ensure com plete co-operation in the preparation as well as in th e su b se q u e n t developm ent of th e plan th u s evolved.

3 4- To give effect to th is resolution, an d in conform ity w ith th e indications of th e U nd ersecretary of State for H ealth, the H ealth O rganisation of the League of N ations sent to Athens the Medical Director, accom panied b y Professor H aven Em erson, of the U niversity of Colum bia; Dr. Allen McLaughlin, of the U nited S tates Public H ealth Service ; D r. C. L. P ark, of the Public Health Service of the Com m onw ealth of A ustralia ; Professor B. Borcic, D irector of the In stitu te and School of Hygiene, Zagreb, an d Dr. M. D. Mackenzie, of the H ealth Section of th e S ecretariat of the League of N ations, in order to m ake the surveys upon w hich would be based the advice to be given to the authorities in Greece in conform ity w ith the declarations of the Greek representative at the Council table. These experts arrived a t A thens on Jan u a ry 25th, 1929, and were requested b y th e U ndersecretary of State for H ealth to carry out enquiries in : M acedonia, including th e c ity of Salonica. Thrace. The A thens-piræ us m etropolitan region. P atras (city and district). Corfu (island a n d city). The C ity of Canæa and the w estern region of Crete. E pirus (the c ity a n d prefecture of Jan n in a). These districts were selected by the U nder-secretary of S tate for H ealth as being typical of the country and as lending them selves for financial and o th er reasons to a serious developm ent of the activities of preventive m edicine and public h ealth w ithin the near future. These districts were visited and studied in detail b y one or more of the experts betw een January 25th and A pril 7 th, an d the results described in 148 notes and reports. In the districts assigned for study, 48 hospitals were subjected to detailed exam ination from th e point of view of administration, budget, expenses and activities. A large num ber of dispensaries, orphanages, pharmacies, laboratories an d o ther State, local an d private institutions were visited and reported on in detail. A to ta l of 14 prefectural tow ns an d 82 villages were m ade th e objects of surveys and reports, w ith regard to budgets, dem ographic and economic conditions, m eans of communication, sanitation, w ater supply and the whole of th eir facilities for m edical and san itary work. Similar studies were m ade of the A thens-piræ us M etropolitan region and Salonica, and detailed reports on these were prepared. 5. The President and perm anent V ice-president of the H ealth Com m ittee, as well as Professor Léon Bernard, Sir George B uchanan and the Chairm an of the M alaria Commission, who had been asked by the H ealth Com m ittee to place them selves a t the disposal of th e Council of the League of Nations and th e Greek authorities, in order to stu d y the situation and give advice to the Greek S anitary A dm inistration, m et a t A thens on April 7th, Professor G. Pittaluga, Professor of Parasitology in the U niversity of M adrid, m em ber of the M alaria Commission and of the Health Com m ittee of th e League of N ations, joined the group on April n t h, in order to make a special stu d y of certain m alaria problem s. After studying all th e d a ta collected b y th eir experts and following an exchange of views with the U nder-secretary of S tate for H ealth and his colleagues in Athens, and during visits made to Macedonia th is Commission of the H ealth C om m ittee has the honour to present a series of recom m endations em bodying the advice which it has been invited to give.

4 - 4 II. G E N E R A L OBSERVATIONS. 1. The initiative of the Greek G overnm ent, above described, h as w ithout doubt resulted from the consideration th a t m easures to provide its citizens w ith healthier conditions of living, and w ith m ore effective m ethods of preventing and treatin g disease, are am ong the first requirements of the country, which, after m any years of w ar, economic crisis and political change, and after th e influx of its new population, is seeking peaceful developm ent a n d stab ility. 2. It is no m a tter for surprise, when the circum stances are considered, th a t such measures are urgently needed. We do n ot atte m p t to com pare Greece w ith other countries of Europe in regard to the prevalence of sickness which is preventable. Such com parisons would be unprofitable and m ight easily be misleading. I t suffices to say th a t ab u n d an t evidence has come before us th a t m alaria, tuberculosis, enteric fever, dysentery an d o th er essentially preventable diseases are far too com m on, th a t the welfare of m others and infants is often capable of great im provem ent, and th a t the treatm e n t of the sick is often lam entably defective. There can be no d o u b t th a t th e Greek people and its G overnm ent would find th a t system atic atten tio n to the prevention of disease and reduction of m orbidity and m o rtality would profit the country econom ically, as well as in m an y o th er ways. 3. As will be seen from the recom m endations below, the proposals of the Commission for this purpose relate m ainly to w hat m ay be term ed ex p ert questions, e.g., th e establishm ent and utilisation of a public health service, th e training of its personnel, th e teaching of hygiene, the cam paign against m alaria, and m any like m atters. B ut, how ever com petent and devoted the service of the hygienist and the doctor m ay be, it forms, of course, only one of m any factors which are necessary to secure the healthiness of a people. Its success m ust always depend in large m easure on concurrent social conditions and on sim ultaneous efficient local government. In o ther words, the necessary am enities of m odem com m unal life, w hether in larger or smaller com m unities, m ust be obtained a t the sam e tim e public w ater supplies, sewerage, good roads an d paving, public b ath s, p ark s a n d recreation grounds, facilities fo r sp o rt, m eans of communication, construction of healthy houses, factories an d schools, public lighting, town-development planning, and m any other exam ples could be given. We have h ad evidence th a t num erous works of this kind are contem plated, or are being already u ndertaken in Greece, some of them involving im p o rtan t schemes and large capital expenditure. W e have, how ever, been struck by the small ex tent to which, up to the present, these am enities of p articu lar cities or regions are being considered and dealt w ith as a whole b y the m unicipal, prefectural or o ther local-govem em ent authorities possessing reasonable autonom y and funds in regard to them. There is, as a rule, no greater aid to public health th an an active local patriotism and efficient and responsible regional administration. Some decentralising of au th o rity in local m atters, if wisely planned, m ight be productive of much advantage to the public h ealth of Greece. 4. We would add also th a t in Greece, as m uch as, if not even m ore th an, elsewhere, it is a tradition th a t individuals, from patriotic or philanthropic m otives, should contribute generously to works of public u tility in th eir private capacity or by supporting v o lu n tary societies which are completely independent of any S tate or m unicipal control. H aving seen some of the benefits th u s conferred, and hospitals and o ther in stitu tio n s w hich have been th u s provided, we wish to m ake it clear th a t none of the recom m endations which we m ake below are intended in any w ay to depreciate this valuable v o luntary w ork; we consider, on the contrary, th a t certain of these institutions are w orthy of every encouragem ent. The organisation of th e official public h ealth services which w e recom m end should give every support to those which have real value, and the voluntary agencies in their tu rn should profit from the advice, direction and counsel which an expert public h ea lth personnel would have th e d u ty of giving them. 5- T urning now to m ore d irectly m edical questions, we w ould first call a tte n tio n to an unsatisfactory feature of the medical profession in Greece, which has been brought to our notice in m any ways. The profession is overcrowded. There are too m any doctors seeking to obtain a livelihood from the practice of curative m edicine or as hospital doctors. The num ber of stu d en ts at the U niversity Medical School a t Athens and its associated hospitals is m uch too great, and the equipm ent of the school, in regard to laboratories and clinical facilities, is c o n sp ic u o u sly defective. There is no possibility, under present conditions, of the stu d en t being educated up to a sufficiently high sta n d a rd of curative m edicine, to say n o thing of the teaching in the art of

5 5 prevention of disease, knowledge of which has become so im p o rtan t for every medical stu d en t.1 Facilities for post-graduate studies are also lacking. As regards post-graduate studies directly concerned w ith practical hygiene, certain specific recom m endations are m ade later in th is report. 6. Still more notable is the need of form ing a personnel of hospital nurses and health visitors. The tradition has n o t been sufficiently established in Greece th a t hospital nursing is am ong the most honourable of th e professions, an d one th a t offers a career to educated and intelligent women of every social class. An a ttem p t should, we consider, be m ade to establish this trad itio n of w ell-disciplined and w ell-instructed hospital nursing, beginning w ith those hospitals which can provide their nurses w ith the conditions of board, lodging, pay and opportunities of rest and recreation which are essential for th e purpose. 7. A similar need for im provem ent exists in the case of m id wives. The opportunities and nature of the training given a t the one training centre a t A thens are lam entable ; the midwives leave it very im perfectly equipped to follow th eir vocation, and th ey receive subsequently no expert supervision or in stru ctio n. 8. Our inform ation and inspections show us th a t there are some very satisfactory hospitals in Greece. B ut m any others are badly equipped, badly constructed, overcrowded, and do not supply to the patients even the* m inim um of effective m odern treatm e n t which th ey require. This observation applies to m any hospitals m aintained b y the S tate as well as to specialised hospitals for tuberculosis and m ental diseases. B etterm ent could seem ingly in some cases be obtained by radical change in m ethods of adm inistration ra th e r th an b y increase in personnel or even in expenditure. M utual arrangem ents are desirable betw een hospitals in the same locality to permit b e tte r specialisation in tre a tm e n t an d to save dup lication of personnel. 9. Finally, an d as the key to the beginning of substantial im provem ents in the health conditions of Greece, we come to th e steps to be taken to provide an ex p ert public h ealth service in the future, and to th e interim m easures which appear desirable w hilst th a t expert service is being formed. In this m a tte r we can b est fulfil our m andate b y m aking th e recom m endations which appear in the following ch apter in some detail. 1 Reckoning one doctor per thousand oi population and a professional life of thirty-five years, one hundred medical graduates leaving the school annually should suffice for the needs of the country. We believe >t to be the case, however, that, with the means at present at the disposal of the Faculty, it is impossible to give adequate teaching even to this reduced number of students.

6 III. RECOM M ENDATIONS R E G A R D IN G T H E PU B LIC H E A L T H SERVICE. The Commission has atten tiv ely considered the inform ation regarding the existing public health services which its experts have obtained, and in concert w ith th em has form ulated the proposals set out below. In so doing, th e Commission considers it unnecessary to set out th e nature and position of th e public h ealth services, central an d local, as th ey exist a t present. Although there are com petent m en in A thens an d in th e provinces who have w orked hard and produced good results, w ithin the lim its im posed b y the present system, or ra th e r lack of system, the Commission cannot consider th a t satisfactory results could be obtained b y an y m ere expansion of th e existing organisation. The public h ealth service, to be effective, should be arranged on a new basis and should have new objectives. 1. The technical personnel of th e public h ealth service, w hether w orking in the centre or in the provinces, should consist of m en thoroughly train ed in m odem m ethods of preventing disease and in the m odem practice of hygiene. Save in a few isolated cases, this is not so at present. 2. The Public H ealth M edical Service should have a t its disposal an appropriate personnel of trained san itary inspectors and of h ealth visitors. A t present th e S anitary Police act independ en tly of an y public h ealth organisation, and h ealth visiting, so far as it is done, is left to volu n tary agencies. 3. To m eet these needs, the establishm ent of new Technical Services and of a School of H ygiene is indispensable. W e propose below th a t certain regions of the co u n try should be chosen in which to commence public h ealth w ork on th e new lines. These regions are as follows: M acedonia, including Salonica. The m etropolitan area of A thens and Piraeus W estern Crete. A prefecture in E pim s. A prefecture in Peloponnesus. The Islan d of Corfu. These areas would form the field to which the technical services would be applied and in which instruction would be given from the Centre which will be established in A thens. 4. Pending th e com pletion of this Centre, selected Greek m edical officers should be given im m ediate facilities for practical studies abroad a m a tte r in which assistance would be given willingly b y th e H ealth O rganisation of th e League of N ations. Meanwhile, th e principal officers of th e Centre should be appointed w ithout delay. They should include three expert instructors w ith large experience respectively in general hygiene and preventive m edicine, m alaria prevention and san itary engineering. W e understand it is the intention of th e Greek G overnm ent to call upon experts from abroad for these three professorships. 5. The appointm ent of th e la tte r will place a t once a t the disposal of the G overnm ent as well as of th e authorities adm inistering the special regions com petent technical advisers who can be consulted on any m atter of public health developm ent, and who would be in the closest association w ith the health officers referred to im m ediately above when these officers retu rn from abroad and take u p th eir duties. 6. Sim ultaneously, suitable m en should be selected to be trained as san itary inspectors, and suitable women to be trained w ith the aid of the Hellenic Red Cross as hospital nurses and as health visitors. 7- This process of form ing a trained public h ealth personnel from w hich th e h ealth service would be recruited would be the first step tow ards the form ation of a P erm anent Hellenic Health Service in a few years say, in Our experts, after consideration of m any alternatives, have outlined a series of proposals regarding the nature and responsibilities of such a service. These proposals, which th e C o m m issio n endorses, are set out a t th e end of th e following chapter (p. 13).

7 8. The practical m easures which can be tak en now w ith this as the u ltim ate objective, in order to make a su b stan tial beginning w ith public health adm inistration on new lines, are the subject of detailed recom m endations a t the beginning of the following chapter (p. 8). In effect, we consider th a t th e nucleus of the P erm anent Hellenic H ealth Service should be formed a t the earliest practicable date. I t would consist a t th e Centre of the new Technical Services and the School of H ygiene and in th e provinces of the personnel responsible for the areas selected fo r the application of th e scheme. The rem aining areas of Greece for th e tim e being w o u ld continue under the present adm inistrative regime. It seems to us necessary, however, a t once to transfer to the existing C entral S anitary Administration those central services which are a t present included in other Ministries. These sanitary services could provisionally retain th eir offices in the several M inistries concerned, but they should be considered as units detached from th e C entral S anitary A dm inistration, and they would receive th eir instructions from th e perm anent head of th a t A dm inistration. 9. The existing C entral S a n ita ry A dm inistration, according to our proposals, w ould consequently come to be com posed of : (a) The present adm inistrative sections of th e U nder-secretariat of S tate for Health. (b) D etached services now w ith other M inistries. (c) The new Technical Services which will be created, including the School of Hygiene We consider it an indispensable condition for the w orking of a m odem and effective health service th a t it should be fully protected from political influences ; such a service ought to be a purely technical service, having a t its head a perm anent technical chief and form the advisory and executive organ of the G overnm ent on h ealth questions. In all countries, especially in those which go through a period of intense economic reconstruction, public health activ ity ought to be considered as an instrum ent of n ational progress and, to secure its success, should be system atically co-ordinated w ith th e activities of o ther S tate d ep artments. Looking to the au th o rity exercised b y th e P resident of the Council of M inisters over every department of the S tate, we believe th a t there would be advantage in th e present U nder- Secretariat of S tate for Health, w ith its new services, being attach ed to the Prim e M inister s office. 11. We think it impossible to fom i a m odem h ealth service w ithout requiring public health officers to give the whole of th eir tim e to th e requirem ents of th e service or w ithout ensuring th a t they should receive adequate pay. W e propose th a t tem porary contracts should be m ade w ith the medical officers who would be necessary when our scheme begins to operate, and th a t in general they should receive a m inim um p ay of 8,000 drachmae per m onth. A higher p ay u p to 12,000 and 15,000 drachmae ought to be contem plated, however, for certain officers because of their competence or the im portance of the service en tm sted to th em ; for exam ple, the D irector of Divisions or the Chief Medical Officer of the M etropolitan A thens-piræ us Service. These medical officers ought in addition to be assured th a t th eir salary will be periodically increased, and that they will receive preferential treatm e n t in the nom ination of m em bers of the P erm anent Hellenic H ealth Service if th eir w ork has been satisfactory. 12. Finally, it seems to us essential to recom m end th a t a special com m ittee should be set up with the object of studying G reek san itary legislation in order to codify existing laws and render the legislation easier of com prehension and facilitate its enforcem ent. 13. The budget estim ates necessary for the application of th e scheme have been worked out so far as the lim ited inform ation a t our disposal a t the present tim e has perm itted. T hey should therefore only be considered as an approxim ate indication of the to tal sum required. The proposals contained in th e chapter which follows constitute a m ore detailed description of the scheme which has ju st been outlined. r~

8 IV. D E T A IL E D SCHEM E F O R T H E RE-O R G A N ISA TIO N O F T H E SA N ITA RY A D M IN ISTRA TIO N. C e n t r a l S a n it a r y A d m in is t r a t io n. This adm inistration, w hich a t present constitutes an U nder-s ecretariat of S tate and which we suggest should be attached to the Prim e M inister s office, would continue to function until the P erm anent Hellenic H ealth Service itself begins to function say, in 1932 or It would include : 1. The present adm inistrative sections of the U nder-s ecretariat of State for H ealth. These would have to undertake : (a) General direction of th e local san itary services in those p arts of Greece which are not included in the d istricts selected for th e application of the scheme. This general direction would include questions of personnel and finance, as well as the preparation of the b udget in respect of these districts. (b) The control of hospitals in th e sam e districts. (c) P o rt san itary service. (d) R egistration of doctors, pharm acists, m idw ives, etc. 2. The various h ealth services of th e M inistries of th e Interior, Communications, Public In stru ctio n and Justice. The M inistry of N ational Econom y would retain its service of fa cto ry inspection a n d in d u stria l hygiene. 3. The new C entral Technical Services of hygiene and preventive medicine, and th e School of H ygiene, called th e A thens C entre N e w T e c h n ic a l S e r v ic e s a n d Sc h o o l o f H y g i e n e (t h e A t h e n s Ce n t r e ). 1. F u n c t i o n o f t h e C e n t r e. The C entral Technical Services an d the School of H ygiene, referred to as the Athens Centre, will be constituted as soon as the necessary staff of directors can assum e their posts, as th e nucleus of the future P erm anent Hellenic H ealth Service. T he functions of the Centre will be: (a) To direct and adm inister th e public h ealth w ork in the districts selected for th e application of the scheme, u nder the au th o rity of the U nder-secretary of State for H ealth. (b) To tra in all classes of public h ealth personnel. (c) To advise the head of the C entral S anitary A dm inistration on all m atters in th e field of public h ealth. 2. T h e D i v i s i o n s o f t h e C e n t r e. The Centre will be com posed in th e beginning of five divisions, which in the first instance will be restricted to public h e a lth problem s of im m ediate im portance. I. D ivision of H ygiene a n d P rev en tiv e M edicine, including th e School of H ygiene. II. D ivision of M alariology. III. Division of S anitary Engineering IV. Division of Pharm acology an d B iochem istry. V. D ivision of R esearch. U nder the technical au th o rity of the D irector of the School, th e general adm inistration of these divisions will be assum ed b y a h ead responsible to th e U nd er-s ecretary of State for H e a lth in th e exercise of his ad m in istrativ e duties. The divisions, as will be specified in each instance, will be under the technical authority of th e several ex p e rt instructo rs.

9 I. Division of Hygiene and Preventive Medicine, including the School o f Hygiene. This division will be under the technical au th o rity of th e D irector of the School of H ygiene, whom the Governm ent proposes to invite from abroad and who will also a c t as Professor of Hygiene and Preventive Medicine. The Division will consist of: A. T he T echnical Services. B. The School of H ygiene. A. The Technical Services will include the following sections: 1. M aternal, In fa n t an d Child W elfare (the pre-school child). 2. T uberculosis an d o th er social diseases. 3. School H ygiene (welfare of the child of school age, th e adolescent and physical education). - This section will be constituted by the existing Medical Service a t the M inistry of Public In stru ctio n, which will becom e a service of th e C entral S anitary A dm inistration attach ed to the M inistry of Public Instruction. 4. Venereal Diseases. The first task of this section will be to study the existing system for the control of these diseases, w ith a view to the provision of adequate diagnosis, treatm ent and supervision a t the health centres and other institutions, and the control of diagnostic lab oratories. 5. C ollaboration w ith the H ealth and Social Insurance Services. This section will act in collaboration w ith the com petent services of th e M inistry for N ational Econom y. 6. Epidem ic Diseases. This section will be en tru sted w ith th e study of epidem ic diseases and of the statistics relating to them, as well as w ith th e control of these diseases in the d istricts selected for th e application of th e plan. The above-m entioned services will also have the d u ty of collecting the d a ta which will serve as the basis for reports to be prepared periodically on the state of th e public health in Greece. To these services will be en tru sted from the beginning th e adm inistration and control of h ealth activities in the regions selected for this purpose and m entioned Sbove. T hey will ex ten d th eir scope gradually to other areas so as to include progressively all the existing official health agencies in the country as well as tho se w hich m ay be established in future. B. The School o f Hygiene. The prim ary purpose of this School is to train : (a) the future medical officers of th e Permanent Hellenic H ealth Service; (&) candidates for positions in the m unicipal and com m unal health services ; (c) m edical officers for th e social insurance services, as well as m edical inspectors of labour and of industrial hygiene. The School will m ake the arrangem ents necessary to facilitate th e training of h ealth visitors and sanitary inspectors. It will provide fo r special courses for social w orkers an d for teachers in th e public schools. The School m ay co-operate w ith th e Medical F acu lty in arranging for courses in hygiene for medical students. Examinations. An entrance exam ination will be required of all candidates for th e Degree in Public H ealth. On the term ination of the course, diplom as or certificates will be aw arded to those who have been successful in the exam inations. These diplomas and certificates will be of different types according to th e studies for which they are aw arded, and the possession of one or another ty p e of these will be m ade a legal requirement for candidates for appointm ent to perm anent positions in the S tate or local h ealth services. Nevertheless, the possession of a foreign diplom a will satisfy th e requirem ents in cases where an equivalent course of stu d y is known to have been followed, based on inform ation obtained from the Commission on E ducation in H ygiene and Preventive Medicine of th e H ealth Com m ittee of the League of N ations. Teaching Staff. The teaching staff will consist of the D irectors of th e A thens Centre and of other Divisions of the C entral S anitary A dm inistration, as well as of o ther professors invited on the recom m endation of th e D irector of the School by th e H ead of th e S anitary A dm inistration. This staff will constitute a com m ittee, of which the D irector will act as C hairm an, for th e purpose of organising courses and preparing a detailed program m e of training, an d requirem ents for m atriculation an d final exam inations, in collaboration w ith th e Commission on E ducation m Hygiene and P reventive Medicine of the League of N ations, to whom an annual report on the working of the School will be subm itted. The School will establish teaching laboratories, a lib rary for th e A thens Centre, a m useum of hygiene and a service of p o p u lar h e a lth education.

10 10 II. D ivision of Malariology. As m alaria is a m ajor public h ealth problem in Greece, the following recom m endation of the M alaria Commission of th e League of N ations should guide the organisation and activities of the division: E ach G overnm ent should establish a central perm anent organisation, either independent or attach ed to an in stitu te, com posed of several selected workers who would devote th e ir whole tim e to m alaria research an d w ould a c t as scientific advisers. Besides teaching, th e fu nctions of th is division w ould b e: 1. S tudies a n d applied research. 2. O rganisation of an ti-m alaria m easures in Greece. 3. Control of th e purchase, m anufacture an d distrib u tio n of quinine and of other drugs used in th e treatm e n t of m alaria. This division will be placed under the technical direction of th e m alariologist whom the G overnm ent proposes to in vite from abroad. The headquarters of the division will be a t the C entral M alaria L aboratory, to be established at th e A thens Centre. R egional m alaria laboratories will be established by this division a t Salonica and other centres, using th e public h e a lth laboratories alread y existing or to be created, as th e need arises. I t is proposed th a t this division should ad o p t the program m e of applied research and field activities set out by the M alaria Commission of the League of N ations. The application of th is program m e to local conditions should be studied system atically in collaboration with the M alaria Commission. III. Division o f Sanitary Engineering. This division will be placed under th e technical direction of th e san itary engineer whom the G overnm ent proposes to invite from abroad. In addition to its functions of teaching, it will undertake surveys in Greece, faith special reference to the districts organised under the new scheme. These surveys will relate to th e provision of pure w ater supplies, sewerage and refuse disposal, housing and like questions. The surveys will be followed b y th e issue of periodic reports. The division will give expert advice to central and local authorities on plans for w ater supply, sew erage a n d refuse disposal an d to w n-planning schemes. I t will m aintain a special lab o rato ry for the exam ination and control of w ater supplies and sew erage a n d refuse disposal. A cting w ith th e D ivision of M alariology, it m ay be consulted in regard to drainage and irrig atio n schem es a n d o th er public w orks in m alarious regions. I t will p ay p articu lar atten tio n to the installation of pure w ater supplies, sewage disposal and th e general san itatio n of ru ral homes and sm all villages. IV. D ivision o f Pharmacology and Biochemistry. This division m ay be placed under th e technical direction of the Professor of Pharmacology a t the F acu lty of Medicine, U niversity of A thens. T he functions of th is division will be, in a d d itio n to teach in g in th e school : 1. The control of pharm acies, pharm aceutical products, and eventually of foodstuffs from th e p o in t of view of hygiene. 2. The control of biological products. 3. The preparation of a program m e of studies on nutritio n. V. Division o f Research. W e consider it desirable th a t th e functions of this division, including teaching, should be undertaken b y the Hellenic P asteu r In stitu te, which will preserve its sta tu to ry independence. W e propose th a t the D irector of th e School of H ygiene and an o th er of the D irectors of the C entre should have seats on th e A dm inistrative Council. The G overnm ent, on the re c o m m e n d a - tio n o f the A thens Centre, could utilise this In stitu te in the stu d y of scientific and practical health problem s of interest to G re e c e. Moreover, this In stitu te m ight b e en tru sted b y the G o v e rn m e n t w ith routine bacteriological exam inations, and as its responsibilities on behalf of th e State w ould thereb y be increased, the S tate subvention should be proportionally augm ented.

11 3- T h e U t i l i s a t i o n o f t h e R e g i o n s b y t h e S c h o o l. The regions to which th e new plan of organisation will apply will be utilised for the practical training of th e stu d en ts of the School. It shall be the d u ty of th e D irector of the School, together w ith the Professors of Malariology and Sanitary Engineering, to serve as technical advisers to the C entral S anitary A dm inistration on the public health activities and preventive m easures going on in these regions, and to report on these activities to th e head of th a t A dm inistration. 4. A d v i s o r y C o m m i t t e e o f t h e C e n t r e. An Advisory C om m ittee should be co n stitu ted com posed as follows : 1. The D irector of the School. 2. The D ean of th e F acu lty of Medicine. 3. The Professor of H ygiene of th e F aculty. 4. The Delegate of the C entral Medical Syllogue. 5. The representative of th e Superior Council of Public Instruction. 6. The R ector of th e Superior School of A griculture. 7. The R ector of th e Polytechnic School. 8. The D irecto r of Colonisation. 9. The D irector of W orks. 10. The D irector of the A rm y Medical Service. 11. The D irector of the N aval Medical Service. 12. A representative of the Engineers Syllogue. 13. A representative of the C entral Cham ber of Commerce. 14. A representative of th e A ssociation of Shipowners. 15. Two representatives of T rade Unions. 16. A representative of the N ational Association of E lem entary and Secondary School-teachers. 17. A representative of the A gricultural Co-operatives Association. 18. A representative of the Association of Journalists. 19. The President of the Hellenic R ed Cross Society. 20. The D irector and th e Chief Medical Officer of the C entral Sickness Insurance O rganisation. 21. The M ayor of A thens. 22. A representative of th e P atriotic League. 23. A representative of the O rthodox Church. 24. A representative of th e Association of M unicipalities. 25. O ther persons nom inated b y the Prim e Minister. The President of th e A dvisory Com mittee will be nom inated b y the Prim e M inister on the proposal of the head of the C entral H ealth A dm inistration. The Advisory Com m ittee shall be authorised to m ake any proposal it m ay judge useful to the Prime M inister through the interm ediary of the head of the C entral S anitary A dm inistration, and shall be consulted b y th e Prim e M inister w henever he m ay deem necessary. H e a l t h S e r v ic e s in t h e P r e f e c t u r e s s e l e c t e d f o r t h e A p p l ic a t io n o f t h e S c h e m e. 1. The following regions will be selected for th e application of th e p lan: The area adm inistered b y th e G overnm ent General of Macedonia. The City of Salonica. The Prefecture of Canée, W estern Crete. The Prefecture of Corfu. The Prefecture of Jan n in a in Epirus. The A thens-piræ us m etropolitan region. 2. The new plan of organisation will consist essentially in transform ing th e purely bureaucratic prefectural health organisation into a system of h ealth centres. The m edical officer of the prefecture will organise in selected regions an average of three to five of these centres per prefecture. E ach centre will include: 1. One or m ore dispensaries for m alaria, tuberculosis, m atern al and infant welfare; in tow ns in ad d itio n, a school h ea lth clinic. 2. A h e a lth visiting service. 3. A service of san itary inspection especially for the m inor problem s of sanitary engineering (latrines, drainage, m inor sanitation) in relation to farm s, villages and towns. 4. A public h all for in stru ctio n a n d recreation.

12 12 Shower-baths and a sm all pharm acy are also desirable. The health centres m ay be located in public hospitals in regions where these are properly organised. In other regions, on th e other hand, hospital service will be organised as a natural outgrow th of th e centres. The dispensaries of the Refugee Settlem ent Commission in M acedonia, which will be handed over to th e G overnm ent on Ja n u a ry is t, 1930, should be transform ed gradually into health centres, b u t th e y will be used in th e developm ent of th e schem e from th e beginning. 3. In th e chief towns of prefectures, a public health laboratory for the diagnosis of infectious diseases will serve as a base on which the system atic san itatio n of the region will be undertaken. A regional laboratory, w ith a special section for the system atic stu d y of the prevention of malaria, under the direction of the D ivision of M alariology of th e A thens Centre, will be organised at Salonica. 4. F or a province such as M acedonia, covering six prefectures, the position of regional medical inspector should be given to a h ealth officer belonging to th e first group who are to receive training abroad (see p. 6, para 4). H is m ost im p o rtan t w ork will be to organise and direct the sanitary services of those prefectures where h ealth centres are to be established from th e start. The regional centre, of w hich he will be in charge, will be m ade u p of th e following sections: (1) A d m inistrative Section. (2) L ab o rato ry Section of B acteriology an d Epidem iology. (3) Section for M alaria a n d P arasitology. Sections 2 and 3 will form th e regional public h e a lth lab o rato ry. (4) Section for th e S an itary Service of P orts. (5) Section for R u ra l S anitation. A ssistants of the D irector will direct these Sections as soon as suitable candidates are available. One of th e assistants in the A dm inistrative Section will be en tru sted w ith the routine admin istration of those prefectures in M acedonia in w hich for the tim e being it is necessary to retain the old form of organisation. H e would however prepare for th e gradual extension of the new form of organisation to th ese prefectures. A n o th er assistan t will be seconded to th e city of Salonica, to a c t as chief m edical officer. 5. For u rb an areas, dispensaries and h ealth centres m ay be so developed as to allow them to serve as models for th e application in th e fu tu re of the system of health insurance along the lines to be indicated b y the Jo in t Commission of E x p erts for the S tudy of the Relationship betw een th e Public H ealth Services and H ealth Insurance O rganisations, set up b y the Health O rganisation of th e League of N ations an d th e In tern atio n al L abour Office. H e a l t h S e r v ic e s f o r t h e M e t r o p o l it a n A r e a o f A t h e n s - P ir æ u s a n d f o r t h e C i t y o f Sa l o n ic a. A. Athens-Piræus. F o r th e purposes of rational health adm inistration in A thens and Piraeus, there should be created a single health service which would serve th e whole territo ry of these two cities, and be known as th e M etropolitan H ealth Service of A thens-piræ us. Functions o f the Service. The duties and powers of th is service should include : (а) The enforcem ent of general san itary laws and local regulations. (б) Supervision of the public h ealth and the stu d y of local v ital statistics, including those relating to b irth s and deaths according to sex, district, season and, if possible, age and cause of death, differentiating betw een legal residents and transients. (c) Liaison w ith other san itary authorities in m atters w hich m ay concern them. (d) Supervision of all com m unicable diseases, including analysis of notifications, epidemiological studies, control of tuberculosis and venereal diseases, and m easu res for th e control of m alaria, trach o m a a n d leprosy. (e) M aternal, infant and child welfare (including children of pre-school and school age). if) Supervision of w ater supplies, m ilk products and other foods ; inspection of places w here such foods are p repared or exposed for sale, including slaughterhouses an d markets. { ) Supervision of the san itary condition of w orkshops and factories for the b en efit of the health of workers as well as for th e benefit of the neighbourhood. (h) Provision of laboratory service for com m unicable and occupational diseases.

13 13 (t) S anitary supervision of hospitals and dispensaries in the tw o cities. Co-ordination of all hospital services. A pplication to th e com petent authorities for the establishment of new dispensaries, hospitals or other institutions according to the requirem ents. (j) The right to en ter private property to determ ine w hether it is fit for hab itatio n or when th ere is reason to suspect th e presence of a case of contagious disease. (k) All public h ealth activities a t present perform ed w ithin th e area by o ther State departm ents. (I) P reparation of local h ealth regulations. Medical Officers. The service should be adm inistered by a chief medical officer entrusted w ith th e direction of the health service of th e region. He should be a m edical officer devoting the whole of his tim e to the duties of his office. Ultimately, he should be a senior medical officer seconded for the purpose from the Permanent Hellenic H ealth Service. Advisory Board. There should be an A dvisory B oard appointed by the head of th e C entral H ealth Service. The chief medical officer should atte n d th e m eetings of this Board. This B oard would include the following m em bers : The M ayor of A thens \ The M ayor of Piraeus I The Chief of Police > ex-officio. The Inspector of L abour i The School In sp ecto r / A representative of th e labour unions. A physician. A m erchant, director of in d u stry or other m em ber of the Cham ber of Commerce. A rep resen tativ e (preferably a woman) of p riv ate h ea lth agencies. The appointm ent of the four la tte r m em bers should be for four years, in such a w ay as to provide a vacancy to be filled each year. Duties of Advisory Board. The functions of th is B oard should be to advise th e H ead of the C entral S anitary A dm inistration and the chief m edical officer of the m etropolitan area on all m atters relating to th e public health and prevention of disease in th a t area. Duties of Chief Medical Officer. The chief m edical officer should take the steps necessary to carry out the duties of th e service as enumerated above w ithin the lim its im posed by the sanitary regulations. Health Districts. To facilitate the carrying out of the functions of the service, it would appear to be advisable to appoint district m edical officers who would be responsible to the chief m edical officer of the metropolitan area. More detailed suggestions on the organisation of th e A thens-piræus M etropolitan H ealth Service will be p resented later. Functions of the Health Service. B. City of Salonica. The functions of the H ealth Service of Salonica should include for th a t city powers and duties sim ilar to those provided for th e H e alth Service of th e A thens-piræ us m etro p o litan area. Duties. Similarly, the duties of th e chief m edical officer (see. p. 12) should be those proposed in the case of the chief m edical officer for the A thens-piræ us m etropolitan area. More detailed suggestions on th e organisation of the Salonica H ealth Service will be presented later.

14 i 4 S c h e m e f o r t h e P e r m a n e n t H e l l e n i c H e a l t h S e r v i c e. 1. A perm anent public health service shall be created and be know n as the Hellenic Health Service This service will begin to function in I t will act as an advisory technical service attach ed to the Prim e M inister s office and as the executive organ for the co-ordination, organisation and adm inistration of all activities in the field of public health, which are undertaken b y S tate and local authorities or private agencies, in conform ity w ith the provisions of th e S a n ita ry Laws in these m atters. 2. The appointm ent of all m edical officers and of all other technical h ealth officers will be m ade b y the P resident of th e Council of M inisters on th e recom m endation of an Appointments Com m ittee. T his Com m ittee will be composed of th e following : The P erm anent H ead of th e Hellenic H ealth Service. T he D irecto r of th e School of H ygiene. T he D irecto r of th e D ivision of M alariology. T he D irecto r of th e D ivision of S a n ita ry Engineering. T he D irecto r of th e D ivision of P harm acology. 3. The following qualifications are necessary for ap p o in tm en t as m edical officer : {a) Possession of a diplom a in m edicine of a recognised m edical school. (b) Possession of th e diplom a in public h ealth from the School of Hygiene, or of a public h e a lth diplom a from a recognised school abroad. 4. V acant positions for m edical officers in the service shall be advertised. Candidates for positions as m edical officers in the service, before being appointed, m u st subm it to a medical exam ination and shall be appointed on probation for a period of tw o years, after which th ey may be confirm ed in their perm anent positions on the decision of th e A ppointm ents Com mittee, which, before acting, shall inform itself as to th e su itab ility of the candidate for his position. 5. T he A ppointm ents Com m ittee will prepare regulations w hich m ust be approved by the Prim e M inister and w hich will com prise am ong others th e following provisions : appointments in th e service should carry w ith it th e rig h t to pension, periodic leave, sick leave and eligibility for stu d y leave. These regulations should indicate the procedure to be followed in case of default on the p a rt of h ealth officers, who m ay n o t be deprived of th eir office except for incapacity, insubordination or bad conduct, and only after an investigation, th e results of which will be brought before th e A ppointm ents Com m ittee, whose decisions will be subm itted to the Prime M inister for approval. 6. A D irector-g eneral will be appointed, as well as such D irectors of Divisions, senior medical officers, m edical officers, san itary engineers, o ther technical officers and all o th er personnel, including h ealth visitors and san itary inspectors, as the Prim e M inister m ay judge necessary, on th e recom m endation of th e A ppointm ents Com mittee. 7. The m inim um scale of salary of an y m edical officer in the service should be 8,000 drachmae m onthly a t th e beginning, w ith gradual increm ents u n til it reaches 12,000 drachmae a m onth. 8. The service should undertake the d rafting of public h ealth laws on w hich such regulations m ay be based as m ay be found necessary. No law or regulation relating to the public h ealth m ay be prom ulgated b y any other departm ent or w ith o u t th e consent of th e service. The S anitary Code should contain provisions for th e following: 1. (a) The Hellenic H ealth Service will absorb th e present C entral S anitary Administration, the School of Hygiene and all o ther services existing in (6) I t shall have th e power to abolish or to create divisions or institutions within th e service. (c) I t shall tak e m easures necessary to prevent disease and im prove the public health, and shall ap p ly these m easures or supervise th eir application b y delegating its pow er when necessary. (tz) I t shall have the a u th o rity required to stu d y h um an diseases and the methods of preventing them. (e) I t shall be en tru sted w ith th e supervision of all public h ealth and diagnostic laboratories, an d shall issue th e necessary au th o risatio n s. (/) 'I t shall have control of all quarantine m easures. {g) I t shall supervise the m anufacture, p reparatio n and sale of foods for public consum ption. (h) I t shall control the m anufacture, prep aratio n and sale of sera, vaccines and biological products. (*) I t shall act as the advisory body for o ther S tate d epartm ents in questions affecting th e public health.

15 15 (j) Its medical officers m ay be seconded to other S tate or local departm ents. (k) I t shall co-ordinate both public health activities, central and local, w ith those of m unicipal and p riv ate organisations. (I) I t shall deal w ith questions of sanitation, including m ethods of preventing the contam ination of public w ater supplies. (m) I t shall carry out all such o ther public h ealth functions as the President of the Council of M inisters m ay decide to en tru st to it. 2. O rganisation of th e com m unal h ealth services. 3. Supervision of hospitals, dispensaries, h ealth centres and other sim ilar institutions, collaboration betw een voluntary an d S tate bodies concerned w ith the adm inistration of such institutions. 4. R eg istration of physicians, den tists, p harm acists, m idw ives, nurses. B u d g e t E s t im a t e s. We have tried to give a general indication of the am ount of additional credits necessary for applying the scheme proposed in the preceding chapters. The inform ation a t our disposal only perm its us to give approxim ate figures, which can be appraised in th eir detail b y the com petent technical services of the Greek G overnm ent. A part of this expenditure is intended for construction. The rem ainder will be an annual charge on the budget for the work of the new services. The Central Technical Services and the School of Hygiene necessitate the creation of new positions, certain of which m ay b e filled b y officers a t present in S tate service. The new peripheral organisation will gradually replace the present adm inistration, an d this will bring ab o u t corresponding economies in th e present S tate budget. Similarly, th e transfer of the dispensaries of the Refugee Settlem ent Commission to the S tate on Jan u a ry 1st, 1930, will produce economies in the proposed estim ates. As regards buildings, we propose th a t the School and the Technical Services should be installed in Doecker barracks in order th a t th eir work m ay begin im m ediately, w ithout aw aiting the construction of new or th e transform ation of old buildings. These barracks m ay be utilised later on in the provinces, when the School will be established in a special building. The estimates given below include th e cost of the necessary special technical equipm ent and o ther furnishings, excluding, however, the purchase of books for the library. i. School of H y g ie n e... A dorm itory for the School of H ealth V isitors.... The D ivision of S anitary E n g in e e rin g... The Division of M a la r io lo g y... The Division of Pharm acology and B iochem istry... The Division of R e s e a r c h... Drachmae 5,060,000 2,500,000 1,260, Drachmae 10,230, H e alth centres, regional a n d com m unal labo ratories : 20 com m unal centres (3 or 4 to a prefecture) an d 5 centres w ith laboratories in th e prefectural t o w n s... Regional centre w ith public h ealth laboratory and anti-m alaria service a t S a lo n ic a... 11,800,000 2,500,000 T o tal in round figures 25,000,000 As regards th e an n u a l cred its necessary for th e services. 1. The School of H ygiene an d th e Technical Services a t A thens : School of H y g ie n e... Division of S an itary E n g in e e r in g... Division of M a l a r i o lo g y... Division of Pharm acology and B iochem istry D orm itory for h ealth v is ito r s... drachmae , ,000 7,850,000 Carried forward 7,8 5 0,0 0 0

16 i6 Drachma Brought forward.. 7,850, Regional centre a t Salonica... 2,500,000 5 prefectural centres a t 440, ,200* health centres in com m unes a t 2 0 0, ,000, dispensaries belonging to the Refugee S ettlem en t Commission in M acedonia a t 1 5 0, ,000,000 T o t a l...drachmas 24,550,000 U nder the best possible conditions, only the organisation of the Technical Services and of the School of Hygiene a t A thens, as well as some organisation in prefectures, can be foreseen for th e fiscal year The m axim um expenditure would be 14 1/! million drachmae. The work of the Athens Centre and of the prefectural services would entail a m axim um expenditure cf 61/, m illion drachmae, representing a to ta l of 21 m illion drachmae. Fiscal year F or the services a t the A thens Centre and in 6 prefectures, this program m e would require the com pletion of th e buildings referred to above. N ecessary C redits : Drachmae B u i l d i n g s... 10,500,000 W o r k in g... 24,500,000 T o t a l... 35,000,000 Fiscal year The scheme m ight be extended to 5 new prefectures (a to tal of 11), w ith an expenditure of 3 millions per prefecture for building and 1 1/t millions for th e working of the new services. T otal for buildings... 15,000,000 F or w o r k in g... 32,000,000 T o t a l... 47,000,000 Fiscal year Six new prefectures (a to ta l of 17) : B u i l d i n g s... 18,000,000 W o r k in g... 41,000,000 T o t a l... 59,000,000 Fiscal year new prefectures (a to tal of 25) : Buildings... 24,000,000 W o rk in g... 53,000,000 T o t a l... 77,000,000 Fiscal year new prefectures (a to ta l of 35): B u ild in g s... 30,000,000 W orking... 68,000,000 T o ta l... 98,000,000 Fiscal year No new construction. Annual b u d g e t... 68,000,000 B y th a t tim e the P erm anent Hellenic H ealth Service having been established, the credits provided in the ordinary budget of the S tate for the prefectural health services will be completely effaced. It would be interesting to enquire into other im portant economies which m ight also be effected on account of the developm ent in these regions of in stitu tio n s for p reventive m edicine. Finally, as the value of all these health centres is appreciated, it is expected th a t they will receive subventions from communes and m unicipalities, as well as paym ent for services rendered. Thus the am ount of new credits necessary for the estim ated expenditure of 68 million drachmae will probably n o t exceed 50 million drachmae.

17 1 7 V. SPEC IA L RECOM M ENDATIONS OF T H E COMMISSION. i. R e c o m m e n d a t io n s o f t h e S u b j e c t o f H o s p it a l s. 1. Visits to the hospitals of A thens an d Salonica have dem onstrated the differences existing in the different establishm ents. In the first place, a distinction should be draw n betw een the privately supported hospitals a n d those of th e S tate an d m unicipalities. The first group are in general well adm inistered, as, for exam ple, the Evangelism os H ospital at Athens. Of the second group, a num ber are good, such as the M unicipal H ospital a t Salonica, and others are unsatisfactory. Of these, some could be im proved (the Municipal H ospital of A thens), whilst others, such as the M aternity H ospital a t A thens, whose condition is deplorable, should cease to exist. On the other hand, a lack of proportion has been frequently noticed betw een the cost of administration of the hospital and the num ber of p atien ts and personnel of the institution. We recommend in th e first place the reconditioning of those hospitals where this is justifiable, and in the case of o th ers th e ir suppression a n d replacem ent. 2. The num ber of hospital beds would n o t appear to suffice for the needs of the population, b u t fu rth er beds should only be provided according to a scheme indicating th e number of beds necessary as show n b y th e nu m ber of th e population a n d th e diseases existing. The setting up of this scheme should be preceded by an enquiry, and this enquiry should be one of the first tasks of th e Technical Services in the districts where th ey will work. This investigation would necessarily determ ine the general num ber of beds required, and those set aside for special purposes (children s hospitals, infectious disease hospitals, venereal disease hospitals, etc.). The question of beds for tuberculosis has been discussed in an o th e r m em orandum. Our inspection of different hospitals leads us to believe th a t, however sm all the reported prevalence of com m unicable diseases in Greece, a very large num ber of patients suffering from these diseases m ust escape both hospitalisation and control b y any san itary au th o rity. This is a condition altogether opposed to the principles of public h ealth and requiring u rgent reform. 3. It is recom m ended th a t th e personnel of hospitals should be b e tter trained th a n is a t present th e case. («) W ith regard to doctors, it is essential th a t more provision should be m ade in the hospitals for the teaching services. T he num ber of beds available for them a t the present tim e is below any adm issible m inim um for th e teach ing of stu d en ts. (6) A nother necessity of fundam ental im portance is the form ation of a corps of hospital nurses, which m ay be said h ard ly to exist to-day. I t is necessary, therefore, to provide w ith the assistance of the Hellenic R ed Cross, proper teaching facilities for the nurses, and in addition such living conditions and economic guarantees as will ensure a sufficient num ber of suitable candidates for this service. 4. I t is further recom m ended th a t a closer liaison be established betw een the dispensaries, out-patient services and hospitals, in order to ensure a m ore com plete and m ethodical utilisation of these institutions. Moreover, it is recom m ended th a t a service of m otor am bulances should be provided for tran sp o rt in th e tow ns and country districts. This service should be administered from th e hospitals or from the technical services in the districts selected, as experience m ay indicate. 5. I t is desirable th a t the G overnm ent should transfer its hospitals to the m unicipalities and th at, w ith certain exceptions, the public hospitals should depend upon the m unicipalities supported by th e subventions of the State. These hospitals will be adm inistered by a governing body in each m unicipality, and this body will have adm inistrative independence, subject to the financial surveillance of the public authorities and the supervision of the public health services. The adm inistration of private hospitals, while entirely independent, will be subject to the sanitary supervision of th e T echnical H e alth Services. 2. M a l a r ia P r e v e n t io n. In view of the fact th a t m alaria constitutes one of the m ost serious public h ealth problem s in Greece, we have suggested th e creation of a special D ivision of Malariology at the A thens Centre, and th e relevant proposal will be found on page 9. Moreover, the M alaria Commission of th e H ealth O rganisation of the League of N ations is engaged upon th e preparation of a first detailed report for the inform ation of th e Under-Secretariat of S tate for H e a lth on ce rtain problem s of in te re st in M acedonia an d T hrace.

18 i8 3. T u b e r c u l o s is P r e v e n t io n. The G overnm ent should direct its efforts along th e following lines: 1. R aising the stan d ard of life of the people b y increasing earnings and improving n u tritio n. 2. Im proving housing conditions b y m eans of regulations relating to the fitness for hab itatio n of old and m odem buildings, the construction of w orkm en s dwellings a n d housing inspections. 3. Securing healthier factories and workplaces, regulating the conditions of home work, strengthening factory inspection, supervising the application of the International L abour Conventions, restricting th e hours of w ork of wom en and children, and completely p ro h ibiting th e em ploym ent of children u n d er 14 years of age. 4. Increasing G overnm ent action to create a sufficient num ber of consultation centres for children a n d colonies fo r w eakly children. 5. A t the sam e tim e, the H ealth Services should rap id ly increase the number of anti-tuberculosis dispensaries in populous u rb a n areas. 6. F or ru ral areas, the appointm ent of h ealth visitors to assist medical officers in th e ap plication of p reventive m easures should be planned. 7. In a t least one hospital in every large tow n, accom m odation should be reserved for cases of ad v a n ced tuberculosis. 8. Special institutions, called hospital sanatoria, should be available in the vicinity of cities for all o th e r categories of tuberculosis. 9. H o sp italisatio n of tuberculosis cases should be carried o u t in liaison w ith antituberculosis dispensaries. 10. There should be progressive augm entation to m eet th e recognised needs in the num ber of dispensaries, in the num ber of h ealth visitors a t the dispensaries and in the public h ealth services, and also in the num ber of beds for all categories of tuberculous cases, in order to m eet the existing needs. 4. L a b o u r C o n d it io n s a n d S o c ia l I n s u r a n c e. The Commission has exam ined a note dealing w ith lab o u r conditions an d social insurances, d rafted b y Mr. A. Tixier, Chief of th e Social Insurance Service of th e In tern atio n al Labour Office, who, a t the request of the Secretary-G eneral of th e League of N ations, was asked by th e D irector of th e In tern atio n al L abour Office to get into touch w ith th e M edical Director of the H ealth O rganisation a t A thens, in order to assist him p articularly in the prep aratio n of the portions of th e prelim inary rep o rt dealing w ith these questions. The Commission, accepting the conclusions of this note, recom m ends th a t measures should be tak en w ithout d elay : 1. To extend th e regulation of hours of w ork to all industries to which it should apply. 2. To enforce m ore strictly social welfare laws in general and especially the laws lim iting th e hours of work, laws for th e protection of wom en and infants, and laws on h ealth and safety in factories, w orkshops an d stores. 3. To reinforce strongly the service of m edical facto ry inspection in th e Ministry of N ational Econom y. This service should be organised according to the Recommendations as to the G eneral Principles of F acto ry Inspection adopted in 1922 by the In tern atio n al L abour Conference. 4. To hasten the enactm ent of legislation on obligatory social insurance and in particular on h ealth insurance for w orkm en and employees in in d u stry and commerce. H ealth insurance should be organised to conform w ith the provisions of the International Convention adopted b y the L abour Conference in I t is especially im portant th a t this insurance should provide m edical and pharm aceutical benefits as well as cash benefits, and th a t it should co-operate w ith th e Public H ealth Service in order to e sta b lish public health facilities and organise m easures of prevention. The Public H ealth Service and insurance institutions m ight well be guided in respect of this collaboration by indications given b y the In tern atio n al Jo in t Commission on Public H ealth and H ealth Insurance which was established in 1927 b y th e In tern atio n al L abour Office and th e H e alth O rganisation of th e League of N ations. 5. Q u a r a n t i n e S e r v i c e. I. The P o rt Sanitary Services, including their adm inistrative services and equipm ent, should form p art of the C entral S anitary A dm inistration. These san itary services would include : (a) C ontrol of the sanitary condition of ships on th eir arriv al and departure and during th eir stay in th e ports.

19 ig (6) W ork of disinfection, dératisation and of disinsectisation, as well as measures for the destruction of ra ts on th e docks and in th e sheds and stores. (c) Necessary m easures of treatm ent, observation and surveillance of passengers and crews found to be suffering or suspected to be suffering from an infectious or contagious disease. (d) Lazarets, including th e adm inistration of the L azaret of St. George in the case of Piraeus. (e) Furnishing bills of health and certificates of dératisation or of exem ption from d ératisatio n. 2. The necessary legal powers should be taken or regulations adopted to assist the P ort Sanitary Service to apply the rules laid down b y the In tern atio n al S anitary Convention of 1926, recently ratified b y Greece. 3. The Service of Piraeus should be directly under the control of the C entral Sanitary Administration. The sanitary services of the other ports should be placed under the supervision of the chief health inspector attached to th e prefecture. Similarly, the lazaret of Cape B oum ou should rem ain under the supervision of the chief health inspector attached to th e prefecture. 4. The officials of th e h ealth services of th e ports should have the s ta tu s attaching to Government officers. The principal officials should be nom inated by the U nder-secretary of State for H ealth from am ongst technical officers of recognised ability. In the ports of the first category, th a t is to say a t Piraeus and Salonica, th e officials should be full-time. 5. A special report containing detailed recom m endations on th is m a tte r has been prepared and will be com m unicated separately.

20 VI. ANNEX. C O R RESPO N D EN CE B E T W E E N T H E P R IM E M IN IST E R O F T H E G R E E K REPUBLIC AND T H E P R E S ID E N T OF T H E H E A L T H COM M ITTEE. The President of the Health Committee to the Prim e M inister of the Greek Republic. {Translation.] Sir, A thens, A pril 18th, The Commission of E n q u iry appointed by the Council of the League of N ations a t the Greek G overnm ent s request to assist in th e re-organisation of the public h ealth services of Greece has concluded the w ork w ith which it was en tru sted and has forw arded its report, together with its recom m endations, to th e U nder-secretary of S tate for H ealth. A copy has also been sent to Y our E xcellency s chief Secretary. The Commission, while tendering its th an k s to the G reek authorities for the welcome extended to it and the facilities it has been granted, would be very grateful if it could be inform ed of Your E xcellency s views on th e conclusions subm itted, so th a t, when it presents its report a t the League H ealth C om m ittee s May session, it m ay be in a position sim ultaneously to m ake known your decision. I am, etc. {Signed) T h. M a d s e n, President o f the Health Committee. The Prime M inister of the Greek Republic to the President o f the Health Committee. [Translation.] Sir, A thens, A pril 19th, I have th e honour to acknowledge the receipt of your le tte r d ated the 18th in stan t, forwarding a plan for the sanitary7 re-organisation of th e country, together w ith recom m endations draw n up by the H ealth Com m ittee of the League of N ations, in conjunction w ith th e Greek Under-Secretary of S tate for H ealth. I note w ith satisfaction th a t th is plan and th e recom m endations are entirely in agreem ent with the principles of the program m e for the san itary re-organisation of the co u n try which m y Governm ent has h ad in view ever since it cam e in to power. I shall be very pleased, therefore, to ask the C ham bers to take th e legislative decisions required to give effect to th is plan, an d to a d o p t all m easures necessary for th e app licatio n of the recomm endations you have subm itted to me. I concur w ith your view th a t it is n o t possible to establish a m odem health service without requiring the m edical officers of h ealth to devote th eir whole tim e to this service, and consequently w ithout giving them adequate rem uneration. A lthough th e application of this principle runs counter to existing adm inistrative rules, th e fact th a t these m edical officers give up their right to practise m edicine en titles th em to special com pensation. The Greek G overnm ent is fully aw are th a t th e execution of this plan will have to be proceeded w ith m ethodically, and will require a very thorough technical preparation. F o r this reason, the Governm ent requests the H ealth O rganisation of the League of N ations, in accordance with the Council s invitation in D ecem ber last, to place a t the disposal of the G reek G overnm ent all its technical facilities, including its technical commissions, in order to ensure com plete co-operation in the subsequent developm ent of th e plan which has ju st been agreed upon. I would take this o p portunity to ten d er m y heartfelt th an k s to you an d to th e em inent members of the delegation over whose work you preside w ith such signal ability, as also to the Medical Directo r of the League of N ations and the highly qualified experts for th e im p o rtan t w ork th ey have already accomplished w ith a conscientiousness and ra p id ity th a t do th e greatest credit to the organisation of the technical services of the League of N ations. I am, etc. (Signed) E. K. V e n iz e l o s, Prim e M inister.

21 NEW TECHNICAL SERVICES AND SCHOOLOF HYGIENE A T H E N S C E N T R E Division of Preventive M edicine. Technical Services School of Hygiene. Division Division of Sanifary Engineering. Division of Pharmacology and Biochemistry. Division Research Maternity Infani Welfare. Tuberculosis Social Disease School Hygiene. Venereal Diseases. Social Insurance. Epidemic Diseases.

22 PERMANENT HELLENIC PUBLIC HEALTH SERVICE PDIME MINISTER UNDER-5ECRETAPY 0F5TATE FOR HEALTH Director Genera! of the Permanent Hellenic Health Service. ( Permanent Technical Head) ATHENS CENTRE Technical Services. School of Hygiene Administrative Services. Independent Services. ( 5) Regional Cen très, one For each Govern ment"- Gen e ral. (35) Prefectural Centres. Health Centres (3 to 4 in each Prefecture.) The working of (he Permanent Hellenic Heal hh Service will be assured by: H A Director-General Directors of Divisions, j Senior Medical Officers and Technical Officers. Medical Officers and Technical Officers. A Corps of Visiting Nurses. Th/s Tab/e represent th e sifo a t/o n e s i t w i//ôeaôout > There is, in fe c t, every hope th a t, a t th a t tim e, the orm e ion o e com petent personne/ Tor/he tte /tenic H ealth Service i/ift 6e com p/e/ed a n d w ///a /tow o f the d p p /ic a tio n o fth e p e rm a n e n t reg im e.

23 P E R IP H E R A L H E A L T H S E R V IC E S Under -Secretariat of State Director-General Athens Centre Regional Inspector Malaria Parasitology Administration Port Sanitary Service Rural S a n ita tio n Prefectural Centre Laboratories Dispensaries Administration School Hygiene Rural Sanitation Health Centre Health Centre Health Centre Health Centre Health Centre Dispensaries. Social Welfare M alaria, contagious diseases, tuberculosis, m atern ity, infant welfare, hygiene, s a n ita tio n, propaganda, meetings, etc. b a t h s Doctor health visitor sanitary inspector pharmacy

24 TEMPORARY REGIME PRIME MINISTER UNDER-SECRETARY OF STATE FOR HEALTH Administrative Sections (Jnder-5ecreWiat of State for Health. ôanifary Services transferred from other Ministries. ATHENS CENTRE Director-General with Dean of the School of Hygiene Administrative responsibility with technical authority. j NewTechnicalServ/ces, Public Health, Preventive Medicine and School of Hygiene. Region» to which the plan i s bo be applied. The p /a n wi//begr<3</ua//y ei/&>cfe</ fo o /h e r regions o /ih e country: in 193/ -3 2 to I I Prefectures IT. /S r Z u 35 (/. e. /h r who/c country)

25 m v [Distributed to the Council Official No.: C (a). M. 6 3 (a ) I I I. and the Members of the League.] [C.H.798]. Geneva, May LEAGUE OF NATIONS Health Organisation COLLABORATION WITH THE GREEK GOVERNMENT IN THE SANITARY RE-ORGANISATION OF GREECE NOTE BY THE PRESIDENT OF THE DELEGATION OF THE HEALTH COMMITTEE (Annex to Report C M I I I.) As you are doubtless aware, the task entrusted to your delegation has proved to be a difficult and delicate one. Having been instructed by you to place ourselves at the disposal of the Council of the League and of the Greek authorities in order to study the health situation in Greece and advise the Greek health authorities in respect of the present position, we have done our best to accomplish our mission and, after exam ining a great num ber of docum ents collected by the experts nominated by the H ealth Section, we subm itted to the Greek Government, before leaving Greece, a series of recom m endations em bodying our suggestions and advice. Our mission was a difficult one, since it is no easy m atter to tender advice to a Governm ent on the strength of an enquiry which, if it had been possible, should have extended over a much longer period. Our mission was also delicate in that, having form ulated the principles of development which our enquiry into the present health situation in Greece suggested to us, we had to consider how these principles could be applied to an existing adm inistrative system. Moreover, as representatives of your Committee, authorised by you to report direct to the Greek Government, we were anxious to prove w orthy of th a t confidence which we hope we shall not have forfeited, now the results of our work are before you. We would draw attention in the first place to the general observations regarding public health progress in Greece which will be found at the beginning of the report. In this we em phasise the consideration th a t the im provem ent of the sanitary situation in Greece depends upon many other factors, political and civil, besides the existence or organisation of a sufficiently competent public health service. If the details of our report are lim ited almost wholly to the organisation or re-organisation which seems desirable to secure such a service at the present time, it is because, in our view;, this m ust form the first step to all other useful action or recommendations for action. 2. In connection with the Public H ealth Service, it should be stated th a t there is in Greece an Under-Secretariat of State for H ealth which, although attached to the Ministry of Social Welfare (a M inistry m ainly occupied w ith refugee relief), is under the political direction of an U nder-secretary of State whose im m ediate superior is the Prim e Minister. Various health services also exist in a num ber of other Ministries, while health authorities w ith an important range of duties are attached to the various prefectures and tow n councils. I t would therefore seem necessary to suggest in the first place th at all these services should be transferred to the Under-Secretariat of State, except the D epartm ent of Industrial Hygiene in the Ministry of National Economy, whose work is carried on at present outside of the ordinary routine of the sanitary authorities. 3 - W e have found th a t there has been for some time, in the thirty-five prefectures representing the adm inistrative divisions of the Greek Republic (with an average population f 150,000 inhabitants per prefecture), a State health service composed of prefectural medical officers, while in the provinces th a t include several prefectures (as, for instance, the district of the Governor-General of Macedonia) there is, over the prefectural medical officers, a regional inspector of health attached to the Governor-General. s - d. N ( F.) - f 85o(A ) 5/2 9. Im p. J. de G.

26 On the other hand, the m unicipal health services of the urban districts of Athens, the Piræus and Salonica were only organised last October at the tim e of the dengue epidemic They comprise only one medical officer in each city ; these medical officers hold office on a purely tem porary basis and their duties are not at all clearly defined. 4. For the reasons set out in our recom m endations (which form the third chapter of our report), we feel th at satisfactory results cannot be obtained by merely extending the present organisation. In our opinion, if the health service is to be effective, it m ust be organised on a new basis with different aims. 5. We did not wish to propose any alteration in the general health adm inistrative system we have therefore recom m ended th a t the posts of regional inspectors and prefectural medical officers should remain. We are of opinion, however, th a t the purely bureaucratic system obtaining in the present prefectural health organisation should be transform ed by the creation of a netw ork of health centres. The prefectural medical officers would establish on an average three to five of these centres in selected localities in each prefecture. Each centre would include, in addition to the ordinary dispensaries, a service of health visitors and sanitary inspectors, which do not exist at present in Greece. In each centre there should also be a hall for the instruction and entertainm ent of the people, and shower-baths. In the chief town of each prefecture, the public health centre should also possess a health laboratory for the diagnosis of infectious disease, which would serve as a basis for system atic work for im proving the general health of the district. In the large provinces Macedonia, for instance, which includes six prefectures the regional centre would be more highly developed. In addition to the public health laboratory, there should also be a departm ent for m alaria and parasitology, a departm ent for port sanitary adm inistration and one for rural hygiene which would direct sanitary welfare work in the various outlying districts. An adm inistrative section, forming an integral p art of the regional centre, would deal with the current work of the regional inspectorate. Finally, in the towns, perm anent m unicipal health services should take the place of the provisional organisation which has been in force for the last few m onths. 6. If the above services are to be effective, they m ust consist of officials properly trained in accordance with m odern prophylactic m ethods and possessing a knowledge of modern health practice. At the present tim e only a very few officers possess these qualifications. 7. We have therefore recom m ended the creation of a School of Hygiene and new technical services, the former for the form ation of the necessary staff, and the latter for the direction of the work of this staff when once it has been trained. We have been inform ed th at the Greek Governm ent intends to call in foreign experts as technical directors of this training centre and the technical services. Accordingly, three professors will be appointed who are experts in public health and social medicine, m alaria and sanitary engineering. We have also stated th a t our Organisation would be prepared to help in according certain im m ediate facilities for the rapid training abroad of a first group of medical officers of health pending the organisation of the Athens Centre. 8. Under the above conditions, we were, as you will understand, unable to recommend th a t the new scheme should be applied forthw ith throughout the whole country, for it was obvious th at it could only be applied in certain areas. In these areas, again, only certain districts could be organised by the first group of medical officers whom we will train rapidly abroad. They will have at their disposal an adequate num ber of women visitors and sanitary assistants trained in the m eantim e in Greece. These areas were selected beforehand by the U nder-secretary of State for H ealth, who indicated to the experts of the H ealth Section certain prefectures and towns as being typical sectors and sectors which, for financial or other reasons, m ight be extensively developed in the near future from the point of view of social medicine and public health. These areas include six prefectures, comprising the urban district of Athens, Piræus and the City of Salonica. We think, however, th at during the new organisation might be extended to five new prefectures. In the num ber of prefectures m ight be seventeen : i.e., half of the country would thus be covered. In , tw enty-five prefectures would be organised, and officially the new system would be applied to the whole of Greece between 1934 and Meanwhile, the present adm inistrative system would continue to be applied in the areas not included in the scheme. The present system necessarily includes the central services of the Under-Secretariat of State for H ealth and the services transferred to it as suggested above. There would therefore be no change in the powers and duties of the central services of the enlarged Under-Secretariat of State, or of the prefectural sanitary authorities in the areas in which the present system is still to rem ain in force. 10. On the other hand, the areas to which the scheme is to be applied would from the outset be under the direction of the new technical services, whose jurisdiction would gradually be extended to the other prefectures as the new organisation itself expands. You will find the details concerning the organisation of this Athens Centre in our report.

27 3 11. In our opinion, this plan would m ake it possible to train a com petent staff, both at the training centre and in the field, by m eans of the practical work in the prefectures. It would thus be possible, somewhere about 1933 {i.e. when the plan would cover half the total num ber of prefectures ; when the School of Hygiene would have been in operation for two years ; and when a considerable num ber of medical officers would have been trained abroad under our guidance), to create a perm anent public health service in Greece in lieu of the present State health services. This service would incorporate all the central services, including the School of Hygiene, both those already in existence and those which would by then have been established. We have given a general indication of our proposals regarding the nature and powers of this service, the establishm ent of which seems to us to be a conditio sine qua non for any appreciable im provem ent in the health conditions of Greece. 12. We think it indispensable th a t this service should be entirely free from all political influences. It should therefore be a purely technical service having a t its head a perm anent technical chief ; it should constitute an advisory and executive organ for the Governm ent in health matters. We feel sure th a t our colleagues will agree th a t in all countries, and particularly in countries which are passing through a period of extensive economic reconstruction, health measures must be regarded as a factor contributing to national recovery, and th at, in order to ensure their success, they should be system atically co-ordinated w ith the activities of other Government departments. Having regard to the Prim e M inister s authority over all G overnm ent departm ents, we have considered it expedient to suggest th a t it would be advisable th a t the U nder-secretariat of State for Health, with its new services, should form a departm ent under the Prime M inister s control. We have refrained from m aking any recom m endations as to the methods which the Prime Minister m ight find best suited for the political organisation of the Governm ent of the country. As there is already an U nder-secretariat of State, it was logical to recom m end th at this Department should be placed under this direct authority ; we have not wished, however, to prejudge the constitutional position of the Hellenic Perm anent Public H ealth Service in the Government organisation. W e have merely urged the necessity for constituting this service as a purely technical service w ith a perm anent technical head, so th at it would be completely unaffected by political influences. 13. We have considered it necessary to lay equal stress on the im possibility of constituting an up-to-date health service unless medical officers are required to devote their whole time to the work and are granted adequate salaries. We have recommended, on the basis of inform ation on the scales of salaries for State officials and physicians fees, th a t this salary scale be given to the officials to whom the new services are first entrusted, as their responsibilities will be m uch greater. All the other officials attached to the present adm inistrative system, and those in charge of sections of the U nder-secretariat of State and of the services transferred to th at D epartm ent, as well as those engaged in work in the outlying districts, can apply for the Hellenic Perm anent Public Health Service. The Greek Governm ent proposes to obtain from am ong these officials the first team of workers to whom the carrying-out of the plan will be entrusted. The present officials will not lose any of their prerogatives, bu t will have the opportunity of working under m uch more favourable conditions during the tem porary period, if they are selected as m embers of the staffs successively chosen for the application and gradual extension of the plan, or as m em bers of the permanent service, if selected. W e have thought it advisable to recommend, however, that the conditions for admission to this service, which should constitute a corps d élite w orthy of the task entrusted to it by the Governm ent, and w orthy of the special consideration to be shown it, should be very strict. W e therefore recom m end th at candidates for the Perm anent Service should be required to undergo an exam ination for admission to the School of Hygiene, followed by system atic studies at the School and in the field, and a final exam ination for the diploma, and th at they should be required to forgo the right of private practice. Equivalent diplomas and previous experience will, of course, be taken into account. Finally, w ithin the lim its of the inform ation at present available, we have been able to estimate the necessary credits required for carrying out the proposed plan. For the year (in Greece the financial year begins on April 1st), these credits amount to 21,000,000 drachmae, i.e., 1,470,000 Swiss francs. For the year , the sum required will be 2,450,000 Swiss francs ; for , 3,290,000 francs ; for , 3,930,000 francs ; for , 5,380,000 francs ; for , 6,860,000 francs. By th at time, the whole country would reap the benefit of the new plan and there would be some 200 health centres in the prefectures, capitals, towns and provinces. From onwards, by which tim e building operations will have been completed, the sum required for the work of the Hellenic Perm anent Public H ealth Service should not, in our opinion, exceed 3,500,000 francs per annum, in view of the saving in the budget due to the abolition of the present system, which will be fully absorbed. 15. You will be glad to learn th at the Prim e Minister, after taking note of our recommendations, decided to request the Chambers to enact the necessary legislation for the execution of the plan and to take necessary measures for the application of the

28 recom m endations which we had the honour to subm it to him, including th at relating to the provision of an adequate salary for health officers. The head of the Greek Governm ent also told us th a t his G overnm ent fully realises that m ethodical work on the p art of experts w ith special technical training will be necessary for carrying out the plan. He added th a t his Governm ent has accordingly decided to apply to our H ealth Organisation, requesting it to pu t at the Greek G overnm ent s disposal all the technical help which the Committee can give, including th at of its technical commissions, in order to ensure complete co-operation in the subsequent developm ent of the plan. The detailed plan contains definite suggestions providing for continued co-operation either w ith certain of our Commissions, such as the Malaria Commission, the Commission on E ducation in Hygiene, the H ealth Insurance Commission, or w ith the H ealth Committee itself. The Greek Governm ent will be able to avail itself of our technical assistance, but will, of course, itself assume entire administrative responsibility. As regards the execution of the plan, the Greek G overnm ent has decided to entrust the technical control to three foreign experts, all adm inistrative functions being, however, carried out by Greek officials. 16. W e venture to hope th a t the m anner in which we have accomplished our task will meet w ith your approval. The League Council having invited the H ealth Com m ittee to p u t at the disposal of the Greek G overnm ent for the subsequent developm ent of the plan the various technical possibilities of collaboration of the Committee, including those of its technical commissions, in order to ensure complete co-operation, we propose th a t a num ber of fellowships should be awarded to the first group of health officials entrusted w ith the application of the plan in the areas first selected. The candidates will be interview ed by the Medical Director and inform ation will be given as to the posts to be entrusted to those officials on their return from abroad and w ith regard to the guarantees given by them to the Governm ent to rem ain in the Governm ent service for a definite period of time. The usual procedure will be followed in regard to the acceptance of these candidates.