Cecil Evelyn Aufrere (known as ‘Mick’) Cook was born in Sussex, England in 1897 and moved with his family to Barcaldine in central Queensland at the turn of the twentieth century. Can you describe the main influences on Cook during his upbringing, and how they shaped his subsequent career in public health?
Cook’s mother and father were among his main influences. The Southport School, an English-styled boarding school for boys was also important in establishing a daily rhythm of learning and life. His elder brother, Errol Aufrere (Frere) was a guiding influence. Cecil valued his father’s rural medical and hospital practice and wanted to be a doctor, but in tropical diseases not public health as his father suggested and definitely not in medical practice for which he had no interest.
His residency at St Andrews College, and the Faculty of Medicine, University of Sydney imposed more discipline and his 6 months post-graduate education in London at the London School of Tropical Medicine and University College London (public health) brought together the elements of health and medical practice on which he based his research of Leprosy and eventually, his career. In 1923, Dr J.H.L. Cumpston, Australia’s first Director-General of Health became Cecil’s mentor and population health and public service became his destiny.
Cook trained as doctor in Sydney in the early twentieth century when public health was an emerging and exciting field of medicine. What attracted Cook to practising in public health?
On its own, public health did not interest him. However, when connected to tropical diseases, epidemiology and the endemicity of diseases affecting communities, public health was essential. The recently formed Commonwealth Department of Health envisaged a new Northern Territory Medical Service. Cumpston clustered four roles into one position, partly at Cecil’s suggestion, and appointed him to the position.
Cecil possibly recognised at UCL his professional inheritance of Chadwick’s 1840s public health practice, as well as Cumpston’s and Elkington’s development of quarantine in Australia. These became the platform for a broad-scoped career in Australia’s tropics. Cecil had planned his post-graduate medical residencies around treating infectious diseases and remote area hospital and medical practice.
As your biography shows, Cook had many other professional roles, including as a medical officer based in Australia, Sri Lanka and Papua New Guinea during the Second World War. Can you tell us about his work during the war?
Cook requested an overseas appointment as a condition of his enlistment and again he got the job he wanted, fighting tropical diseases that disabled more troops than the enemy killed or wounded. He made the most of being a malaria pathologist for first time in his career. Like the leprosy he researched in the 1920s, malaria in the 1940s had no certain prevention, treatment or cure. He then reverted to hygiene and disease prevention as his war career priorities. As a hygienist, Cook assessed the adherence to camp and individual standards, winning an argument on the disposal of thousands of tin cans as road base and not as water receptacles for mosquito breeding. He surveyed the health risks in areas where troops would be deployed, whether in battle or in the occupation of Japan after the war ended.
Cook was one of a group of medical practitioners who sought to reshape public health administration during the twentieth century. What particular ideals and skills did these doctors possess that enabled them to combine medical expertise with public administration, policy-making and politics?
Cook usually proposed actions with a future objective in mind, not just a current problem to solve. He usually aimed to create a benefit and avoid a disadvantage – a double benefit. He only decided on a course of action after giving equal thought to all the alternative courses of action. Understanding diseases and preventing infection in the future needed strategic thinking and tactical action. Cook’s policy proposals were ‘frank and fearless advice’ and he then left the decisions to administrators and politicians. He reacted with discipline, determination and persistence if they did not accept his ideas.
Cook served as the Director of the Public Health Division in the Commonwealth Department of Health and was a long-time member of the National Health and Medical Research Council (NHMRC). Can you tell us about the kinds of public health issues that Cook tackled in these roles?
From 1928 Cook was exposed to the politics of health—was it a State or Federal responsibility? As a constructive federalist (as suggested by Tim Rowse), Cook’s focus on Australia’s northern tropics demanded a federal approach, as tropical diseases did not recognise state borders. He appealed to the newly formed Federal Health Council, the forerunner of the NHMRC, to authorise his coordination of the state medical services on either side of the Northern Territory. The Council, chaired by Cumpston and containing the states’ Chief Health Officers, rejected his request and suggested cooperation instead.
As the Northern Territory’s Chief Health Officer from 1927 and a Commonwealth employee, Cook was the health inspector of the Darwin Council’s region, but not responsible to the Council, which was elected by the residents. From 1946 in Western Australia, Cook sponsored annual conferences for local government health inspectors. He regarded them as his inspectors of conformance with the state’s Health Act. Re-examining the structure and resources of the public hospital system in 1947, Cook identified the essential but ‘honorary’ system by which the private medical profession provided services that supported the public hospitals. In 1947-8, when local government rates-based funding of health inspection was grossly inadequate, he sought Commonwealth funding of local area health services in the state’s north-west in the national interest. Redefining the role of the state public health department in 1948, Cook strengthened and made formal the connection between public health and medical practice by forming a committee of medical specialists that gave policy advice to the Minister.
Moving to Canberra in 1950, Cook brought his state initiatives for the structure of a modern public health department with its State Health Council advising the Minister. He continued the debate over Commonwealth support for northern Australia and its tropical diseases through the NHMRC committees. Indigenous health was a key factor in preventing tropical diseases and Cook brought attention to what he perceived as the national failure to integrate Indigenous people into the Australian community. Infant mortality was a state concern with national relevance and for two years, he surveyed the states’ legislation and practices directed at developing a national standard aimed at preventing infant deaths.
At the national level, through the NHMRC and its committees, Cook brought attention to the effect on Commonwealth and state quarantine services from the increasing air travel to Australia. On the NHMRC Epidemiology committee, he shared the concern at increasing levels of poliomyelitis. Cook then chaired the new Poliomyelitis Committee, which had oversight of the national immunisation campaign in 1956. He also chaired the new Food Additives committee as a first national attempt to regulate this aspect of food quality, with the food manufacturing industry representatives on the committee. He also sat on the new Food Standards Committee that attempted a national approach to the relevant legislation. British research into the connection between tobacco smoking and lung cancer prompted the Public Health Committee to appoint Cook to determine Australia’s approach to this source of increasing deaths.
Cook’s work with the NHMRC between 1946–69 was explicitly concerned with redefining the concept of public health. How did the concept change over the course of his career?
Cook’s concept of public health developed from the beginning of his career. From 1924, he regarded Aboriginal Protection as an aspect of health and explained in numerous papers how aspects of protection such as employment related directly to health. As Chief Protector of Aboriginals in the Northern Territory, Cook worked in the Department of Territories, not Health, so ‘protection as the province of health’ did not gain traction, nor could the Department of Health intervene to support him.
In Western Australia in 1948, Cook considered that his Public Health Department needed a strong and direct link with the medical profession and on his request, the Minister formed the State Health Council. Thus, Cook’s view was different to Cumpston’s on the relationship between public health and the medical profession. After retiring in 1946, Cumpston thought a new form of connection was not needed, whereas Cook believed the relationship had broken down and should be restored. Cook regarded medical practice and the diseases it treated as a source of public health’s ‘inspiration’. In 1952, Cook advised the Director-General of his opinion and later he wrote and spoke broadly on the issue. In 1956, Cook negotiated an arrangement between the Royal Australian College of General Practitioners and the NHMRC Public Health Committee. Cook remained a member of the College’s NSW Committee of Preventive and Community Medicine until 1978, 16 years after he retired.
Formation of the NHMRC’s Public Health Committee in June 1950 coincided with Cook’s appointment to the Commonwealth Department of Health. While the states’ Chief Health Officers had always been members of the Council, the new Committee provided them with a specialised forum in which to develop national or federal positions on public health issues. Council, with the Director-General of Health as Chair and the Chief Health Officers among its members, then decided on the Public Health Committee’s submissions.
Cook’s surveys and reports on Indigenous health from the late 1940s reached the ministers of Health and Territories and Cook’s urging for a joint approach gained traction. Indigenous health as an aspect of public health then had a broader responsibility, aligned with the Commonwealth’s Aboriginal policy. Minister Hasluck formed the Native Welfare Council of Ministers, under-pinned by a council of senior government officers from welfare and health departments.
You describe Cook’s wide reading habits and his commitment to applying evidence and analysis to policy making. How would you describe Cook’s lasting contribution to public health policy and policy development more generally?
Cook’s working life was that of a constructive federalist, as Tim Rowse has suggested. This means that Cook constructed arrangements within Australia’s federal governance system to make best use of and coordinate the federal and state public health resources and policies for improved achievement of important public health objectives.
Cook based his policy development model on a logical, Aristotelian/J.S. Mill approach, that after equal consideration of all relevant alternatives, aimed to achieve strategic objectives, not just solve health and social problems.
Starting with his national survey of leprosy and continuing throughout his career, at different times, Cook considered Aboriginal policy for the many aspects of physical, social and economic health, for different clusters of Australia’s Indigenous population, which were at different stages of transition from their pre-settlement life.
Cook’s definition of a modern public health department and the State Health Council he created to provide health policy advice to the Minister in 1948 bear a striking likeness to the current activities of state and territory public health departments. (see APPENDIX 1)
Cook reinforced this bond between state public health and local government health inspection through local government health inspectors’ annual conferences starting in 1946, that continued for about 50 years (source: Dr Richard Lugg, former senior officer in W.A. Department of Public Health)
In WA, the State Health Council Infant Mortality committee, which Cook formed in 1948 survived for about 50 years (Dr Lugg was a member of it, not knowing Cook had founded it).
From June 1950, state Chief Health Officers appointed to the newly formed NHMRC-Public Health Committee coordinated state, territory and federal health policies and services. Cook developed this structure, which still exists in the Australian Health Protection Principal Committee.
APPENDIX 1
Comparing Cook’s 1948 design of public health structures with the standard in 2020
The functions of a Department of Public Health (in 1948) should be:[1]
- To study the incidence of disease and the causes of morbidity and mortality in the community;
- To identify factors which are preventable and to devote itself to removing them;
- To conduct research into improved diagnosis and methods of treatment in order to shorten the period of illness, avert a fatal outcome or mitigate the effects of innumerable lesion, and actively to engage in extending the knowledge of and facilities for the universal application of these [elements of public health]
The functions of a State Health Council (in 1948) should include:
- Discussing of and recommendations regarding factors of morbidity and mortality;
- The organisation of medical practice both in its preventive and therapeutic phases;
- The initiation of such public health and hospital legislation as may be necessary from time to time to establish the health and medical organisation on a secure basis;
- To serve as a liaison body between the Government and the medical profession;
- To give the medical profession an effectual voice in health and medical organisation;
- To serve as a co-ordinating body organising the medical profession in public health and medical practice within the State;
The State and Territory Governments Public Health Structure (2020)[2]
Most core functions of public health have traditionally been the responsibility of the States and Territories. Under the various Health Acts (which usually cover environmental health, communicable diseases, food safety and tobacco controls), States and Territories pursue the following public health objectives:
- Identify public health issues state wide through epidemiological surveillance.
- Allow for timely intervention and monitoring of health outcomes.
- Develop policy related to communicable diseases, environmental health, immunisation, food, radiation safety, workplace risk, water quality, drugs and poisons, and emergency management.
- Organise preventive and early detection programs such as cancer screening, school health, etc.
- Support population health literacy and health promoting behaviour.
- Develop strategies for new and emerging health problems.
- Give government the power to act quickly in public health emergencies.
- Examine the effectiveness, and collaborate with all other government and non-government public health sectors and relevant authorities, to address public health issues and provide for an appropriately skilled public health workforce.
[1] Cook Corpus p376-379
[2] Fact Sheet: Public Health Policy and the Australian Public Health Landscape
