H001 20537 I WA 900 AN 8 P743 1947 C.2 Hospital and Medical Care for all Our People A Program of Great Hope, of Almost Infinite Promise, and Yet of Great Practicability** Reports of Chairman and Sub-Committees of North Carolina Hospital and Medical Care Commission 1944-45 (Data Revised February, 1947) C O N T E N 1 S PAGE {Sec "Index of Charts, Tables and Articles," page 110) Members of Hospital and Medical Care Commission ii Introduction iii Coordinated Hospital Service iv Hospital and Medical Care for All Our People Title Our Three Supreme Health Needs Are: i)More Doctors, 2) More Hospitals, 3) More Insurance {Preliminary Report to Governor Brouijhton and to the People of North Caroina) I "A Program of Great Hope, of Almost Infinite Promise, and of Great Prac- ticability" {Chairman's Final Report to Governor Cherry and the General Assembly of 1945) ; 9 Here's How i)Our State Ranks Among the States . . . and How 2) Your County Ranks Among the Counties {Charts and Statistics to Illustrate Medical and Hospital Needs of Our North Carolina People) 17 Our Industrial and Urban Population Needs "More Doctors, More Hospitals, More Insurance" 55 In Rural North Carolina the Need for "More Doctors, More Hospitals, More Insurance" Is Doubly Serious {Report of Committee on Medical and Hospital Needs of Our Rural People) 59 North Carolina Needs i)More Doctors and Medical Personnel and 2) A Much Better Distribution of Doctors {Report of Committees on Medical School and Central Hospital and on Number and Distribution of Doctors in North Carolina) 69 Our Negro Population Asks Equal Opportunity to Get Hospital Service and Medical Training {Report of Committee on Special Needs of Our Neijro Population) 79 Competent Psychiatric Help Must Be Provided All the Way from Commu- nity Clinic to Teaching Hospital {Report of Committee on Mental Hygiene and Hospitalization) 87 Every School Child Must Have i)A Medical Examination With 2) Correc- tion of Discovered Defects bv the Parents or the Public 93 Both the Counties and the State Should Better Support an Enlarged and Ade- quate Public Health Program lOi The Origin, Progress and Statutory Organization of the Movement for Better Hospital and Medical Care . . . With a Final Re-Statement of Its Ultimate Hopes and Ideals 105 UNIVERSITY OF NORTH CAROLINA 1 MAR22I990 HEALTH SCIEMCES LIBRARY NORTH CAROLINA HOSPITAL AND MEDICAL CARE COMMISSION AND ITS SUB-COMMITTEES, 1944-45 Clarence Poe, Raleigh, Cliairman Dk. C V. Reynolds, Secretary Hospital and Medical Care for Our Rural Population Tiios. J. Peabsall, Chmn., Rocky Mount R. Flake Shaw, Greensboro De. G. M. Coopek, Vice-Chmu., Raleigh J. G. K. McClure, Asheville Dr. G. Horace Hamilton, Raleigh, Secretary Dk. B. E. WAiSHBURN, Rutherfordton J. B. Slack, P.S.A., Raleigh Dr. S. H. Hobbs, Jr., Chapel Hill Dr. Jane S. McKimmon, Raleigh M. G. Mann, Raleigh Harry B. Caldwell, Greensboro Dr. W. C. Davison, Durham Hospital and Medical Care for Our Industrial and Urban Population Charles A. Cannon, Chmn., Concord C. C. Spaulding, Durham Chas. a. Fink, Vice-Chmn., Spencer Dr. Edson E. Blackman, Charlotte Db. I. G. Greer, Thomasville Dr. C. C. Carpenter, Winston-Salem Dr. J. B. SiDBUKY, Wilmington Miss Flora Wakefield, Raleigh E. T. Sandefub, Winston-Salem Mrs. W. T. Bost, Raleigh Reuben Robeetson, Canton Special Needs of Our Negro Population De. E. E. Blackman, Chmn., Charlotte Dr. Clyde Donnell, Durham C. C. Spaulding, Durham Dr. N. C. Newbold, Raleigh Dr. R. E. Wimberly, Raleigh Alexander Webb, Raleigh Four-Year Medical School for University and Hospital Facilities Dr. p. p. McCain, Chmn., Sanatorium James A. Gray, Winston-Salem JosEPHus Daniels, Vice-Chmn., Raleigh Alexander Webb, Raleigh Dr. Donnell Cobb, Goldsboro Dr. W. R. Berryhill, Chapel Hill Dr. Paul Whitaker, Kinston Dr. C. C. Carpenter, Winston-Salem Mrs. Julius Cone, Greensboro Dr. W. C. Davison, Durham Dr. Hubert B. Haywood, Raleigh Mental Hygiene and Hospitalization Dr. James W. Vernon, C'hmn., Morganton Paul Bissette, Wilson Bishop Clare Puecell, Vice-Chmn., Charlotte John W. Umstead, Chapel Hill Mes. R. J. Reynolds, Winston-Salem W. G. Clark, Tarboro D. Hiden Ramsey, Asheville Mrs. Feances Hill Fox, Durham Judge S. J. Ervin, Morganton Dr. Maurice H. Greenhill, Durham Connuillee on Statistical Studies Dr. C. Horace Hamilton, Chairman, N. C. State College, Raleigh Hospital and Medical Care Plans in Other States Dr. W. M. Coppridge, Chmn., Durham Dr. Roscoe D. McMillan, Red Springs R. G. Deyton, Raleigh ii Foreword by the Chairman In 1944-45 I served, by appointment of Governor Broughton, as Chairman of the newly created "North Carolina Hospital and Medical Care Commission." This commission was not only composed of 60 distinguished North Carolina men and women, representing all important classes of our citizenship, but in order to make its labors more effective, was subdivided into seven ably manned Com- mittees as shown on the preceding page. These sub-committees made ivhat Dr. Carl V . Reynolds, State Health Officer, called at the time "the most coi7iprehensive, accurate and informing review of health conditions ever made in the history of North Carolina — and probably the best ever vet made for any Southern Slate." For this reason both the Medical Care Commission and the North Carolina Good Health Association have called for the republication of the veritable treas- ure house of information collecteil in these reports. In doing this it has also seemed wise to revise all data, where practicable, so as to bring it up to date. That is to say, the latest available data as of February, 1947, rather than November, 1944, is now presented herewith, in so far as possible. For this revision especial thanks are due to Dr. C. Horace Hamilton. In effect this volume becomes a condensed but fairly complete report of all major activities of the campaign for "More Doctors, More Hospitals, More In- surance" in North Carolina from the time the Hospital and Medical Care Com- mission was appointed by Governor Broughton, February 28, 1944, until the offi- cially State-sponsored Medical Care Commission took over on July 27, 1945. In this period the 60 members of the Hospital and Medical Care Commission were privileged to play an active part in four fortunately fruitful efforts: — 1. To Inform niid nronse onr people as to existing conditions and needed remedies. L'. To secnre needed State legislation. ."5. To assist in the nation-wide slndy of liospital cimditions and needed remedies by the National Com- mittee on Hospital Care. 4. To enlist the snpport of all North Carolina Senators and Repre.sentatives in behalf of the Hill- Rnrton Act from which North Carolina should ultimately receive .1;17,500.00() for hospital building. Furthermore, while resolutely determined to discover and uncover all the facts about North Carolina hospital and medical care conditions, the highlight of all our activities was not the discovery about the shockingly high 57% rejection rate of North Carolina boys in the American armies but rather the far more astonish- ing discovery that among draftees who had grown up in North Carolina orphan- ages and who had had not-too-expensive hospital and medical care plus sound but not-e.\pensive nutrition, the rejection rate had been only 3%! This is a beacon light to guide our people as they fare forth on a program which is indeed one of "great hope, of almost infinite promise, and yet of great practica- bility." Clarence Poe Raleigh, March i, 1947. iii COORDINATED HOSPITAL SERVICE PLAN Pasrd on date f mm th* I' S Commi tt»* on Edurciion •nd Labor ■ HOSPITAL L HEALTH CENTER ^ million people of North Carolina combined arc now asked to provide only as much ($1 a day) as one deceased North Caro- linian (James B. Duke) gives them constantly through his will. All other costs in the proposed program we believe are equally reasonable. Question Number 4 Brings Great Hope As proud North Carolinians, let us say to your Excellency, Governor Cherrv, and the honored members of our House and Senate, it has been no pleasure to your Commission to recite the proof that North Carolina so desperately needs "More Doctors, More Hospitals, More Insurance." When, however, we come to your fourth (Question, "Can you cite us an example where this proposed program has been translated into human-interest, flesh-and- blood Tar Heel terms . . . and if so, with what results?" then a great sunrise of hope and inspiration breaks upon the whole scene. One of the most honored members of your Commission, Dr. I. G. Greer, as spokesman for the numerically largest religious denomination in North Carolina and its oldest social service agency, the Baptist Orphanage at Thomasville, N. C, reveals what can be done not only with our average North Carolina stock, but even with young North Carolinians who have been more-than-normallv handicapped bv 12 poverty — our orphans. First, let us repeat our earlier figures — 48.1 and 56.8 — as the percentage of army rejections of North Carolina draftees . . . and then let's listen to this officially signed report by Mr. I. G. Greer, superintendent of the Thomasville Baptist Orphanage, who wrote us February 9, 1945: "Sometime ago you asked me to verify a statement I made to you regardinq boys in service ic/io grew up here in the Orphanage. At the time I think I told you ive had 284 boys in uniform and that only 3 had failed to pass the physical examination. IVe know now that we have 318 in the service, and only 3 have failed to pass the physical examination — less than 1%." "Nor do our Baptist Orphanages difTer from other North Carolina orphanages in this respect. From the superintendents of four other white orphanages I have just received data, making a total showing for boys of draft age who have been in these institutions as follows: Accepted for Service Rejected Baptist Orphanages (Mills and Kennedy) 318 3 Methodist Orphanage. Raleigh 150 1 Children's Home (Methodist), JVinston-Salem 225 2 Barium Springs Orphanage (Presbyterian) 220 5 Oxford Orphanage 225 5 Totals 1,138 16 "This shows 1.4% army rejections, and with 1,873 children now in these orphanages there have been only 7 deaths in five years. "Practically every child who enters our orphanages comes to us undernourished and in need of some kind of medical attention. This combined North Carolina orphanage record of 98.6% army-acceptance shows what might be done for both the children and older people all over North Carolina through improved medical and hospital care if the General Assembly approved such a program of 'More Doctors, More Hospitals, More Insurance' as the State's Hospital and Medical Care Commission is now advocating. If at any time you can use this statement in helping advance this much needed legislation, you have my permission." The boys in our North Carolina orphanages are not coddled. They are not given luxuries. They are given sound nutrition and the reasonably adequate med- ical and hospital care from school age on as advocated by Governor Cherry and your Commifsion — and what do we find? Whereas the State's latest reported percentage of army rejections is 56.8 (and when the writer's youngest son went to Fort Bragg with 52 boys from your capital city, he was one of only 18 accepted) a not-expensive program of hospital and medical care provided for North Caro- lina orphanage boys of draft age brings an army acceptance of 98.6%! North Carolina Can Become Famous For Low Death Rate Deliberately as a result of a year-long study of all the data, good and bad, I would say this : 13 North Carolina has an almost ideal climate — seldom zero in winter or loo in summer — and we have a remarkably sturdy middle-class population, free alike from dissipations of the idle rich and the physical deterioration of poverty-cursed slums. For these reasons of fine climate, fine physical stock, and freedom from extreme wealth and blighting poverty, our death rate has been amazingly low in spite of the absence of proper hospital and medical care. With proper medical examination and treatment for all school children and proper hospital and medical care for all our older people, I believe that North Carolina can become nationally and even internationally famous for having the lowest death rate of any state of equal population in the American Union — ivith all that this would mean in increased efficiency, happiness and pride for all North Carolinians/ It is to such an inspiring opportunity for carrying North Carolina forward through adequate legislation in 1945 and 1947 that your North Carolina Hospital and Medical Care Commission presents its case! Seven Highlights of Ten Reports Just one more question I can hear His Excellency, the Governor, and busy members of the House and Senate asking as follows: "Every one of your Commission Reports deserve detailed study, but in every article some one statement or paragraph stands out above all else. From all your Commission Reports suppose you had to pick out seven or eight paragraphs which you think every legislator should resolve to read, re-read and remember, no mat- ter what else he might read or miss reading, what paragraphs would you select?" This is perhaps the hardest of all four questions to answer but here would be my selections: I. Farmers Need More Doctors, More Hospitals // is upon our farm people that the lack of doctors and lack of hospitals falls most heavily. It is heavy in cost of medical service . . . in inability to get medical attention . . . in unnecessarily prolonged illnesses . . . in unnecessary deaths. In 34 North Carolina counties — all rural counties of course — there is now not a single hospital bed for anybody, white or black! In the matter of doctor shortage we note — — The American standard is / for each 1 ,000 people — Urban North Carolina, 1940, had 1 for each 613 people — Rural North Carolina, 1940, had 1 for each 3,613 people — Rural North Carolina, 1944, had 1 for each 5,174 people n. Industrial Workers Need the Program The most praiseworthy "hospital insurance" plan, in effect in various North Carolina industries, has increased the demand for hospital care where the insured workers live . . . and should be expanded to cover not only industrial employees 14 but other citizens. As a physician in a presumably typical Piedmont industrial small town testifies: "The share-croppers of Eastern Carolina are not the only people ivho urgently need better care. The factory workers and Negroes of this section are in need , too. Except during rare periods of prosperity , only about one- half of the people of this community are able to pay the modest fees we charge." III. School Children Need Examination and Treatment The need to examine and correct the defects of all school children — at private expense where possible and at public expense where necessary — as etnphasized by Governor Cherry, is plain and urgent. After Pearl Harbor the State had com- pulsory examinations of all boys in the two upper grades and the percentage of those showing some defects was amazing — — 85% had dental defects — 16% defective in vision — 16% were underweight — 14% had diseased tonsils, etc. A majority of the children examined in preschool clinics each year are also found to have some defect. A strict system of annual inspection of every school child enrolled in the schools of every county must be provided under the leadership of the State Board of Health co-operating with city and county health departments. IV. Negroes Need Doctors, Hospitals, Insurance The Negro death rate in North Carolina in 1940 was 146% that of the white death rate — an appallinq difference . . . The State's Negro population in 1940 was 983,574 (and now probably exceeds 1,000.000) but the State has only 129 active Negro physicians — or 1 for each 7 ,783 Negro people . . . and only 7 ,760 hospital beds, or 1.7 hospital beds for each 1 ,000 Negroes— less than half the American standard . . . A regional Negro Medical School should be established . . . Hos- pital associations should be encouraged to extend the Blue Cross program to Negroes. V. Why a Four-Year Medical School Is Needed Average number of physicians who die or retire in North Carolina each year — 50. Average need for new physicians in order to maintain present ratio approxi- mates — 100 each year. Average number of medical students graduated from North Carolina medical schools each year who are residents of North Carolina: about 65 (Duke, 20; Wake Forest, 45). The State thus needs 50% more new North Caro- lina doctors each year than these two excellent schools have provided. VI. A Statewide Psychiatric Program Is Needed Mental disorder is more prevalent than tuberculosis and poliomyelitis, and its total cost to the State is as great as all other diseases combined, yet little attention IS is paid to it. Now perhaps something may be done . . . From 40 to 70%_ of the average physician's practice is devoted to the diagnosis and treatment of disorders at least partly psychiatric in nature . . . By using the psychiatric unit of the pro- posed Four-Year Medical School as a "receiving hospital" and establishing one other such "receiving hospital" in the State, tee can decrease the number of patients in hospitals for the insane, prevent many patients from becoming permanent wards of the State, and ultimately make a vast financial saving for the State . . . Every county hospital should also have a small number of beds (5 to 10) for psychiatric patients . . . Unless psychiatric care permeates through the entire state system of hospital rare in this tcay, North Carolina will be sorely neglecting one of its larg- est problems. VII. Types OF Hospital and Health Centers Needed A large Central Hospital of approximately 600 beds . . . A small number of District Hospitals of approximately 100 beds . . . Small Rural Hospitals of ap- proximately 60 beds . . . Some counties with less than 12,500 population might find it practical to build small 20- or 30-bed hospitals . . . There should also be "Health Centers" in small rural communities, including diagnostic and labora- tory services, facilities for minor operations, obstetrical service, and a small num- ber of beds for cases not requiring the specialized services of a larger hospital, these health centers also to be used by the public health service in carrying on its work. In Conclusion In conclusion, I wish to express my thanks to all the members of the Hospital and Medical Care Commission who have labored with me in finding and inter- preting the facts and in seeking to present a sound and reasonable program — "To the Good Health of All North Carolina." To my constant co-laborer, President Paul F. Whitaker of the State Medical Society, the State owes more than it will ever know. And finally the thanks of all the people are due to the two Governors under whom we have labored — to Ex-Governor J. M. Broughton who acted with characteristically prompt and adequate statesmanship when the State Medical So- ciety appealed for State action . . . and to Governor R. Gregg Cherry who not only cheered us by immediate and vigorous endorsement of our efforts the day after your Commission was appointed but enriched and rounded out our program bv his statesmanlike insistence that any campaign for "Better Health in North Carolina" must begin with the boys and girls in our public schools and must equally safeguard the health and future of the child of the rich and the child of the poor. Respectfully submitted. Chairman. Raleigh, N. C. February lo, 1945. Ill Here's How i)Our State Ranks Among the States . . . and 2) Your County Among the Counties (Charts and Statistics to Illustrate Medical and Hospital Needs of Our North Carolina People. Prepared by Dr. C. Horace Hamilton, Head Rural Sociology, N. C. State College.) "Just how does North Carolina rank among- the states in all impor- tant features of hospital and medical care? Just how does my county rank among the counties?" To answer these often-asked questions Dr. C. Horace Hamilton, Head of Rural Sociology Department, North Carolina State College, and chairman of our Committee on Statistical Studies, prepared an invaluable set of tables and charts. Some of the most important (revised to include the latest available data as of February 1, 1947, wherever possible) are shown on the following pages with explanatory comments by Dr. Hamilton. How North Carolina Ranks In Health and Medical Care and In Social and Economic Conditions Affecting Health.* Average ob Peecentaoe Noeth SUBJECTS United North Carolina States Carolina Rank HEALTH AND MEDICAL CARE Hospital beds per 10,000 population 35 Days hospitalization per 100 population 90 Doctors per 100,000 population 125 White doctors per 100,000 white population 136 Nonwhite doctors per 100,000 Nonwhite population 28 Dentists per 100,000 population 58 White dentists per 100,000 population 58 Nouwhite dentists per 100,000 nonwhite population 12 Nurses (including students) per 100,000 population 270 White nurses per 100,000 white population 295 Nonwhite nurses per 100,000 nonwhite population 54 Percentage live births in hospitals (1942) 67.9 Percentage white births in hospitals (1942) 72.7 Percentage Negro births in hospitals (1942) 28.9 Percentage urban (over 10,000) births in hospitals 80.5 Percentage rural (under 10,000) births in hospitals 36.5 Percentage of live births with no medical attendant (1942) 7.4 Percentage of white births with no medical attendant (1942) 2.5 Percentage of Negro births with no medical attendant (1942) 46.8 Percentage of urban births with no medical attendant (1942) 2.6 Percentage of rural births with no medical attendant (1942) 14.2 Maternal deaths per 1,000 live births 3.8 Kural maternal deaths per 1,000 live births 4.0 Nonwhite maternal deaths per 1,000 live births 7.7 Infant deaths plus stillbirths per 1,000 births 76 White infant deaths plus stillbirths per 1,000 births 69 Nonwhite infant deaths plus stillbirths per 1,000 births 123 Mortality rate (per 1,000 population)! 7.56 White mortality rate (per 1,000 population)! 7.02 Nonwhite mortality rate (per 1,000 population)! 13.14 Rural white mortality rate (per 1,000 population)! 6.18 Live births per 1,000 females 15-44 years of age 73.7 White births per 1,000 females 15-44 years of age 72.5 Nonwhite births per 1,000 females 15-44 years of age 83.3 POPULATION Population per square mile 44.2 Kural jjopulation jicr square mile 19.2 Farm peoi)lc per square mile farm land 18.4 Percentage of population living on farms 22.9 Percentage of population living in rural areas 43.4 Percentage of population which is Negro 9.8 Percentage of employed males over 14 years of age engaged in agriculture 23.2 People under 15 and over 65 per 1,000 people between 15 and 65 .. 468 Total number of people in 1,000's 131,669 Percentage of population increase, 1930 to 1940 7.0 INCOME AND LEVEL OF LIVING Net income per capita $573 Average value of dwellings $2,503 18 23 42 52 44 72 45 94 41 17 30 22 43 28 46 6 34 175 38 226 30 46 25 38.1 41 49.0 41 13.6 43 55.9 44 17.1 39 20.7 40 6.1 40 54.0 40 10.0 40 24.7 39 5.1 41 4.9 38 7.6 31 89 38 74 35 120 26 8.12 38 6.72 15 12.25 21 6.40 32 90.0 14 85.4 14 101.6 11 72.7 35 52.9 39 56.4 48 46.4 43 72.7 43 27.5 43 41.4 37 585 43 3,572 11 12.7 9 $317 44 $1,346 42 How North Carolina Ranks . . . Continued. avebaoe ob Percp:ntage North SUBJECTS United Nobth Caboi.ina States Cakouna Rank Average value of farm homes $1,070 $700 38 Percentage of home ownership 43.6 42.4 36 Average number (median) of people per home 3.3 4.0 48 Percentage of homes with more than one person per room 20.3 35.3 38 Percentage of homes with electricity 78.7 54.4 38 Percentage of homes with radios 82.8 61.8 41 Percentage of homes with running water 69.9 39.1 41 Percentage of homes with mechanical refrigeration 44.1 28.2 38 Percentage of adults with less than 5th grade education 13.5 26.2 42 Kural-farm Level of Living Index 100 84 40 STATE AND COUNTY FINANCE Per capita State Government expenditures $36.80 $26.96 38 Per capita State Government expenditures for public health $ .37 $ .40 29 Per capita County Government expenditures, 1942 $12.09 $11.53 28 Percentage State and local tax collections are of total income pay- ments 11.2 11.3 24 Percentage taxable income over $5,000 is of total income payments, 1938 9.9 6.2 30 Per capita Federal aid to states $28.82 $20.78 43 Katio (per $100) Federal aid to state and local tax collections 44.7 57.8 26 * These data are for the year 1940 unless otherwise stated. t Exeliuliiis age groups under one and 75-up. Adjusted to the age distribution of tlic total United States population. Source: Based largel.v on U. S. Census, reports of State Departments, American Medical Association Direc- tory, and reports of special agencies conoenied. CRUDE DEATH RATE NORTH CAROLINA 1941-1945 RATE UNDER 7.0 7.0- 7.9 ^ 8 0-8.9 9 -9 9 10.0-10.9 I I.O-UP N.C. AGR. EyP. STA. RURAU SOCIOLOGY DEPT. 19 Inadequate Hospital Facilities and Personnel In 1944, North Carolina had only 2.6 general and allied special hospital beds per 1,000 population. Only twelve states had fewer beds than North Carolina and the national average was 3.4 beds per 1,000 population. Seven states and the Dis- trict of Columbia had more than 4.5 beds per 1,000 population, which is consid- ered a reasonable standard if adequate hospital care is to be provided for every one. Of the general hospital beds, 41.0 per cent are located in the six big urban counties of the state; 30 counties have no hospital beds; 20 counties have less than 50 beds; 26 counties have from 50 to 99 beds; 14 counties have from 100 to 199 beds; and 10 counties have more than 200 beds. Negro hospital facilities are seriously inadequate. We have now about 1,700 general hospital beds for Negroes and at least 2,800 more are needed to supply the recommended minimum of 4.5 beds per 1,000 population. GENERAL HOSPITAL BEDS PER 1,000 POPULATION UNITED STATES 1944 RATIO 4 5 -UP 'Xn^' 3 5-4.4 2 5-3 4 UNDER ^ N C AGR. EXP. STA RURAL SOCIOLOGY DEPT. 20 General and Allied Special Hospital Beds and Days Hospitalization, United States, 1944 BEDS PER 1000 POPULATION Rank and State Number of Beds DAY.S HOUPITALIZATIOS PER. IVO POPULATWX Rank and State NuMBEB OF Days UNITED STATES . 1 Montana 2 Massachusetts 3 New York 4 North Dakota 5 Minnesota 6 New Hampshire 7 Nevada 8 District of Columbia., 9 Delaware 10 Colorado 11 Arizona 12 Vermont 13 Washington 14 Wisconsin 15 Connecticut 16 Pennsylvania 17 Oregon 18 South Dakota 19 Nebraska 20 Illinois 21 Maine 22 Maryland 23 New Jersey 24 California 25 Missouri 26 New Mexico 27 Kansas 28 West Virginia 29 Wyoming 30 Utah 31 Iowa 32 Michigan 33 Idaho 34 Ohio 35 Louisiana 36 Indiana 37 North Carolina 38 Oklahoma 39 Florida 40 Ehode Island 41 South Carolina . 42 Virginia 43 Texas 44 Tennessee 45 Kentucky 46 Georgia 47 Alabama 48 Arkansas 49 Mississippi Source : 3.40 6.25 5.17 4.85 4.79 4.77 4.73 4.62 4.50 4.37 4.36 4.22 4.13 3.95 3.94 3.93 3.92 3.89 3.83 3.78 3.76 3.75 3.67 3.63 3.60 3.59 3.40 3.35 3.30 3.29 3.21 3.19 3.08 3.07 3.06 3.01 2.82 2.57 2.56 2.34 2..M 2.33 2.32 2.28 2.11 2.02 1.95 1.93 1.73 1.65 UNITED STATES 90 1 Montana 151 2 Massachusetts 186 3 Minnesota 134 4 New York 132 5 North Dakota 126 6 District of Columbia 120 7 Vermont 114 8 New Hampshire 114 9 Nevada 109 10 Washington 109 11 Colorado 109 12 Wisconsin 106 13 Maine 106 14 Connecticut 105 15 Pennsylvania 103 16 Delaware 102 17 Illinois 102 18 Nebraska 100 19 Arizona 100 20 Oregon 100 21 South Dakota 99 22 California 98 23 Missouri 97 24 Maryland 96 25 New Jersey 94 26 Kansas 93 27 Ohio 88 28 Iowa 84 29 West Virginia 84 30 Michigan 83 31 Utah 80 32 Indiana 78 33 Louisiana 76 34 New Mexico 75 35 Wyoming 74 36 Idaho 71 37 Rhode Island 71 38 North Carolina 65 39 Oklahoma 59 40 Virginia 59 41 South Carolina 57 42 Tennessee 56 43 Texas 55 44 Florida 55 45 Kentucky 51 46 Georgia 49 47 Alabama 42 48 Arkansas 41 49 Mississippi 37 Journal of the American Medical Association, March 31, 1945. Population — Special Reports, Series P-45, No. 9, October 1, 1945. 21 Hospital Beds for White Persons Per 1,000 White Population, North Carolina, 1943* Count II Rank Alamance 64 Alexander No Alleghany No Anson 47 Ashe 61 Avery 3 Beaufort 26 Bertie No Bladen No Brunswick 20 Buncombe 10 Burke 16 Cabarrus 38 Caldwell 49 Camden No Carteret 26 Caswell No Catawba 29 Chatham 62 Cherokee 62 Chowan No Clay No Cleveland 49 Columbus 44 Craven 38 Cumberland 12 Currituck No Dare No Davidson 55 Davie No Duplin No Durham 1 Edgecombe 42 Forsyth 4 Pranklin No Gaston 49 Gates No Graham No Granville 33 Greene No Guilford 23 Halifax 21 Harnett 35 Haywood 38 Henderson : 10 Hertford No Hoke No Hyde No Iredell 5 Jackson 58 Number Ratio Beds .8 37 hospital beds hospital beds 1.7 24 1.1 25 6.4 85 2.8 65 hospital beds hospital beds 3.2 36 386 122 106 53 4.2 3.4 2.1 1.6 hospital beds 2.8 43 hospital beds 2.6 119 1.0 17 1.0 18 hospital beds hospital beds 1.6 71 1.9 59 2.1 36 4.0 156 hospital beds hospital beds 1.3 64 hospital beds hospital beds 13.0 674 2.0 46 6.2 526 hospital beds 1.6 118 hospital beds hospital beds 2.3 33 hospital beds 3.0 363 3.1 2.2 2.1 4.2 77 70 70 100 hospital beds hospital beds hospital beds 5.5 226 1.2 23 County Rank Johnston 65 Jones No Lee 21 Lenoir 14 Lincoln 12 McDowell 47 Macon 7 Madison No Martin 29 Mecklenburg 5 Mitchell No Montgomery No Moore 25 Nash 7 New Hanover 2 Northampton No Onslow 23 Orange No Pamlico No Pasquotank 32 Pender No Perquimans No Person 49 Pitt 55 Polk 33 Randolph 49 Richmond 49 Robeson 29 Rockingham 38 Rowan 45 Rutherford 58 Sampson 66 Scotland 35 Stanly 18 Stokes No Surry 26 Swaiii No Transylvania 45 Tyrrell 9 Union 55 Vance 18 Wake 16 Warren No Washington No Watauga 42 Wayne 35 Wilkes 58 Wilson 15 Yadkin No Yancey No Number Ratio Beds .6 30 hospital beds 3.1 41 3.9 4.0 1.7 5.4 91 84 37 84 hospital beds 2.6 35 5.5 594 hospital beds hospital beds 2.9 62 5.4 175 6.7 208 hospital beds 3.0 39 hospital beds hospital beds 2.5 30 hospital beds hospital beds 1.6 25 1.3 2.3 1.6 1.6 2.6 2.1 1.8 1.2 .3 2.2 3.3 42 24 66 40 131 96 99 47 9 26 96 hospital beds 2.8 110 hospital beds 1.8 21 17 40 53 248 4.8 1.3 3.3 3.4 hospital beds hospital beds 2.0 35 2.2 73 1.2 47 3.7 107 hospital beds hospital beds Source : Duke Endotoment Hospital Statistics. * Based on 1940 population. 22 HOSPITAL BEDS FOR WHITE PERSONS PER 1.000 WHITE POPULATION Norlh Carol ina, I9M3 N.C. Aitf icul t uf B I EKprriment Station DEPARTMENT OE Rl'RAL SOCIOlOf.V Bs:r(l en ttali from Dukp Enilo>»(nent Hospitnl Stfltiilt HOSPITAI PEOS FOR NEGROES PER 1.000 NEGRO POPULATION North Carol ina. I9U3 RATIO Ovtt 3.0 J 1- JO 1 1-2.0 0.1-1.0 N C Aericiiltutal Liprtin.rnt Station wfPARTMENT OF RURAL SOCIOLOGY B»sf<1 on daia (rom Dul-c Er.do»r^fnl HoipMal St«ti«tlci 23 Hospital Beds for Negroes Per 1,000 Nejjro Population, North Carolina, 1943* County Rank Alamance 60 Alexander No Alleghany No Anson 51 Ashe 27 Avery 2 Beaufort 46 Bertie No Bladen No Brunswick 21 Buncombe 12 Burke 10 Cabarrus 19 Caldwell 19 Camden No Carteret 25 Caswell No Catawba 43 Chatham 58 Cherokee 1 Chowan No Clay No Cleveland 40 Columbus 55 Craven 15 Cumberland 31 Currituck No Dare No Davidson 43 Davie No Duplin No Durham 6 Edgecombe 58 Forsyth 3 Franklin No Gaston 40 Gates No Graham No Granville 51 Greene .' No Guilford 21 Halifax 57 Harnett 46 Haywood ,... 4 Henderson -. 10 Hertford No Hoke No Hyde No Iredell 12 Jackson 36 Number Ratio Beds .5 5 hospital beds hospital beds 1.1 16 2.1 1 7.7 2 1.3 18 hospital beds hospital beds 2.4 14 3.1 50 3.8 12 2.5 24 2.5 7 hospital beds 2.2 6 hospital beds 1.4 7 .6 5 16.5 3 hospital beds hospital beds 1.7 22 .9 13 2.8 39 1.9 39 hospital beds hospital beds 1.4 8 hospital beds hospital beds 5.3 151 .6 16 6.6 272 hospital beds 1.7 22 hospital beds hospital beds 1.1 16 hospital beds 2.4 76 .7 23 1.3 15 5.6 5 3.8 8 hospital beds hospital beds hospital beds 3.1 30 1.8 1 County Bank Johnston 62 Jones No Lee 40 Lenoir 50 Lincoln 16 McDowell 16 Macon 9 Madison No Martin No Mecklenburg 29 Mitchell No Montgomery No Moore 31 Nash 18 New Hanover 4 Northampton No Onslow 31 Orange No Pamlico No Pasquotank 27 Pender No Perquimans No Person No Pitt 60 Polk 21 Eandolph 36 Richmond 56 Robeson 31 Rockingham 46 Rowan 43 Rutherford 36 Sampson No Scotland 51 Stanly 24 Stokes No Surry 8 Swain No Transylvania 7 Tyrrell 29 Union 51 Vance 25 Wake 14 "Warren No Washington No Watauga No Wayne 46 Wilkes 36 Wilson 31 Yadkin No Yancey No NUMBEB Ratio Beds .4 5 hospital beds 9 22 9 5 2 1.7 1.2 2.7 2.7 4.3 hospital beds hospital beds 2.0 85 hospital beds hospital beds 1.9 18 2.6 60 5.6 95 hospital beds 1.9 9 hospital beds hospital beds 2.1 18 hospital beds hospital beds hospital beds .5 2.4 1.8 .8 L9 1.3 1.4 1.8 15 4 8 10 49 16 18 11 hospital beds 1.1 13 2.3 9 hospital beds 4.7 12 hospital beds 4 4 10 30 110 4.8 2.0 LI 2.2 3.0 hospital beds hospital beds hospital beds 1.3 33 1.8 5 1.9 41 hospital beds hospital beds Source: Duke Endowment Hospital Statistics. * Based on 1940 population. 24 Number of General and Allied Special Hospital Beds Needed and Available, and Additional Beds Needed by County and Community: One Plan for Consideration Number Ni.mbeb Adhitionai, OF HEDS or l{i;i)B r.Et>s COUNTY AND TOWN NekdeiiI Kei-okteh^ Neei>ei>i iSfOEXn CAROLINA 15,674 9,:526 6,77cS Alamance : Burlington 191 45 J46 Alexander : Taylorsville* 38 38 Alleghany : Sparta* 34 34 Anson: Wadesboro 110 40 70 Ashe : Jefferson 74 28 46 Avery: Total 65 90 Banner Elk 45 70 Crossnore* 20 20 Beaufort: Washington 160 91 69 Bertie: Windsor* 20 18 2 Bladen : Elizabethtown 69 69 Brunswick: Southport* 32 49 Buncombe : Total 926 403 523 Asheville 902 379 523 Candler* 24 24 Burke: Total 132 155 Morganton 85 108 Valdese* 47 47 Cabarrus : Concord 191 163 28 Caldwell : Lenoir 104 56 48 Camden^ Carteret : Morehead City ! 71 48 23 Caswell: Yanceyville* 36 36 Catawba: Total 187 134 53 Hickory 126 88 38 Newton 61 46 15 Chatham: Siler City 65 19 46 Cherokee: Murphy 110 28 82 Chowan : Edenton 57 45 12 Clay: Havesville* 20 20 CleVeland': Shelby 129 99 30 Columbus : Wbiteville 141 60 81 Craven: New Bern 139 132 7 Cumberland: Fayetteville 673 205 468 Currituck : Currituck* 20 20 Dare: Manteo* 19 19 Davidson : Total 156 78 78 Lexington 91 26 65 Thomasville 65 52 13 Davie : Mocksville 65 65 Duplin: Wallace 84 84 Durham : Durham 652 861 Edgecombe:^ Tarboro 92 71 21 Forsyth : Winston-Salem 1,036 696 340 Franklin : Louisburg '. 118 118 Gaston : Gastonia 255 118 137 Gates : Gatesville* 20 20 Graham : Robbinsville* 32 32 Granville : Oxford 83 52 31 Greene: Snow Hill* 20 20 Guilford : Total 695 450 245 25 NUMBEB OF Beds COUNTY AND TOWN NeededI Greensboro 513 High Point 182 Halifax: Total 236 Roanoke Eapids 146 Scotland Neck 90 Harnett : Dimn-Erwin 142 Haywood : Waynesville 119 Henderson : Total 145 Fletcher« 65 Heiidersonville 80 Hertford : Ahoskie 92 Hoke : Raeford 73 Hyde : Swan Quarter* 23 Iredell : Total 189 Mooresville 76 Statesville 113 Jackson : Sylva 48 Johnston : Smithfield 116 Jones: Trenton* 20 Lee: Sanford 97 Lenoir : Kinston 414 Lincoln : Lincolnton 80 McDowell : Marion 67 Macon : Franklin 61 Madison : Marshall 85 Martin : Williamston 65 Mecklenburg: Charlotte 941 Mitchell : Spruce Pine 60 Montgomery: Troy 60 Moore : Pinehurst 97 JSTash: Rocky Mount 557 New Hanover: Wilmington 572 Northampton : Jackson* 20 Onslow: Jacksonville 96 Orange: Chapel Hill 400 Pamlico: Bayboro* 20 Pasquotank : Elizabeth City .". 225 Pender: Burgaw* 20 Perquimans : Hertford* 20 Person : Roxboro 76 Pitt: Greenville 190 Polk : Tryori 68 Randolph : Asheboro 100 Richmond : Hamlet 150 Robeson : Total 163 Fairmont* .• 25 Lumberton ...; 138 Rockingham : Total 188 Leaksville 99 Reidsville 89 Rowan : Salisbury 163 Rutherford : Rutherfordton 96 Sampson : Total 117 Clinton 117 Roseboro* 10 26 Number Additional OP Beds BEa>s Repoeted2 Needed3 328 185 122 60 114 122 114 32 90 85 57 75 44 112 33 65 47 33 50 42 73 23 238 16 60 16 178 25 23 30 86 20 53 44 132 282 93 41 26 96 85 35 30 953 60 60 80 17 204 353 427 145 20 55 41 400 20 94 131 20 20 16 60 65 125 28 40 79 21 94 56 180 25 155 124 64 50 49 74 15 149 14 64 32 7 110 107 7 3 NuMBEK NuMutm Additional OP Hki>s of Beds Heus COUNTY AND TOWN Neededi Uei-okted^ Nekdeus Scotland : Laurinburg 92 64 28 Stanly : Albemarle 108 89 19 Stokes : Danbury 57 57 Sun-y: Total 168 135 33 Elkin 63 60 3 Mount Airy 105 75 30 Swain : Bryson City* 27 27 Transylvania: Brevard 57 25 32 Tyrrell : Columbia* 26 21 5 Union: Monroe Ill 53 58 Vance : Henderson 126 89 37 Wake: Kaleigh 544 455 89 Warren : Warrenton 81 5 76 Washington : Plymouth* 20 20 Watauga: Boone 51 28 13 Wayne: Goldsboro 263 126 137 Wilkes: North Wilkesboro 80 54 26 Wilson : Wilson 231 152 79 Yadkin: Yadkinville* 20 20 Yancey : Burnsville* 20 20 iTentative estimates by the Department of Rural Sociology, North Carolina Agricultural Experiment Sta- tion, based on probable hospital service areas and on the establishment of regional hospital centers. The need for hospital beds has been related to average birth and death rates in tlie areas ccjMccrned. Population figures are for the year 1043. 2As reported in use in 104G. SDoes not include lieds that need replacement or lio.spitals that need to be recunstrnctcd (ir rcliwated. In- cludes beds for county and other health centers. ••Served by Elizabeth City. 5See, also, Roek.v Motuit in Nash County. BIncludes some TB beds. *Health center or community clinic. 27 PHYSICIANS PCR (00.000 POPULATI ON. I9u0 Un I ted Slates N.C.ARr Icul t ural Experiment Station DEPARTMENT OF RURAL SOCIOLOGY Baaed orTdata fron the U.S.Bureau of the Census PHYSICIANS PER 100.000 POPULATION Nor th Carol ma. I QUO N-C/rsricultural Experiincnt Stat ion DEP;»RTMENT OF RURAL SOCIOLOGY Besfd on data from thp American Meficat Association Pircct Total Physicians and Surgeons, and Nurses Per 100,000 Total Population, 1940 Rank 1 2 3 4 5 6 9 10 11 11 11 11 15 15 17 18 19 19 21 22 22 24 25 26 27 27 29 30 31 32 33 34 35 35 37 38 39 40 41 42 42 44 44 Jk6 47 47 49 PIIYSICIAXS AND SURGEONS ANU State Ratio UNITED STATES 125 District of Columbia 262 New York 193 Massacliusetts 164 Maryland 161 California 158 Colorado 146 Illinois 146 Connecticut 145 New Jersey 141 Missouri 132 Nevada 130 Ohio 130 Pennsylvania 130 Rhode" Island 130 Oregon 128 Vermont 128 Delaware 125 Minnesota 122 Nebraska 120 "Washington 120 Michigan 117 Iowa 115 Kansas 115 New Hampshire 114 Indiana 113 Arizona 112 Florida 108 Wisconsin 108 Maine 105 Utah 100 Louisiana 99 Virginia 98 Texas 97 Oklahoma 96 Montana 94 Tennessee 94 West Virginia 91 Wyoming 90 Kentucky 89 Arkansas 86 Georgia 82 New Mexico 80 North Dakota 80 Idaho 78 South Dakota 78 North Carolina ... 12 Alabama 66 South Carolina 66 Mississippi 61 TRAINED NURSES AND STUDENT NURSES Rank and State Ratio UNITED STATES 270 1 District of Columbia 569 2 Massachusetts 488 3 Connecticut 443 4 New Hampshire 403 5 New York 398 6 California 395 7 Maryland 350 7 Vermont , 350 9 Minnesota 341 10 Delaware 339 10 New Jersey 339 12 Colorado 333 13 Washington 329 14 Oregon 327 15 Rhode Island 313 16 Maine 302 17 Arizona 298 IS Montana 296 19 Illinois 289 20 Pennsylvania .' 284 21 Ohio 267 22 Michigan 263 23 Wisconsin 256 24 Nevada 251 25 Florida 250 26 Utah 242 27 North Dakota 236 28 Kansas 219 29 Iowa 216 29 Missouri 216 29 Nebraska 216 32 South Dakota 213 33 Virginia 210 34 Indiana 209 35 Idaho 203 36 Wyoming 202 37 Louisiana 181 38 Texas 176 39 North Carolina 175 40 West Virginia 161 41 South Carolina 160 42 Tennessee 159 43 New Mexico 152 44 Georgia 145 45 Oklahoma 134 46 Kentucky 131 47 Alabama 118 48 Arkansas 96 49 Mississippi 92 Source: United States Census, 1940. 29 North Carolina's Death Rate: Sound vs. Unsound Data One of the most misunderstood of all statistics regarding North Carolina is that dealing with our average death rate. Many sincere but misinformed people have said, "Well, North Carolina's health and hospital conditions must not be bad because our average death rate is one of the best in America." This is true only because of our astonishingly high birth rate and our consequent excessive propor- tion of children. Actually if we compare i,ooo people in each age group from I year to 75 years in North Carolina with 1,000 people in the same age groups in the United States as a whole. North Carolina is often not among the dozen best states in average death rate, nor the second best, nor the third best, but often among the worst 12 states in the Union! In other words, in states having much higher-than-average birth rates, the age level of the population is so low that the unadjusted death rate is spuriously low and misleading. In such states, "age- adjusted death rates" afford the only fair basis for comparison with other states. RURAL WHITE MORTALITY RATE • Excluding age groups under one and 75-up Death R ate Under S.50 5.50-5.99 6.00-6.49 6.50-6.99 7.00-up • AdJuatiSa to the age distribution of the total U.S. population, 1940 tl.C. Agricultural Experiment Station DEPARTMENT OF RURAL SOCIOIDOY Baaed on data froo the U. S. Cenaus. 30 Adjusted Mortality Rates Per 1,000 Population, 1940' Excluding age groups under one and I'j-up. TOTAL NONWHITB KUKAL WHITE AUK State Kate Uank State Kate Kank State Kate 29 United States 7.56 27 United States 13.14 27 United States 6.18 1 Nebraska 5.65 1 Vermont 1.59 1 Iowa 4.61 2 Iowa 5.68 2 Maine 5.66 2 Arizona 4.62 3 North Dakota 5.72 3 New Mexico 6.83 3 Kansas 4.82 4 South Dakota 5.75 4 Utah 10.00 4 Oregon 4.89 5 Minnesota 5.78 5 Arkansas 10.26 5 Nebraska 4.92 6 Kansas 5.85 6 California 10.32 6 South Dakota 4.93 7 Wisconsin 6.22 7 Kansas 10.72 7 Oklahoma 4.95 8 Oregon 6.59 8 Nebraska 10.86 8 North Dakota 5.15 9 Oklahoma 6.60 9 Arizona 10.89 9 Minnesota 5.21 10 Idaho 6.6S 10 Oklahoma 11.10 10 Arkansas 5.30 11 Maine 6.78 11 Iowa 11.12 11 Idaho 5.38 12 Utah 6.83 12 Massachusetts 11.18 12 Missouri 5.54 13 Wyoming 6.81 13 Connecticut 1L41 13 Texas 5.81 14 New Hampshire 6.85 14 Minnesota 11.52 14 Florida 5.73 15 Colorado 6.94 15 Idaho 11.74 15 Wyoming 5.74 16 Vermont 6.96 16 Mississippi 11.92 16 Wisconsin 5.76 17 Washington 7.01 17 Colorado • 11.93 17 Connecticut 5.80 18 Connecticut 7.02 18 Texas 12.00 17 Washington 5.80 19 Missouri 7.04 19 North Dakota 12.18 19 Georgia 5.91 20 Indiana 7.07 20 Montana 12.19 20 Colorado 5.93 20 Michigan 7.07 21 North Carolina, 12.25 21 Louisiana 6.07 22 Montana 7.16 22 South Dakota 12.28 21 New Mexico 6.07 23 Massachusetts 7.19 23 Louisiana 12.63 23 Mississippi 6.11 24 Arkansas 7.20 23 Oregon 12.63 23 Montana 6.11 25 Ohio 7.26 25 Michigan 12.69 25 Kentucky 6.13 26 California 7.34 26 New York 12.94 26 Indiana 6.14 27 West Virginia 7.40 27 Wisconsin 13.08 27 Delaware 6.18 28 Rhode Island 7.45 28 Indiana 13.31 28 Tennessee 6.21 29 Kentucky 7.55 29 Alabama 13.37 29 West Virginia 6.28 30 Texas 7.59 30 Washington 13.45 30 Ohio 6.33 31 New Mexico 7.64 31 Ohio 13.83 31 Maine 6.36 32 Illinois 7.75 32 Tennessee 13.93 32 Alabama 6.40 33 New York 7.79 33 New Jersey 13.95 S2 North Carolina 6.1,0 34 New Jersey 7.88 34 Georgia 14.06 34 Utah 6.43 35 Pennsylvania 7.98 34 Missouri 14.06 35 Vermont 6.51 36 Delaware 8.03 34 West Virginia 14.06 36 Michigan 6.53 37 Tennessee 8.04 37 Kentucky 14.10 36 South Carolina 6.53 S8 North Carolina 8.12 38 Rhode Island 14.40 38 New Hampshire 6.55 39 Florida 8.G5 39 Pennsylvania 14.48 39 Illinois 6.56 40 Maryland 8.72 40 Illinois 14.79 39 Virginia 6.56 41 ViROINIA 8.83 41 South Carolina 14.89 41 Rhode Island 6.80 42 Arizona 8.84 42 Virginia 14.91 42 Maryland 6.89 43 Mississippi 9.05 43 Florida 15.00 43 Massachusetts 7.00 44 Alabama 9.08 44 Wyoming 15.21 44 California 7.24 45 Gboegia 9.16 45 Maryland 15.31 45 Pennsylvania 7.35 46 Nevada 9.27 46 Delaware 15.35 46 New York 7.42 47 Louisiana 9..',4 47 Nevada 16.95 47 Nevada 7.Q8 48 South Carolina 10.28 48 New Hampshire 17.57 48 New Jersey 7.94 * Adjusted to the age distribution of the total United .States population. Source : U. S. Census. 31 Infant and Maternal Mortality Rates, United States, 1944 MATERXAL DEATHS I'ER I.IKJO LIVE BlIlTBti IX F Rank a.nd State Infant Deaths Rank United States S9.8 1 Oregon 30.5 1 2 Connecticut 30.7 2 3 Minnesota 31.3 3 4 Wisconsin 32.0 4 5 Illinois 32.4 5 6 Xew York 32.8 6 7 Nebraska 33.0 7 8 Massachusetts 33.1 8 9 Iowa 33.1 9 10 Kansas 33.3 10 11 Washington 33.S 11 12 Utah 33.9 12 13 Idaho 34.0 13 14 New Jersey 34.0 14 15 California 34.5 15 16 Indiana 34.5 16 17 Arkansas 34.7 17 18 South Dakota 34.9 IS 19 Ehode Island 35.3 19 20 North Dakota 35.4 20 21 Montana 36.1 21 22 Missouri 37.6 22 23 New Hampshire 37.7 23 24 Michigan 37.9 24 25 Ohio 38.5 25 26 Pennsylvania 40.0 26 27 Vermont 40.6 27 28 Oklahoma 41.2 28 29 Wyoming 41.2 29 30 Maryland 41.5 30 31 Mississippi 44.1 31 32 Georgia 44.5 32 33 District of Columbia 44.8 33 SJf North Carolina iM 34 35 Florida 45.5 35 36 Tennessee 45.5 36 37 Alabama 45.5 37 38 Louisiana 46.3 38 39 Kentucky 46.7 39 40 Maine 46.7 40 41 Virginia 47.1 H 42 Delaware :. 48.7 42 43 Colorado 49.4 43 44 Nevada ' 50.2 44 45 Texas 50.4 45 46 "West Virginia 52.0 46 47 South Carolina 54.9 47 48 Arizona 68.8 48 49 New Mexico 89.1 49 AXT DEATHS I'ER 1,000 LIVE BIRTHS AND State Matebnal Deaths United States 2.3 Wyoming 0.9 Utah 1.4 Minnesota 1.4 Montana 1.5 Delaware 1.5 Connecticut 1.5 Washington 1.6 New Jersey 1.6 Michigan 1.7 California 1.7 Nebraska 1.7, Wisconsin 1.8 North Dakota 1.8 Oregon 1.8 Iowa 1.8 Illinois 1.8 Massachusetts 1.8 South Dakota 1.8 Rhode Island 1.8 Kansas 1.8 New York 1.9 Maryland 1.9 Vermont 1.9 Ohio 1.9 Indiana 2.0 District of Columbia 2.1 West Virginia 2.2 Missouri 2.2 Maine 2.3 Nevada 2.3 Oklahoma 2.4 Idaho 2.5 Colorado 2.5 Kentucky 2.5 Texas 2.5 Pennsylvania 2.5 Virginia 2.6 Arkansas 2.8 Tennessee 2.8 New Hampshire 2.8 North Carolina 2.9 Arizona 3.0 Florida 3.3 Louisiana 3.4 Georgia 3.6 Alabama 3.7 South Carolina 3.7 Mississippi 3.8 New Mexico 4.0 Source: Vital StatiKtics of the United States, 191,1,. Part II. TaWcs 2, 22 and J. 32 Infant and Maternal Mortality In 1944, there were 266 deaths of mothers at childbirth and 4,115 deaths of infants under one year of age. In addition there were 2,401 stillbirths. Our infant mortality rate is 50 per cent higher than that of the lowest ranking state — Oregon. Only 15 states have higher infant mortality rates than North Carolina. It is possible to reduce infant mortality to less than 15 per 1,000 — but not without modern clinics and hospitals. Our maternal mortality rate is three times as high as that of Wyoming, the low- est ranking state. It is possible to wipe out maternal mortality almost entirely. The death rate among Negro infants (60 per 1,000 live births), is 55 per cent higher than among white infants. The maternal death rate among Negroes in North Carolina is more than double that among the white population. Of the 266 maternal deaths, 130 were Negroes and 136 were white. MATERNAL MORTALITY RATE UNITED STATES 1944 N.C AGR EXP STA RURAL SOCIOLOGY DEPT 33 Deaths Per 100,000 Popiilation by Principal Cause, North Carolina, 1940. PRINCIPAL CAUSE OF DEATH RATE Total Nonwhite TOTAL DEATHS 893.26 1,160.07 Typhoid, paratyphoid fever 1.06 1.49 Cerebrospinal meningitis .62 1.00 Scarlet fever .28 .30 Whooping cough 2.52 5.08 Diphtheria 3.00 2.89 Tuberculosis, pulmonary 41.77 93.83 Tuberculosis, other forms 3.25 8.17 Malaria 1.68 2.69 Syphilis 12.38 32.67 Poliomyelitis, polioencephalitis .45 .60 Cancer and other malignant tumors 58.57 52.49 Acute rheumatic fever 1.88 3.09 Diabetes mellitus 14.08 12.75 Exophthalmic goiter 1.18 1.20 Pellagra (except alcoholic) 4.68 4.18 Intercranial lesions of vascular 88.59 111.36 Diseases of ear, nose, throat 6.83 8.37 Chronic rheumatic heart diseases 14.70 18.33 Diseases of coronary arteries, angina 37.66 20.32 Diseases of heart, other forms 113.90 126.30 Influenza, pneumonia — all forms 75.15 108.67 Ulcer of stomach or duodenum 3.56 3.39 Diarrhea, enteritis 13.72 23.31 Appendicitis 6.27 6.18 Hernia, intestinal obstruction 5.77 7.97 Cirrhosis of the liver 4.31 3.49 Diseases of the gall bladder 2.69 1.00 Nephritis 96.12 127.79 Puerperal septicemia 3.70 6.57 Other puerperal causes 7.84 12.95 Congenital malformation 9.58 7.77 Premature birth 37.21 48.11 Suicide 8.15 2.59 Homicide 10.86 28.39 Motor vehicle accidents 28.36 27.09 Other accidents 36.93 43.83 Deaths from all other causes 134.00 193.93 Source : United States Vital Statistics, 1940. Ratio of Ratio of NONWHITE RUEAI, TO TO White RATE Urban Rate RUBAL Rate 147 844.06 82 166 .89 58 213 .69 168 111 .19 37 334 2.73 140 95 3.27 145 438 35.80 62 619 2.69 57 209 2.00 244 736 10.09 55 154 .42 82 86 51.74 67 221 2.08 156 87 12.09 62 103 1.00 61 86 5.24 165 140 83.50 82 134 6.93 105 138 15.09 111 46 29.95 51 116 107.07 81 175 74.88 99 94 3.04 62 234 15.09 150 98 5.43 64 162 5.20 71 75 3.20 44 30 2.04 46 153 91.13 83 256 3.73 104 222 7.82 99 76 9.82 110 146 36.38 92 25 6.93 61 708 7.82 41 94 26.03 75 128 36.15 93 175 135.90 105 15,000 Preventable Deaths In 1940, there were 31,904 deaths in North Carolina and 42 per cent of these were under 45 years of age. Most of these premature deaths were no doubt pre- ventable. If the mortality rates in North Carolina had been as low as found in the most healthy age groups of any state, we would have had only 15,295 deaths in 1940. Instead of 13,306 deaths under 45 years of age we would have had only 5,263 such deaths. 34 Maternal Deaths Per 1,000 Live Births by Color, United States and North Carolina,' 1922-1942. YEAR 1944 1943 1942 1941 1940 1939 1938 1937 193G 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 TOTAI. WHITK iNONWlIITE U. S. N. C. U. S. N. C. U. S. N. C. 2.3 2.9 1.9 2.2 5.1 4.6 2.5 3.2 2.1 2.0 5.1 6.1 2.6 3.4 2.2 2.8 5.4 4.8 3.2 4.0 2.7 3.1 6.8 5.7 3.8 5.1 3.2 4.0 7.7 7.6 4.0 4.7 3.5 3.7 7.6 6.8 4.4 5.3 3.8 4.0 8.5 8.0 4.9 5.4 4.4 4.2 8.6 7.9 5.7 6.6 5.1 5.6 9.7 8.8 5.8 6.5 5.3 5.3 9.5 8.9 5.9 7.1 5.4 6.2 9.0 9.1 6.1 6.8 5.6 5.8 9.7 9.0 6.2 6.8 5.8 5.4 9.8 9.8 6.6 8.0 6.0 6.4 11.1 11.6 6.7 8.3 6.1 6.7 11.7 12.1 7.0 8.4 6.3 7.2 12.0 11.2 6.9 7.8 6.3 6.7 12.1 10.5 6.5 6.6 5.9 5.1 11.3 9.9 6.6 8.8 6.2 7.1 10.7 12.6 6.5 8.7 6.0 6.8 11.6 12.8 6.6 7.7 6.1 6.6 11.8 10.4 6.7 8.0 6.3 6.7 10.9 10.7 6.6 8.0 6.3 7.0 10.7 9.9 Maternal Mortality Rates- By Color and Population-Size Groups,-' Carolina, 1940. United States and North TOTAL POPULATION SIZE GROUPS U. S. N. C. TOTAL 3.8 5.1 Cities of 10,000 and over population : Total 3.4 5.2 100,000 and over 25,000-99,999 10,000-24,999 Cities under 10,000 and rural : 3.1 3.7 4.0 4.8 5.4 5.2 Total 4.0 5.1 2,500-9,999 Rural 4.3 4.0 7.1 4.9 WHITE U. S. N. C. 3.2 4.0 3.0 2.8 3.1 3.5 3.4 3.8 3.3 4.3 3.4 3.8 5.4 .3.9 3.6 3.9 Source: United States Vital Statistics, 1 Place of occurrence. 2Rates are the number of deaths of mothers in a specified group per I.OIK) live births sPlace of residence. NONWHITE U. S. N. C. 7.7 7.6 7.3 6.2 9.3 10.1 8.0 10.2 7.7 7.1 8.0 8.2 4.7 7.7 18.5 7.0 in that group. 35 INFANT MORTALITY RATE UNITED STATES 1944 RATE UNDER 35 35-39.9 40-44 9 45-49 9 50-UP N.C. AGR. EVP. STA. RURAL SOCIOLOGY DEPT. NFANT MORTALITY RATE NORTH CAROLINA 1941-45 AVERAGE UNDER 40 40-44.9 45-49.9 50-54.9 55-59.9 60-UP N C AGR EXP STA. RURAL SOCIOLOGY DEPT. Crude* Death Rate; s and Infant M ortality ] lates, North Carolina Coi inties, Average 1941-1945 l.N'FAJJT Infant STATE DEAi'qis Deaths STATE Deaths Deaths AND Pes 1,000 I'ER 1,000 ^VND Per 1,000 IV.Rl.OOO COUNTIES Population Live Births COUNTIES Population lavK liUtTHS Xorlh Carolina S.9 48.5 Alamance 7.0 32.5 Johnston 7.8 38.4 Alexander 9.4 51.9 Jones 8.3 46.8 Alleghany 7.6 16.6 Lee 9.1 48.2 Anson 8.8 44.5 Lenoir 10.9 55.2 Ashe 8.0 52.3 Lincoln 8.1 50.1 Avery 7.8 46.9 McDowell 8.5 46.0 Beaufort 12.5 70.5 Macon 7.9 34.0 Bertie 10.4 62.0 Madison 8.6 51.5 Bladen 9.3 53.4 Martin 9.2 43.3 Brunswick 10.0 59.0 Mecklenburg 9.1 46.3 Buncombe 10.3 47.6 Mitchell 6.8 40.0 Burke 10.4 28.4 Montgomery 8.2 35.3 Cabarrus 6.2 41.3 Moore 7.9 se..-) Caldwell 8.1 49.6 Nash 9.5 52.7 Camden 10.8 69.3 New Hanover 8.7 54.0 ( 'arteret 10.3 45.0 Northampton 7.1 40.4 Caswell 8.0 42.9 Onslow 7.8 54.1 ( 'atawba 7.7 37.3 Orange 8.4 44.3 Chatham 8.8 41.1 Pamlico 10.2 57.1 Cherokee 7.8 48.8 Pasquotank 10.3 57.3 Chowan 10.6 48.0 Pender 11.2 51.8 Clay 8.1 37.7 Perquimans 9.6 34.4 Cleveland 6.5 36.2 Person 7.8 41.1 Columbus 9.4 60.3 Pitt 8.9 50.6 Craven 11.2 64.6 Polk 8.6 41.8 Cumberland 9.9 52.8 Eandolph 8.3 33.5 Currituck 11.7 51.8 Richmond 10.5 62.2 Dare 12.5 47.3 Eobeson 9.8 59.1 Davidson 7.8 48.1 Eockingham 8.0 52.5 Davie 9.4 48.6 Eowan 9.5 44.8 Duplin 9.2 52.1 Eutherford 7.9 40.3 Durham 9.1 44.0 Sampson 8.5 50.3 Edgecombe 10.0 58.7 Scotland 10.3 71.8 Forsyth 9.7 44.7 Stanly 7.8 44.8 Franklin 9.1 56.8 Stokes 7.3 41.5 Gaston 6.9 56.3 Surry 8.2 56.3 Gates 10.7 64.7 Swain 4.7 31.2 Graham 3.0 38.9 Transvlvania 7.9 42.9 Granville 9.4 45.2 Tyrrell 10.5 52.9 Greene 6.7 35.1 Union 8.6 43.5 Guilford 8.2 41.5 Vance 10.3 63.9 Halifax 9.0 49.6 Wake 10.3 45.3 Harnett 7.7 43.0 Warren 11.0 73.1 Haywood 7.7 41.4 Washington 10.8 63.8 Henderson 9.4 46.1 Watauga 6.9 32.7 Hertfoid 9.7 54.7 Wavne 12.0 59.8 Hoke 10.6 63.1 Wilkes 9.1 49.5 Hyde 10.6 35.3 Wilson lO.C. 61.5 Iredell 8.8 49.2 Yadkin 7.4 34.1 Jackson 8.9 61.3 Yancey 7.3 37.9 * "Crude" means that the rates have ■ not been adjusted for differences in age distribution as between counties. 37 Births and Deaths in Hospitals The extent to which hospital facilities are used is indicated by the percentage of births and deaths in hospitals. In 1944, only 51.1 per cent of all North Carolina births occurred in hospitals: 64.1 per cent of the white and 22.2 per cent of the Negro. Also, 4.1 per cent of white infants and 43.2 per cent of Negro infants were delivered by midwives. 89.3 per cent of white urban infants were delivered in hospitals as against only 54.1 per cent of rural white infants. The corresponding rates for Negro urban and rural infants were 48.5 per cent and 13.3 per cent, respectively. One-half of Negro rural infants were delivered by midwives as compared with one-fourth of Negro urban infants. Only 8 states had fewer babies born in hospitals than is the case for North Carolina, and in the lowest ranking state, Connecticut, 97.9 per cent of all infants were born in hospitals. PER CENT OF BIRTHS IN HOSPITALS UNITED STATES 1944 85- 89 9 80- 84.9 55- 79.9 UNDER 55 NC.AGR. EXP. STA. RURAL SOCIOLOGY DEPT. 38 Per Cent of Births and Deaths Occurring in Hospitals, United States, 1944 IIIRTBS IN HOSPITALS Rank and State Per Cent United States 75.6 1 Connecticut 97.9 2 Washington 97.1 3 Oregon 96.8 4 Massachusetts 95.3 5 California 95.2 6 New York 95.0 7 District of Columbia 95.0 8 Nevada 94.6 9 Montana 93.4 10 New Hampshire 93.1 11 New Jersey 92.5 12 Idaho 92.3 13 Rhode Island 91.9 14 Utah 90.3 15 Illinois 90.0 16 Minnesota 90.0 17 Wyoming 89.7 18 Michigan 88.2 19 Wisconsin 87.9 20 North Dakota 86.2 21 Iowa 85.3 22 Nebraska 84.4 23 Ohio 84.0 24 Kansas 83.9 25. Delaware 83.6 26 South Dakota 82.3 27 Colorado 82.1 28 Pennsylvania 81.5 29 Vermont 81.4 30 Maine 81.2 31 Indiana 80.9 32 Arizona 79.6 33 Maryland 73.8 34 Missouri 68.5 35 Oklahoma 68.1 36 Florida 66.8 37 Texas 65.9 38 Louisiana 61.7 39 New Mexico 55.9 40 Virginia 55.7 il North Carolina 51.1 42 Georgia 50.7 43 Tennessee 47, 44 West Virginia 42 45 Arkansas 41 46 South Carolina 41 47 Alabama 39 48 Kentucky 38 49 Mississippi 31 DEATHS IN HOSPITALS Hank and State Per Cent United States 38.6 1 Montana 52.2 2 Washington 51.4 3 District of Columbia 51.1 4 Nevada 49.6 5 Wyoming 49.2 6 California 48.8 7 Colorado 47.3 8 Connecticut 46.5 9 North Dakota 46.3 10 Minnesota 45.9 11 New York 45.9 12 Arizona 45.9 13 Oregon 44.8 14 Wisconsin 44.2 15 Illinois 44.1 16 Idaho 43.6 17 New Jersey 42.6 18 Delaware 40.8 19 Utah 40.7 20 Massachusetts 40.4 21 South Dakota 40.1 22 Nebraska 38.7 23 Kansas 38.7 24 Pennsylvania 38.6 25 Michigan 38.5 26 Rhode Island 38.3 27 Iowa 37.8 28 Maryland 37.6 29 Vermont 37.0 30 New Hampshire 36.9 31 Missouri 36.8 32 New Mexico 36.5 33 Florida 36.3 34 Ohio 36.0 35 Louisiana 35.6 36 Maine 33.7 37 Oklahoma 32.7 38 Indiana 32.0 39 Texas 31.6 40 Virginia 30.8 41 West Virginia 30.7 42 North Carolina S0.6 43 Tennessee 27.4 44 Georgia 27.1 45 South Carolina 26.7 46 Kentucky 24.8 47 Arkansas 24.8 48 Alabama 24.2 49 Mississippi 21.3 Source: Vital Statistics of the United States, 19U- Part II. Tables R and 25. 39 PER CENT OF DEATHS IN HOSPITALS UNITED STATES 1944 PER CENT '^ <5-UP 40-4*9 W 35-39.9 30-34.9 25-29.9 UNDER 25 N.C. AGR EXP STA RURAL SOCIOLOGY DEFT DEATHS IN HOSPITALS NORTH CAROLINA 194 5 PER CENT 35-UP 30-34.9 25-299 20- 24.9 IS - 19.9 UNDER 15 N.C AGR. EXP. STA. RURAL SOCIOLOGY DEPT. Per Cent of Births and Deaths in Hospitals and Per Cent of : Births Attended by Midwives, North Carolina, 1945. 1*EB Cent Pee Cent STATE Pee Cent Vkr Cent Births STATE I'KK ("ENT Percent Bibths AND Births in Deaths in Attended AND Births in Deaths in Attended COUNTIES IIOSPITAI-S Hospitals Bv Mi I) wives COUNTIES Hospitals Hospitals By Midwives North Jackson 31.6 19.3 20.7 Carolina 53.5 30.1 17.3 Johnston 36.8 25.3 14.0 Alamance 63.6 22.7 2.7 Jones 30.9 20.5 32.5 Alexander 35.6 23.4 2.8 Lee 62.2 32.5 14.2 Alleghany 24.5 12.2 2.7 Lenoir 53.5 37.0 23.8 Anson 25.5 15.7 50.7 Lincoln 66.9 29.5 10.3 Ashe 41.1 15.9 20.9 McDowell 63.1 26.6 4.3 Avery 78.0 22.8 16.3 Macon 23.8 16.7 14.2 Beaufort 59.2 23.9 28.0 Madison 17.4 14.0 39.0 Bertie 33.3 15.1 46.1 Martin 17.0 20.1 28.7 Bladen 16.9 16.7 34.3 Mecklenburg 89.8 41.3 3.9 Brunswick 50.4 37.8 46.4 Mitchell 32.4 17.6 25.2 Buncombe 73.0 34.2 7.6 Montgomery 51.7 20.5 23.0 Burke 80.7 44.0 14.3 Moore 60.2 37.0 16.1 Cabarrus 81.8 40.1 6.3 Nash 39.3 34.6 20.1 Caldwell 59.4 26.8 4.1 New Hanovei 92.2 55.4 6.4 Camden 18.4 12.1 56.1 Northampton 17.6 16.7 51.7 Carteret 70.6 24.2 13.2 Onslow 52.8 39.2 17.9 Caswell 8.6 14.2 37.1 Orange 62.3 30.3 11.2 Catawba 84.6 35.2 10.5 Pamlico 9.5 14.1 22.0 Chatham 40.8 24.4 16.5 Pasquotank 40.2 16.3 29.8 Cherokee 42.9 31.5 47.8 Pender 26.7 27.9 48.7 Chowan 9.5 9.3 30.2 Perquimans 8.2 9.5 43.6 Clay 51.6 21.9 21.4 Person 38.5 29.0 9.2 Cleveland 56.2 39.7 18.2 Pitt 27.2 17.3 22.1 Columbus 46.3 27.0 38.8 Polk 47.8 31.0 5.1 Craven 61.7 31.0 29.3 Randolph 74.2 35.7 5.5 Cumberland 43.8 37.2 31.1 Richmond 31.3 22.8 24.8 Currituck 16.9 5.5 48.4 Robeson 34.5 24.5 27.5 Dare 22.8 10.2 18.5 Rockingham 55.6 31.6 4.7 Davidson 73.9 24.6 2.2 Rowan 71.3 34.9 7.5 Davie 44.6 29.2 2.3 Rutherford 23.2 21.7 7.0 Duplin 18.7 16.9 12.6 Sampson 23.2 18.9 25.6 Durham 88.9 41.6 5.3 Scotland 22.0 20.3 54.4 Edgecombe 37.5 29.7 25.8 Stanly 77.3 33.7 2.5 Forsj^h 84.6 39.9 0.9 Stokes 24.5 16.6 8.0 Franklin 32.7 29.5 27.0 Surry 44.7 25.4 5.9 Gaston 61.9 30.5 5.3 Swain 26.2 30.8 25.2 Gates 30.9 0.0 42.0 Transylvania 47.8 18.9 9.7 Graham 24.9 17.9 33.0 Tyrrell 66.7 5.7 20.4 Granville 36.2 25.1 10.3 Union 44.6 23.2 12.3 Greene 19.6 20.8 13.8 Vance 57.9 24.9 31.5 Guilford 80.8 39.4 2.5 Wake 63.3 43.0 11.1 Halifax 31.1 29.3 52.8 Warren 15.8 19.5 66.8 Harnett 49.6 27.8 11.9 Washington 21.6 15.1 47.3 Hay^vood 80.6 28.8 3.5 Watauga 74.8 33.6 11.8 Henderson 78.8 34.9 5.2 Wayne 34.2 27.2 10.0 Hertford 14.9 7.0 20.7 Wilkes 44.6 18.9 18.7 Hoke 12.8 23.2 47.6 Wilson 44.5 32.2 19.0 Hyde 30.1 25.6 61.9 Yadkin 68.4 25.0 3.4 Iredell 64.1 31.3 9.2 Yancey 29.3 10.8 45.7 Source: North Carolina State Board of Health. 41 Income Per Capita, Average 1943-45. United States Rank State Income in Dollaks United States $1,108 1 New York 1,489 2 Connecticut 1,480 3 California 1,473 4 Washington 1,441 5 Delaware 1,371 6 New Jersey 1,360 7 District of Columbia 1,313 8 Nevada 1,302 9 Illinois 1,299 10 Oregon 1,276 11 Massachusetts 1,271 12 Ohio 1,266 13 Michigan 1,260 14 Rhode Island 1,258 16 Maryland 1,222 16 Pennsylvania 1,149 17 Indiana 1,136 18 Montana 1,133 19 Wisconsin 1,091 20 Kansas 1,080 21 Maine 1,055 22 Nebraska 1,051 23 North Dakota 1,051 24 Iowa 1,044 25 Utah 1,028 26 Wyoming 1,027 27 Colorado 1,025 28 Idaho 1,008 29 Missouri 991 30 iMinnesota 981 31 South Dakota 966 32 Vermont 958 33 Florida 942 34 Texas 894 36 Arizona 891 36 New Hampshire 891 37 Virginia 876 38 Oklahoma 826 39 West Virginia 776 . 40 Louisiana 765 41 New Mexico 755 42 Tennessee 747 43 Georgia 710 44 Kentucky 683 45 NORTli CAROLINA 681 46 Alabama 660 47 South Carolina 630 48 Arkansas 597 49 Mississippi 527 Source: Schwartz. Charles F., and Graham, Rohert E., .Ir.. "State Income Payments in 194.5." fiiirvcy of Currrtit Business. Vol. 26. No. 8, August, J946. page 16, tahle 4. 42 Economic and Social Factors North Carolina has inadequate medical and hospital services because its people earn relatively low incomes and have a relatively large number of children and elders to support. Net income per capita in 1940 was $317 as compared with $573 for the nation as a whole. Only four states had lower incomes in 1940. The average net income per capita, 1943-1945 inclusive, was $681 and still only four states (Alabama, Mis- sissippi, South Carolina, and Arkansas) had lower incomes. INCOME PER CAPITA UNITED STATES AVERAGE 1943-1945 DOLLARS IJOO-UP 1100- 1299 900- 1099 700- 899 UNDER 700 N C. AGR EXP STA RURAL SOCIOLOGY DEPT Rejections for Military Service In 1943, February through August, North Carolina led the nation in percentage of registrants rejected for military service. From August, 1944, through August, 1945, only three states had higher rejection rates than North Carolina. Preinduction rejection rates for the two periods, for which published data are available, are:* jq^^ JQ44.4S All registrants 56.8 48.6 White registrants 49.2 44.6 Negro registrants 71.5 57.1 Percentage of Registrants Rejected for Military Service (At local hoards and induction stations, February, 19 J, J, through August, IdJfS) Preliminary ALL UEGISTKANTS WHITE REGISTUANTS NEGRO REGISTRANTS Pek I'tR Per Rank State Cent Kank State Cent Ran k State Cent 32 United States 39.2 23 United States 36.0 38 United States 56.9 1 Oregon 24.4 1 Oregon 24.4 * Arizona * 2 Kansas 25.4 2 Kansas 24.8 * Colorado * 3 Utah 26.1 3 Utah 26.0 * Idaho * 4 "Washington 28.2 4 Washington 28.0 * Iowa * 5 Wyoming 29.1 5 Delaware 28.2 '^ Maine * 6 Idaho 29.3 6 Idaho 29.0 * Minnesota * 7 Connecticut 31.0 7 New Jersey 29.1 * Montana * 8 South Dakota 31.1 8 Wyoming 29.2 * Nebraska * 9 I^ebraska 31.6 9 Connecticut 30.4 * Nevada * 10 Pennsylvania 31.8 10 Pennsylvania 30.9 * New Hampshire * 11 Delaware 31.9 11 South Dakota 31.1 * New Mexico * 12 Illinois 32.9 12 Nebraska 31.3 * North Dakota * 12 Nevada 32.9 13 Illinois 31.6 * Oregon * 14 New Jersey 33.0 14 Maryland 32.4 * Rhode Island * 15 Iowa 33.1 15 Nevada 32.6 * South Dakota * 16 North Dakota 33.S 16 Mississippi 32.9 * Utah * 17 California 35,6 17 Iowa 33.0 * Vermont * 18 Minnesota 35.7 18 North Dakota 33.7 * Washington * 19 Ohio 35.8 19 Ohio 34.8 * Wisconsin * 20 Indiana 36.2 20 California 35.2 * Wyoming * 21 Montana 36.5 20 Indiana 35.2 21 Kansas 33.4 22 Missouri 37.2 22 Missouri 35.4 22 West Virginia 41..0 23 Ehode Island 37.3 23 Minnesota 35.6 23 Illinois 41.8 24 Michigan 37.4 24 Michigan 36.3 24 Pennsylvania 43.1 24 Maryland 37.4 25 Montana 36.5 25 New Jersey 44.5 26 Maine 37.5 26 New York 36.8 26 Delaware 44.7 27 Massachusetts 37.7 27 Rhode Island 37.2 27 Connecticut 45.1 27 New York 37.7 28 Maine 37.4 28 California 46.4 27 West Virginia 37.7 28 Massachusetts 37.4 29 Ohio 46.9 30 New Hampshire 38.9 28 West Virginia 37.4 30 New York 48.0 30 Wisconsin 38.9 31 Oklahoma 38.2 31 Indiana 48.3 32 Arizona 39.0 32 Arizona 38.4 32 Kentucky 49.7 33 New Mexico 40.1 33 Wisconsin 38.7 33 Missouri 50.4 34 Oklahoma 40.6 34 New Hampshire 3S.9 34 Michigan 51.2 35 Texas 42.9 35 Texas 39.4 35 Massachusetts 52.4 36 Colorado 43.1 36 Alabama 39.5 36 Maryland 53.1 37 Tennessee 44.7 37 New Mexico 39.9 37 Mississippi 54.2 38 Mississippi 45.0 38 Tennessee 40.1 38 Oklahoma 55.9 39 Kentucky 45.4 39 Florida 41.4 39 Tennessee 57.4 40 Vermont 45.7 40 Louisiana 42.5 40 Georgia 57.8 41 Alabama 49.0 42 South Carolina 42.9 40 Texas 57.S 42 Georoia 51.5 42 Colorado 43.0 42 Alabama 61.0 43 ViROINIA 52.2 43 Kentucky 45.1 43 Virginia 63.9 44 Louisiana 52.6 44 Virginia 45.5 44 Louisiana 64.0 45 Fi.oRinA 53.2 45 Vermont 45.7 45 Florida 65.8 46 Arkansas 55.9 46 Arkansas 46.9 46 South Carolina 69.4 46 South Carolina 55.9 46 Georgia 46.9 47 Arkansas 70.9 Jt8 North Carolina 5G.8 ■'i8 North Carolina J,9.2 J, 8 North Carolina 71.5 * States haviuR loss than 0.3 per cent of total Negro registrants are omitted. Source : U. S. Senate Iloarii: igs SnlK'Ommittee on Wartime Ilcjiltli niKl K( incntion. 44 PERCENTAOE OK REGISTRANTS REJECTED FOR MILITARY SERVICE 30.0-34.9 35.3-39.9 40.0-44.9 45.0-49.9 50.0-up N.C. Agricultural Experiment Station DEPARTMEHT OF RURAL SOCIOLOGY Baaed on data from U.S. Senate Hearlnga Subcommittee on Wartime Health and Education PERCENrAGE SELECTIVE SERVICE RCGISTRaHTS REJECTEtJ FOR MILITARY SERVICE THROUGH MARCH 31. I9M3. NORTH CAROLINA TOTAL p/^-M^pfci-'^^^^ WHITE 35-42. 4 uz.u-ag.g 60-57.4 67.5-65 ALove 65 N.C. Agr icul tuf ■! E«p*fim*nl Station DEPARTMENT OF RURAL SOCIOLOGY BASED ON DATA FROM NORTH CAROLINA SELECTIVE SERVICE HEADOl ARTFRS Percentage Selective Service Registrants Rejected for Military Service by Color of Registrant, Through March 31, 1943, North Carolina. Pekcentage Rejected Percentage Rejected NON- Non- COUNTY Kank TOTAI, Whitk WHITK (BOUNTY Rank Total White white North Jackson 10 32.4 32.0 * Carolina 48 48.1 40.9 60.6 Johnston 86 59.0 55.4 66.0 Alamance 27 40.4 32.5 57.5 Jones 58 50.5 40.4 62.0 Alexander 3 17.8 15.8 ']• Lee 44 46.8 46.0 60.5 Alleghany 32 41.9 40.3 * Lenoir 72 55.6 43.7 64.4 Anson 71 55.3 51.7 58.4 Lincoln 37 44.7 41.1 68.9 Ashe 5 25.3 25.6 * Macon 9 31.0 30.8 * Avery 23 39.1 39.7 * Madison 31 41.8 41.2 * Beaufort 91 61.3 53.8 68.8 Martin 60 51.0 51.0 « Bertie 87 59.2 51.8 63.2 McDowell 88 60.3 46.7 69.4 Bladen 89 60.4 51.9 67.6 Mecklenburg 16 35.8 25.0 56.2 Brunswick 97 65.5 67.6 63.7 Mitchell 51 48.9 48.9 * Buncombe 50 48.7 43.7 68.8 Montgomery 4 22.7 19.3 32.0 Burke 19 36.8 36.2 41.9 Moore 84 58.7 48.4 72.2 Cabarrus 11 33.7 30.1 47.3 ISTash 79 57.5 47.6 64.9 Caldwell 29 41.6 38.0 70.0 New Hanover 80 58.0 51.9 64.7 Camden 90 61.0 * * Northampton 99 65.8 63.7 66.7 Carteret 82 58.2 52.8 59.3 Onslow 64 52.4 65.4 31.3 Caswell 35 42.7 33.1 53.0 Orange 47 47.S 43.4 53.2 Catawba 41 46.3 40.7 78.9 Pamlico 68 54.4 51.6 57.4 Chatham . 46 47.3 42.4 55.9 Pasquotank 83 58.6 55.6 60.2 Cherokee 14 35.6 35.0 * Pender 34 42.6 50.0 34.6 Chowan 75 56.0 48.7 62.5 Perquimans 94 63.4 53.1 68.9 Clay 6 27.4 27.4 * Person 43 46.5 35.8 55.0 Cleveland 42 46.4 38.6 64.5 Pitt 73 55.9 44.6 64.7 Columbus 96 64.7 59.3 69.7 Polk 32 41.9 38.4 56.7 Craven 57 50.0 51.9 48.6 Randolph 36 44.6 42.0 58.3 Cumberland 66 53.4 45.8 61.4 Richmond 52 49.0 44.1 56.7 Currituck 93 62.9 * * Robeson 77 56.2 50.8 62.9 Dare 85 58.8 53.3 * Rockingham 99 65.8 62.7 * Davidson 21 37.6 32.6 68.0 Rowan 8 29.0 26.6 46.3 Davie 48 48.3 42.9 64.7 Rutherford 39 45.2 41.6 70.1 Duplin 65 52.5 42.6 60.2 Sampson 63 51.7 47.8 56.8 Durham 73 55.9 52.5 60.4 Scotland 76 56.1 50.5 63.6 Edgecombe 78 56.7 47.4 62.1 Stanly 45 46.9 35.3 65.3 Forsyth 14 35.6 25.0 48.3 Stokes 13 34.7 34.1 * Franklin 52 49.0 50.0 48.4 Surry 25 39.8 39.1 48.6 Gaston 24 39.2 34.5 63.7 Swain 37 44.7 44.3 * Gates * * * * Transylvania 20 37.0 38.2 * Graham 2 4.9 4.9 * Tyrrell 70 55.0 50.0 59.5 Granville 58 50.5 46.4 53.2 Union 56 49.6 42.4 70.9 Greene 29 41.6 25.7 55.7 Vance 53 49.1 45.0 52.2 Guilford 18 36.2 29.3 57.0 Wake 40 45.7 42.2 49.7 Halifax 81 58.3 52.5 62.4 Warren 97 65.5 65.3 65.6 Harnett 61 51.2 52.7 48.5 Washington 54 49.1 45.7 51.5 Hajwodd 22 38.7 38.7 * Watauga 26 39.9 39.7 * Henderson 28 40.5 37.9 60.5 Wayne 95 63.8 55.3 68.9 Hertford 67 53.6 42.2 58.0 Wilkes 7 28.3 28.7 * Hoke 92 62.3 48.6 71.6 Wilpon 69 54.9 4.5.8 61.0 Hyde 61 51.2 43.5 60.0 Yadkin 49 48.6 46.2 68.0 Iredell 12 34.4 31.0 48.6 Yancey 17 36.1 36.1 * * Le.ss than 25 cases in .sample. Source : North Carolina Selective Service Headquarters ; calculations based upim a .systematic sample of records and not upon the entire number examined. Per Capita Effective Buying Income.* STATE AND COIXTIES 1043-45 NOKTH CAROLINA $ 724 Alamance 885 Alexander 368 Alleghany 399 Anson 501 Ashe 315 Avery 198 Beaufort 736 Bertie 451 Bladen 401 Brunswick 264 Buncombe 1,227 Burke 514 Cabarrus 750 Caldwell 545 Camden 197 Carteret 568 Caswell 281 Catawba 708 Chatham 510 Cherokee 369 Chowan 655 Clay 182 Cleveland 633 Columbus 461 Craven 694 Cumberland 591 Currituck 333 Dare 604 Davidson 658 Davie 450 Duplin 464 Durham 1,449 Edgecombe 816 Forsyth 1,287 Franklin 403 Gaston 611 Gates 205 Graham 187 Granville 510 Greene 439 Guilford ; 1,107 Halifax .' 574 Harnett 5S0 Haywood 605 Henderson .'. 845 Hertford .'. 500 Hoke 457 Hyde 194 Iredell 603 Jackson 4S1 STATE AND COUNTIES 1943-45 XORTH CAROLINA Johnston $ 534 Jones 214 Lee 668 Lenoir 853 Lincoln 554 McDowell 480 Macon 430 Madison 362 Martin 640 Mecklenburg 1,482 Mitchell 431 Montgomery 618 Moore 640 Nash 595 New Hanover 973 Northampton 235 Onslow 209 Orange 528 Pamlico 224 Pasquotank 848 Pender 307 Perquimans 495 Person 534 Pitt 774 Polk 503 Randolph 432 Richmond 714 Robeson .••• 595 Rockingham 678 Rowan 911 Rutherford 504 Sampson 444 Scotland 501 Stanly 675 Stokes 366 Surry 696 Swai'n 262 Transylvania 587 Tyrrell 290 Union 554 Vance 749 "Wake 977 WiUMTii 475 Washington 426 "Watauga 440 "Wayne 657 "Wilkes 440 "Wilson 798 Yadkin 278 Yancev 313 * Fi-nni ^nlex Management Magazine. 48 EFFECTIVE BUYING POWER PER CAPITA AVERAGE 1943-1945 NORTH CAROLINA DOLLARS 750-UP 650-749 550-S49 4 50-549 300-449 UNDER iOO N.C AGR EXP SrA RURAL SOCIOLOGY DEPT 49 EXPENDITURES FOR FULL-TIME PUBLIC H EALTH SERVICES North Carolina, ISUa-UU* Per Capita Expend i tures Percentage Conir i tu teJ By Coun ties N.C. AbMcuI lur«I F«p»rimcnl Sl«lion DEPARTMENT OF RURAL 'SOCIOLOOy KCtUDINC ASHtVItlt. CHARLOTTE. GREENSBORO, HIGH POINT, ROCtY MOUNT, AND IINSTON- SALEM BASED ON DATA THOU THE N C STATE BOARD OF HEALTH Expenditures for Full-Time Public Health Services, North Carolina, 1943-44. Total COUNTY, CITY, OR DISTRICT Amount TOTAL STATE $2,134,051 FIVE CITIES: TOTAL 320,633 AsLeville 85,992 Charlotte 90,061 Greensboro 68,349 High Point 39,061 Rocky Mount 37,170 Counties and Districts: Total 1,813,418 Alamance 24,114 Alleghany, Ashe, "Watauga 19,004 Anson, Montgomery 27,538 Avery, Yancey 14,895 Beaufort 15,613 Bertie, Chowan, Gates 28,058 Bladen 14,930 Buncombe, except Asheville 18,415 Burke, Caldwell 22,715 Cabarrus 47,414 Carteret 17,433 Catawba, Lincoln 31,874 Cherokee, Clay, Graham 25,381 Cleveland 25,391 Columbus 17,605 Craven 28,308 Cumberland 51,626 Currituck, Dare 16,049 Davidson 19,574 Duplin 17,120 Durham 123,883 Edgecombe, Halifax, except Kocky Mount 58,752 Forsyth, Stokes, Yadkin, Davie, except Win- ston-Salemf 101,854 Franklin 10,088 Gaston 39,272 Granville 23,980 Greene 16,329 Guilford, except Greensboro and High Point 20,120 Harnett 21,622 Haywood, Jackson, Macon, Swain, and Tran- sylvania 45,131 Hyde, Tyrrell, Washington 23,696 Iredell 18,595 Johnston 16,253 Lenoir 29,320 Martin 16,794 Mecklenburg, except Charlotte 20,040 Moore, Hoke 30,860 Nash, except Rocky Mount 22,820 New Hanover 75,941 Northampton, Hertford 43,862 Onslow, Pender 27,551 Ua.Mv UUGET % Distribution bv I'EB Ptai Source of 1 'UN us (Jap- < 'APITA State Local Other* ITA $ .649 7.0 57.6 35.3 36 1.163 74.5 25.5 1.676 73.9 26.1 .892 78.4 21.6 1.152 70.7 29.3 1.015 71.9 28.1 1.454 76.0 24.0 .601 8.3 54.7 37.1 .419 7.5 52.2 40.3 73 .387 22.7 34.6 42.6 76 .616 13.1 49.6 37.3 40 .484 18.3 21.3 60.4 55 .429 11.5 50.6 37.9 69 .587 18.2 38.2 43.6 43 .550 9.6 40.8 49.6 49 .320 9.8 82.1 8.1 85 .305 15.8 52.2 32.0 87 .798 3.8 61.7 34.5 28 .953 10.3 53.6 36.1 9 .420 11.3 53.7 35.0 71 .802 13.0 35.4 51.6 25 .437 7.1 50.5 42.4 67 .386 8.2 53.5 38.3 79 .905 6.4 50.3 43.3 15 .870 3.5 55.0 41.5 17 1.259 22.4 36.8 40.8 3 .367 8.3 67.4 24.3 81 .431 8.4 48.8 42.8 68 1.544 1.5 71.1 27.4 2 .630 6.1 57.6 36.3 38 .971 5.3 58.5 36.1 5 .332 14.3 50.0 35.7 84 .449 4.6 68.9 26.5 66 .817 7.5 56.7 35.8 24 .880 9.9 37.8 52.3 16 .359 8.9 82.7 8.3 82 .489 8.3 68.6 23.0 53 .478 19.9 40.0 40.1 57 .921 21.9 41.3 36.7 10 .369 9.7 57.0 33.3 80 .255 11.1 52.6 36.3 89 .711 5.5 54.2 40.2 32 .643 10.7 54.6 34.7 36 .393 9.0 80.5 10.5 74 .672 9.9 41.5 48.6 34 .538 7.9 52.9 39.2 50 1.584 2.4 74.5 23.2 1 .920 7.8 34.1 5.S.1 13 .773 15.2 50.5 34.2 29 51 Expenditures for Full-Time Public Health Services, North Carolina, 1943-44r— Continued. Rank Total Budget % Distbibution by Peb COUNTY, CITY, OR DISTRICT Phb Source of Funds Gap- Amount Capita State Local Othek* ita Orange, Person, Chatham 63,227 .868 9.5 27.1 63.4 18 Pasquotank, Perquimans, Camden 30,338 .848 16.4 48.4 35.2 21 Pitt 29,086 .475 6.2 55.7 38.1 62 Eandolph 18,739 .421 7.7 57.2 35.1 70 Richmond 19,393 .527 8.4 51.4 40.2 51 Kobeson 27,477 .357 6.6 50.0 43.4 83 Rockingham 22,488 .388 8.0 59.7 32.3 75 Rowan 32,480 .469 5.5 66.4 28.1 63 Rutherford, Polk 32,305 .562 11.1 34.4 54.4 47 Sampson 22,059 .465 7.3 45.2 47.5 65 Scotland 14,699 .633 12.2 50.2 37.6 37 Stanly 18,476 .563 9.7 56.4 33.8 46 Surry 21,280 .509 7.6 50.0 42.4 52 Union 23,363 .597 7.7 46.7 45.6 42 Vance 14,574 .486 9.1 49.8 41.2 54 Wake 73,704 .673 2.4 71.0 26.5 33 Wayne 43,034 .738 4.2 57.9 37.9 31 Wilkes 13,389 .311 10.8 45.0 44.3 86 Wilson 23,487 .467 6.9 62.3 30.8 64 There was no full-time public health service in the following counties during the fiscal year 1943-1944 : Alexander, Brunswick, Caswell, Henderson, Jones, Lee, McDowell, Madison, Mitchell, Pamlico, Warren. * Other agencies include ; Reynolds Funds — Si>ecial frum Smith Reynolds Foundation Federal Venereal Disease Control Funds Title VI (Federal) Children's Bureau (Federal) t Winston-Salem uses no State or Federal Funds 52 BIRTHS IN HOSPITALS NORTH CAROLINA 1945 PER CENT 80-UP 65-79.9 50-64.9 35-49.9 20-343 UNDER 20 N.C. AGR. EXP. STA. RURAL SOCrOLOGY DEPT. BIRTHS ATTENDED BY MIDWIVES NORTH CAROLINA 1945 :r cent UNDER 5.0 5 0-9.9 100-199 20.0-299 30 0-39.3 40 0-UP N C. AGR. EXP STA RURAL SOCIOLOGY DEPT. IV Our Industrial and Urban Population Needs "More Doctors, More Hospitals, More Insurance" (Report of Chairman Charles A. Cannon.) In this chapter Mr. Charles A. Cannon (whose superb work with his own local hospitals had attracted statewide attention) empha- sizes many valuable points, but especially these two: 1) Enlarge- ment of hospitals should be based not on the population in the area but on the per cent of hospital beds in use. 2) Of supreme impor- tance is service to mothers and babies and: "In order to render this service the hospital must be conveniently located — near the people. This service wUl not be rendered by any hospital that is located at a distance." To THE Governor's Commission on Hospitals and Medical Care We have found some difficulty in drawing a line between rural areas and the industrial and urban areas. Moreover, we do not believe it practical, in consider- ing hospital needs for the population of the State, to make such a distinction. We are, therefore, using the statistics covering the entire State as a basis for our recom- mendations. When this report is coordinated with the other reports, any overlap- ping or conflicting recommendations should be eliminated. In considering the location and needs of hospitals, the county has been consid- ered as a unit in most cases. The reason for this is that the county under the organization of our State Government is a geographical and political unit with definite responsibilities and with large powers and resources with which to dis- charge its responsibilities. Moreover, most counties have assumed and are dis- charging these responsibilities in a praiseworthy degree. Fortunately, for the large number of our counties the population is of such size and the taxable wealth suffi- cient to support and make possible a hospital located in the county, convenient to the people of the county and responsive to administrative patterns of control well established by tradition and justified by experience. Location of Hospitals The location of the hospital, in addition to being convenient to the patients and their families, should also be located so as to be of help to the medical men in the community in their work and to encourage younger men to locate in the various counties in the State. No hospital will be rendering its maximum service if it does not furnish, in addition to the service it renders to the patients, a rallying point for the doctors and thereby improve the quality of their work and their abil- ity to serve the community. It may be desirable for the State Legislature to consider creating by legislative act a few hospital districts incorporating two or more counties and providing some legal apportionment or assessment of the counties involved in the district for the raising of funds, both for the construction and operation of the hospital. Of the 34 counties without hospitals, it is thought that possibly the answer to about Yj, of these counties is to establish hospital districts combining two or more counties in the hospital district. It is believed that Yi of the counties should build hospitals to take care of the requirements of their respective counties. The other Yi of the smaller counties would have to continue to be served as they now are through the hospital provision of their neighboring counties, or else be provided with a small cottage type of hospital capable of providing for the local doctors the diagnostic services of a laboratory and X-ray and facilities for emergency surgery and obstet- rical care. Out of the lOO counties in the State, 66 have hospitals serving 84.4% of the population, and 34 do not have hospitals serving 15.6% of the population. The counties without hospitals are to a substantial degree the rural counties. The 66 counties with hospitals cover rural and urban communities. These counties had 56 2.8 hospital beds per thousand population, or a total of 8,464 beds. If the State is to have the proper hospital facilities, there will have to be a substantial e.xpansion of hospital beds in e.xisting institutions and location of a number of new hospitals for the convenience of the patients and the doctors. How Many Hospital Beds Do We Need? If it is assumed that for the 34 counties without hospitals new hospitals were built with appro.ximately 750 beds, we should have appro.ximately 2.6 hospital beds per thousand population for the entire State, or 9,214 hospital beds. If a minimum of three beds per 1,000 population, the total hospital beds required for the State would be 10,710, leaving to be added to our e.xisting facilities and new hospitals 1,496 beds, or approximately 1,500 beds. It is the judgment of some authorities that a minimum of four beds per thousand population is needed to meet the State- wide demand. This would require a total of 14,280 hospital beds and would re- quire new locations and e.xpansion of present facilities amounting to about 5,816 new beds. This method of estimating the number of hospitals needed on a population basis, that is, number of beds per 1,000 population to be served, is a satisfactory method for establishing a primary hospital unit, but additions to that unit should not be made on a population basis, but on the basis of the percentage of existing beds in use at the average time. To illustrate: A population of 25,000 people is served by a hospital of 50 beds. Of the 50 beds, only 30 are in use at the average time, which is 60% occupancy. Under these conditions, no one would recommend three beds per 1,000 population. The two beds per 1,000 are meeting all demands. From all available information, the existing hospitals of the State are inade- quate to meet the present demands and many of the general hospitals icould need some enlargement, but the extent of the enlargement icoiild be judged not on the basis of population served but upon the per cent of beds in use at the average time. The hospital insurance plan, which is in effect in various industries, has in- creased the demand for hospital care in the counties where the insured workers live. It is believed that hospital insurance will be expanded to cover not only indus- trial employees but other citizens of the State as well. Hospital Construction Loans by State This committee recommends that the primary responsibility for the financing and operation of the hospital remain in the various communities; that in order to promote the expansion of the hospital facilities with as little delav as possible the State of North Carolina set up a loan fund; that the hospitals aided shall be oper- ated under the direction of a Board of Directors composed of representative citi- zens, with the tenure of service of the members expiring at different times, some in two years, some in four years, some in six years, so as to encourage stability of policies and non-political control. The financing of the operation of the hospital should be aided bv countv ap- propriation or local tax, this money to be used in support of the hospital and to help the county take care of its indigent sick. 57 Needs of Our Negro Population In the State we now have six colored hospitals located in cities or areas where they have sufficient Negro population and doctors to support the proper size insti- tution. It is the opinion of this committee that the State should encourage the development of a limited number of general hospitals for the treatment of the col- ored race, these hospitals to be located in urban centers where there are a consid- erable number of Negro physicians. A certain number of Negro hospitals is nec- essary (i) for the training of Negro nurses, (2) for providing training for Negro internes, and (3) for providing hospital facilities for Negro physicians where they are practicing in sufficient numbers to render an adequate service to the patients. It is the opinion of this committee that a great number of separate hospitals for the Negro population would not be advisable for the reason that there is not a sufficient number of Negro doctors nor sufficient Negro population in a great many localities to support a hospital in the proper manner and that separate institu- tions in areas where they do not have the proper staff or number of patients would result in inferior medical service, and it is, therefore, much better to limit the Negro hospitals so that the Negro patients may have the advantage of better hos- pital and medical care. Many of the present general hospitals provide beds for the Negro patients. In the building and expanding of the general hospitals, this plan should be followed and adequate hospital beds should be available throughout the State for the Negro population. Obstetrical Service Must Be Improved The nurses' training schools should be one of the important features in all hos- pitals that are large enough to be able to give the proper training, and special attention should be given to the proper training facilities of all hospitals that come within the qualifications of the State Training School authorities. The committee recognizes that one of the greatest services that the local hos- pital can render is through its obstetrical department. Statistics show that many mothers and babies have been saved by the protection afTorded the mothers in the hospitals throughout the State. // is recognized that the hospital, in order to ren- der this service, must be conveniently located and near to the homes of the people in the community. This service will not be rendered by any hospital that is located at a distance. The care and treatment of what is referred to in hospital circles as "long treat- ment" cases, patients with tuberculosis, mental diseases, orthopedic conditions, and the deaf, should remain as it is, a State responsibility. The cost of treating pa- tients with these diseases of long duration imposes a financial burden that the indi- vidual family cannot assume. The State should expand and improve its facilities for the care of these unfortunates. Charles A. Cannon, Chairman of the Committee on Hospital and Medical Needs of Our Urban and Industrial Population. 58 V In Rural North Carolina the Need for "More Doctors, More Hospitals, More Insurance" Is Doubly Serious (Report of Committee on Medical and Hospital Needs of Our Rural People, Thomas J. Pearsall, Chairman.) With a wealth of data, with extreme conciseness, and with greater comprehensiveness than had ever before been attempted, this Report summarizes hospital and medical conditions in Rural North Caro- lina and needed remedies. The small number of rural physicians . . . and those few rapidly ageing ... the complete absence of hospital beds in 34 counties (all rural) ... the impossibility of getting doctors without first having hospitals near by . . . the low income of our rural people and the consequent inescapable need for Blue Cross insurance — all these basic facts are summarized with power and vision. FOREWORD The nieJical rare problem in North Carolina is to a large degree a rural problem. Nearly three-fourths of our State's population live in open country areas or in towns of less than 2,500 population. The income, particularly the cash incojyie, of our rural people is relatively loiv as compared ivith urban population. Rural people are relatively isolated from hospitals ami towns where most of the physicians live. The rural medical problem is not a simple one. There are many deficiencies and many reasons why these deficiencies exist. In general, however, the problem has these three aspects, all of which result in poor medical care for rural people: (1 ) Lack of medical care facilities and personnel (2) Lack of appreciation for the need of good medical care (3) The inability of rural people to pay for modern medical care These are the three sides of the triangle: facilities, education, economics. No one phase of the problem can be considered without the other. The problem of rural medical care cannot be solved by only building hospitals, or by only educat- ing people to know the value of good facilities, or by only providing more con- venient methods of payment. All three aspects of the problem must be worked on at once. More rural physicians must be trained; more rural hospitals must be built; more educational and preventive work, must be carried on ; and convenient methods of paying for medical care must be devised. These needs and recommendations for meeting them are outlined on the following pages. MEMBERS OF THE SUBCOMMITTEE HOSPITAL AND MEDICAL NEEDS OF OUR RURAL PEOPLE Thomas J. PeaRSALL, Chairman. Rocky Mount, N. C. Dr. G. M. Cooper, Vice-Chairman, State Health Department, Raleigh, N. C. Dr. C. Horace Hamilton, Secretary, N. C. State College, Raleigh, N. C. Dr. L. D. Baver, N. C. State College, Raleigh, N. C. J. B. Slack, Farm Security Administration, Raleigh, N. C. Dr. W. C. Davison, School of Medicine, Duke Universitv, Durham, N. C. Dr. Jane S. McKimmon, N. C. State College, Raleigh, N. C. Harry B. Caldwell, N. C. State Grange, Greensboro, N. C. R. Flake Shaw, Farm Bureau Federation, Greensboro, N. C. J. G. K. McClure, Farm Federation, Asheville, N. C. Dr. B. E. Washburn, Rutherfordton, N. C. Dr. S. H. Hobrs, Jr., Department of Sociology and Economics, Chapel Hill, N. C. M. G. Mann, N. C. Cotton Growers Association, Raleigh, N. C. 60 SUMMARY OF RURAL NEEDS I. The Need for Rural Physicians The shortage of physicians in North Carolina is alarming. Even before the war worsened the situation in 1940, the State had only 2,298 physicians. In order to provide the recommended minimum of one physician for each 1 .000 people, 1 ,300 additional physicians are needed. Nearly all of these physicians are needed in rural areas. In the nation, North Carolina ranks 4t;th in the ratio of physicians to popula- tion. Only Alabama, South Carolina and Mississippi have lower ratios than North Carolina. The number of general physicians practicing in rural areas, or among rural people, becomes distressingly smaller every year. In 19 14 there were 1,125 physi- cians living in rural areas of the State. By 1940 the number of rural physicians had decreased to 719. Seventy-three per cent of our State's population, but only 31% of our physicians, lived in rural areas in 1940. (Rural includes all towns under 2,500 in population.) As older rural physicians retire or die, few young physicians move in to take their places. In 1914 only 14.6% of our rural physicians were over 55 years of age, as compared with 37.5% in 1940. Only 29.6% of the urban physicians were over 55 in 1940. The tendency of young physicians to specialize accentuates the rural problem. In 1914, only 3.3% of the State's physicians were full-time specialists, as compared with 22.7% in 1940. In the poorer rural counties and communities, the shortage of physicians is much more critical than in the richer urban counties and communities. Si.x large urban counties with only 20.5% of the State's population have 33-5% of the physi- cians. Cities above 10,000 with only 20.8% of the State's population had in 1940, 49.1% of the physicians. Only four counties in the State in 1940 had more than one physician per 1,000 people, but 43 counties had less than one physician per 2,000 people. The distribution of physicians within counties is just as unbalanced. The phy- sicians, quite naturally, prefer to live and work in larger towns and cities where modern hospitals are available. Many rural people now live from 10 to 20 miles from a physician. Fifty-five per cent of the area of the State is mf)re than five miles from a physician. There is also a poor distribution of physicians by race. The State has only 129 active Negro physicians, or 7,783 Negro people per physician. The need of rural people for a good general practitioner who lives close to them cannot be overemphasized. General practitioners perform 794% of all physician's services. Specialists perform 18.3% of the services, but account for 52.8% of the cost of all physicians' services. General physicians can and do perform many minor operations and services of specialists. 61 II. The Need for Rural Hospitals North Carolina has 128 general hospitals, approved by the Amer- ican Medical Association, containing 8,475 beds, or 2.4 beds per 1 ,000 population. In order to briny the hospital ratio of beds to the rec- ommended standard of 4 beds per 1 ,000 people, approximately 6,000 additional beds are needed. After allowing for unavoidable vacancies, amounting to 25%, the 6,000 addi- tional beds would provide North Carolina with i.i days of hospitalization per capita. In 1940, North Carolina used .52 of a day hospitalization per capita as compared with .90 for the nation and over i.o for states like Maryland, Minnesota, and Louisiana. In 1940, North Carolina ranked 42nd in the nation in number of hospital beds per 1,000 population; 39th in admissions to hospitals; 40th in percentage of hos- pital beds occupied; and 43rd in days of hospitalization per capita. Eighteen states had more than four general hospital beds per 1,000 population, and 18 states used more than one hospital bed per day per capita total population. Of the 8,475 general hospital beds in North Carolina, 41.7% are located in six large urban counties. The counties of the State, by number of beds per 1,000 population are distributed as follows: 4 counties have 4 or more beds per 1,000 population 12 counties have from 3 to 4 beds per 1,000 population 19 counties have from 2 to 3 beds per 1,000 population 26 counties have from i to 2 beds per 1,000 population 5 counties have less than i bed per 1,000 population 34 counties have no hospital beds At least 20 of the 34 counties without hospital beds are large enough to require a 50-bed hospital. Some of the 14 counties with less than 12,500 population might find it practical to build small 20- or 30-bed hospitals. It is recognized, of course, that the need for a hospital in any particular com- munity should be carefully studied before plans are drawn. A few counties can be served by hospitals in adjoining counties. There is also the problem of finding competent medical personnel to operate new hospitals. The committee assumes that a State Hospital Commission will be set up which, among other things, will study in detail the need for hospitals in specific communities. The need of the Negro rural population for hospital facilities is particularly serious. At present there are only 1,665 hospital beds for Negroes, or 1.7 beds per 1,000 population. Of the 6,000 additional beds needed, 2,450 are needed for the Negro population. This estimate assumes that means will be provided to finance hospitalization for the Negro population, 75% of whom probably cannot pay all their hospital costs. The need for hospitals is closely related to the need for physicians. The young doctor of today is trained in a well-equipped modern hospital. When he begins 62 private practice, quite naturally, he wants to locate near a good hospital where he can put his training to the best use. Therefore, if we are to get more physicians in rural areas, we must build small rural hospitals. There are already a number of small hospitals in rural communities and they are rendering effective service to surrounding rural areas. III. The Need for Rural Clinics In counties and communities that cannot support a full-sized hos- pital, there is a need for public health centers, or clinics, or diagnos- tic laboratories, the facilities of which would be equally available to all general physicians in the area. In time, as the demand grew, some of these clinics might be expanded into full-grown hospitals. For the time being, they would limit their services to simple laboratory and diagnostic service, minor surgical operations, obstetrics, and preven- tive work. Many small private clinics have already demonstrated the need for such insti- tutions. It might be well to encourage the building of more public clinics open to all physicians of the area served. IV. The Need for a Prepayment Plan An individual or a family cannot know when illness or the need for an emergency operation will strike. Therefore, medical and hos- pital expenses cannot be planned or budgeted like such items as food, clothing, or gas for the automobile. Sickness surveys, however, do show how frequently different types of illness occur and what the costs are. In other words, we do have an actuarial basis for medical care insurance, or for group prepayment plans. Furthermore, there is now accumulating much expe- rience which may be used in setting up prepayment plans for farmers. One authoritative study shows, for instance, that i,ooo persons on the average can expect, in the course of a year, i,iii cases of illness which require medical or hospital service. Of these i,iii cases of ilness: 76.4% require only a general practitioner 3.9% require operations 23.0% require a specialist 10.6% require hospitalization 5.7% require a graduate nurse 33.0% require other nursing services The Blue Cross Plan, sponsored by the American Hospital Association and many medical societies, provides limited hospital and surgical insurance in this State for about $30 per family. Lower rates have been made available to Farm Security borrowers but the service is more limited. Although this plan is a fine thing for those able to pay, it does not cover more than a fourth of all medical care costs. 63 The Farm Security Administration has developed county prepayment plans to cover the services of general practitioners; and the principle has been found to be actuarially sound and workable. Unfortunately, this plan has not been extended to help the general population but it is definitely needed. V. The Needs of Low Income Groups Althouyh prepayment plans uill go a long way toivards helping loiv income groups obtain more medical and hospital care, it is quite obvious that a large percentage of our population cannot afford to pay for all the medical care that they need even ivith the help of a prepayment plan. Complete medical, hospital, nursing, and dental care would cost the average family in North Carolina approximately $ioo. This is a most conservative esti- mate, likely being too low rather than too high. It is based on studies of the incidence of illness and on hospital costs and physicians' fees. It does not include drugs or public health expenditures. The $ioo would pay for the following items : General practitioner $ 18.00 Specialist 20.00 Dentists 20.00 Hospital services 18.00 Nursing services 10.00 Laboratory services 5.00 X-ray services 5.00 Eye glasses 2.00 AH other 2.00 Total $ 100.00 The net cash income in North Carolina in 1939 was about $600 per farm fam- ily and at least 60% of the farm families received less than that amount. Obvi- ously no farm familv can afford to pay $100 per year, or a sixth of its total cash in income for medical and hospital care. A national survey shows that only families earning over $3,000 spend over $100 per year for medical care and those earning from $500 to $r,ooo spend $34 per year for medical care. If North Carolina farm families now spend (;% of their total incomes, the total amount for the farmers of the State would be about $10,000,000 in normal years. This is a little less than one-third of the amount needed for the conservative budget outlined above. On the basis of these facts, it can be safely estimated that at least two-thirds of the farm families of the State need help in paying for adequate medical care, or in buying health insurance. Some areas will need more help than others; some low income families can pay a part but many will not be able to pay any of their med- ical care costs. 64 VI. The Need for Preventive and Educational Services Curative medicine is expensive at any price. IVhat farm people ivant and need most of all is a program which in-ill keep them from gcttiufj sick in the first place. Then, if they do get sick, they need to know the advantages of using modern hospitals and well trained doc- tors. They need to know the value of going to a hospital or physician before a small ailment becomes a big one. Also they need to realize the value of frequent health examinations. Finally, they need to know more about good health habits, sanitation, and nutrition. Preventive health work is needed particularly in our schouls through which nearly all of our people pass sooner or later. Our health examinations of school children must be made more intensively, and follow-up work must be done to see that needed treatments and corrections are carried out. Parents should be re- quired to have serious deficiencies of their children corrected, and those not able to pay should be given financial aid by the State and county governments. The program of health education in the schools should be strengthened in every possi- ble way. Although public health work in North Carolina has made substantial progress during recent years, much remains to be done. Our State is spending i6. i cents and our counties are spending 37.4 cents per capita, but the recognized minimum standard for State and counties is $1 per capita. Twenty-eight states spend more per capita than North Carolina on public health activities. Were it not for fed- eral aid, North Carolina would indeed be quite deficient in its public health pro- gram. Federal aid plus foundation funds account for 49.9 cents per capita, mak- ing a total health expenditure for North Carolina of $1.03 per capita. RECOMMENDATIONS I. A State Supported Four-Year Medical School This committee gives its unqualified endorsement to the proposal that a first class four-year medical school be established as a part of the University of Nortii Carolina. North Carolina students trained in North Carolina will remain in North Carolina to follow their chosen profession. II. Loan Funds for Rural Medical Students This committee recommends that a loan fund be established by the State Legis- lature particularly for promising rural youth, male or female, white or non-white, who wish to become rural physicians in North Carolina. Ability rather than wealth or social status would be the principal test for admission to the medical schools of the State. These students should be required to agree to return to rural communities to practice medicine for at least four years with the understanding that one-half of their debt to the loan fund should be canceled in return for ful- filling their agreement. 65 III. Hospital Building Program This committee recommends that $5,000,000 be appropriated for building, and assisting counties and communities to build, hospitals and clinics whenever and wherever they are needed in the State. Careful surveys of needs should be made in every community desiring a hospital before grants are made. This committee endorses the idea of building a large Central Hospital of ap- proximately 600 beds or of such size as is needed for the size and type of medical school established. This committee also recommends that a small number of district hospitals of approximately 100 beds be built (or that existing hospitals be enlarged). These hospitals would be complete in every sense of the word, and would serve both rural and urban people. Most important of all, this committee recommends the establishment of a large number of small rural hospitals of approximately 60 beds. Possibly this will in- volve improvement or enlargement of existing non-profit facilities. IV. Health Centers This committee recommends the building of health centers in small rural com- munities, these centers to be made available to all qualified physicians in the area. These centers would provide diagnostic and laboratory services, facilities for minor operations, obstetrical service. A small number of beds should be provided for cases not requiring the specialized services of a larger hospital. It is also rec- ommended that these centers be used by the public health service in carrying on its preventive and educational work. V. Encouragement of Group Medical Care Plans This committee recommends that the State encourage in every practical way the development of group medical care plans which make it possible for rural people to insure themselves against expensive illness, expensive treatment by specialists, and extended hospitalization. The Blue Cross Plan of hospital and surgical service can, with some modifica- tions, meet the needs of that third of the State's farm population able to pay all of its health insurance. It is also recommended that these groups be asked to expand their services to include the general practitioner and prescribed drugs. This is particularly impor- tant for rural and farm people who depend so heavily on the general physician. VI. Medical Care Fund This committee recommends that there be appropriated annually approximately $3,000,000 to help the counties and other local units meet tlieir expenses for the medical care of the indigent and low income families. It is planned that these funds be used only in those counties willing to contribute some of their own funds. 66 Each county should have the responsibility of expending these funds according to approved plans. It is believed that this fund would give some medical aid to approximately 720,000 North Carolina people most in need. It would not help possibly another 720,000 who are now not getting adequate medical and hospital care. It is planned that these funds would also be used to help those parents of school children who are unable to pay all the costs for correcting defects ur in treating diseases revealed in the regular school health examinations. VII. State Hospital and Medical Care Commission It is recommended that there be set up by the State Legislature a permanent hospital and medical care commission which would have charge of the hospital building program, the medical student loan fund, as well as the administration of the medical care fund. 67 VI North Carolina Needs i)More Doctors and Medical Personnel and 2) A Much Better Distribution of Doctors (Report of Committee on Medical School and Central Hospital, Dr. P. P. McCain, Chairman, with Sub-Committee Report on Number and Distribution of Doctors in North Carolina, Dr. Hubert B. Haywood, Chairman.) Serving on this Committee with its beloved Chairman, the late Dr. P. P. McCain, was the following unusually distinguished group: Hon. Josephus Daniels, Dr. C. C. Carpenter, Dr. Donnell Cobb. Mrs. Laura Weil Cone, Dr. Hubert B. Haywood, James A. Gray, Alex- ander Webb, Dean W. R. Berryhill, Dr. Paul F. Whitaker, and Dr. W. C. Davison. Only its "Summary of Recommendations" is reprinted herewith along with a special report by Dr. Hubert B. Haywood on "Number and Distribution of Doctors in North Caro- lina." The Committee on the Four- Year Medical School and Hospital Facilities for the University has, through two subcommittees, made a careful study of the num- ber and distribution of medical personnel in the State and of representative State- supported schools of medicine in the Middle West and the South. In addition, it has had access to the findings and reports of a previous Commission making a somewhat similar study in 1937. The findings of this Committee and of other Committees of this Commission show clearly the need for more medical personnel of all types — physicians, nurses, public health nurses, physicians in public health, medical technicians, health edu- cators, physiotherapists, and hospital administrators — for the State as a whole and especially for the less populous rural and small town communities. It is estimated that there is a need now for 1,500 additional physicians, well distributed, in the State in order to lower our physician-population ratio to i to 1000, generally con- sidered desirable for the maintenance of the proper safeguards for the health of the population. In a study of this problem by a subcommittee of the Committee on Rural Hos- pitals and Rural Medical Care, it is stated by Dr. W. C. Davison' that 76 new phy- sicians started practice in North Carolina each year for the period 1936 to 1942 inclusive, and that at least 75 more physicians are necessary each year to reach the desired physician-population ratio in a period of fifteen years. In order to insure this increased number of new physicians each year, there is a need for from 87 to 132 additional North Carolina medical students annually, depending on the pro- portion eventually practicing in the State. North Carolina is faced with two alternatives in securing an adequate number of physicians and other medical personnel: (i) To provide means and facilities for training its own residents who desire to study medicine; or (2) To attempt to import physicians from without the State. The Committee feels that the first alternative is a sounder and wiser policy. To quote Dr. W. C. Davison, "The South will not get its physicians by migration. The students should be Southern, and to get country doctors it must be possible for students from the rural counties to study medicine." It is true that the economic factor and hospital facilities play important roles in the number and distribution of physicians in any state. It is also true that be- cause of these factors and that of climate some states in which there are no medical schools have a better physician-population ratio than North Carolina; yet in gen- eral' "local medical schools have an important influence on the number of grad- uates uho practice in the community and state," and those states in which there are greater facilities for medical training have more medical personnel available to serve the population. iDuring period 1936-42 56 physicians died annually. According to Dr. W. D. James, Secretary Board of Medical Examiners, 1938-44, 80 or more physicians are necessary each yeiir to replace losses in profession from all causes. 2Dr. W. C. Davison — Journal Assoc. Am. Med. Colleges, March, 1943. 70 Contributions of Duke and Bowman Gray The two excellent privately endowed four-year medical schools in North Caro- lina are rendering a great service in medical education. The Dui<.e University School, graduating doctors for approximately twelve years, has admitted annually only about 25 per cent of each class from state residents — 15 to 23 students. The remaining 75 per cent of its students, because of its excellent national reputation, come from many states. According to the records of the State Board of Medical Examiners for the past five years, an average of 15 graduates of the Duke Medical School were annually licensed to practice in North Carolina. The Bowman Gray School of Wake Forest College has for many years shared with the University of North Carolina the major responsibility for training North Carolina residents in medicine. It has just graduated its second class. During the five years ending in 1943 an average of 20 physicians annually who had taken their first two years at this institution were licensed to practice in North Carolina. In the future it is reasonable to expect that this number will be at least doubled. The State is greatly indebted to these two institutions and justly proud of their accomplishments. As endowed schools of medicine they have other affiliations and responsibilities and cannot be expected to have as their primary concern the train- ing of medical personnel for the State. This Committee feels very strongly that there is an obligation and an opportu- nity for the State to provide facilities for professional education for its citizens in all branches of medicine, as it does in law, pharmacy, various types of engineer- ing, business, agriculture, and teaching. There is ample precedent in the State for the development of professional training in endowed and State-supported institu- tions in the face of demonstrated need. The presence of three law schools at Duke, Wake Forest and the University has been of great value to each other, the legal profession and the State. The two engineering schools at State College and at Duke are mutually helpful to each other and the State. Why Expand University Medical School Because of the urgent need for training more North Carolina men and women in all branches of Medicine, it is recommended that the State provide adequate financial resources to expand the present two-year Medical School of the Univer- sity which, with the School of Public Health, would serve as a foundation for de- veloping a State University Center for Medical Education in its broad sense. The two-year school at the University has been for over fifty years the largest single source of supply for physicians in the State, educating in part approximately one- fourth of the total. Such a development, in co-operation with and supplementing the two endowed medical schools, would, in a short time, begin to supply the State with the necessary well-trained medical personnel, provided (a) at the same tirne the program for expansion and better distribution of hospital and diagnostic facilities goes forward ; and (b) means are made available through loan funds or scholarships to aid 71 worthy students from rural areas and small communities to finance their medical training. Not only is a medical center on a state university basis necessary to increase the production of doctors and other medical workers, but its influence in maintaining and elevating the standards of medical and hospital service is equally as valuable in a program designed to give better medical care to the people of North Carolina. It would supplement the efforts of the other two schools in this field and make avail- able consultation services in the medical specialties and more technical branches such as X-ray, pathology and general laboratory for physicians and hospitals in the smaller and more medically isolated communities. It would offer a continuous program of postgraduate training for practicing physicians in the community hos- pitals and at the center. It is believed that the tangible returns on these two serv- ices alone in terms of elevating the quality of medical care throughout the State would more than compensate for the cost of operation. Nine Recommendations Regarding Medical School Jn the light of the facts herein set forth and on the advice of competent medical educators, the Committee submits the following recommendations: 1. That the present two-year School of Medicine at the University of North Carolina be expanded into a standard four-year medical school. 2. That the completed school and hospital facilities be located on the Univer- sity campus at Chapel Hill. 3. That a hospital of approximately 600 beds be built to provide clinical facili- ties for teaching and to aid in serving the hospital and general health needs of the State. It is the feeling of the Committee that there should be facilities for both white and colored patients. In addition to the general hospital ward beds, such an institution should have: a. a moderate number of rooms for private patients ; b. facilities for psychiatric patients, both bed and ambulatory ; e. facilities for a limited number of tuberculosis cases, surgical and medical : d. facilities for a large dispensary or out-patient department. We recommend the following distribution of beds: 400 general ward beds; 60 beds for psychiatry ; 60 beds for tuberculosis; and 70-80 beds for private patients. 4. That at a state university it would be a wise policy to provide the major part of income for the clinical staff from salary rather than from private practice. 5. That every facility and encouragement for postgraduate training for prac- ticing physicians in the State be provided, both through intra and extra-mural courses of clinics and lectures. 6. That a School of Nursing be established and that every effort should be made through co-operation with the Woman's College to encourage more ade- quate professional education for students of nursing. A program of co-operation between the University School of Nursing and the nursing training schools in the smaller hospitals in the State should be carefully studied with the view of aid- ing in the elevation of the standards of nursing education in the State. 72 7- The University has the only School of Pharmacy in the State. Its present physical facilities are inadequate for the increasing demand in its undergraduate program and in the development of postgraduate training. The importance of the pharmacist in any medical service program and the need for the expansion of the Pharmacy School is recognized. The Committee, having heard the proposals of the committee from the Pharmaceutical Association, is wholeheartedly in favor of facilities for medical and pharmaceutical education at the University. 8. The shortage of dentists is acute in this State and facilities are urgently needed for training more personnel in this field. The Committee recommends that a studv of this problem be continued and that the possibility of establishing a dental school in the future should be given careful consideration. 9. The Committee recognizes the need for more well-trained Negro physicians in North Carolina and in the South and feels that an opportunity should be pro- vided for more t]ualified Negro citizens to study Medicine and Dentistry. Careful thought has been given to possible ways of providing educational facilities in Medicine for the Negro race. The Committee recommends that the State of North Carolina join with neighboring Southern States in exploring the possibility of developing a regional medical center for the education of Negroes. Number and Distribution of Doctors By Hubert B. Haywood, M.D., Chairman of Sub-Committee In 1944 North Carolina had a population of 3,571,623. The population is largely rural. There is only one city with over 100,000 inhabitants. Poor hous- ing, poor food, and poor sanitation is responsible for much of the illness in the State. To correct this educational, economic and medical measures must be insti- tuted and carried through. There is a lark of medical and hospital facilities in the State to meet its needs: There are 66 counties with hospitals. Their total population is 3,015,639. There are 34 counties without hospitals. Their population is 555,984 (15.6% of total). There are 2.37 hospital beds per 1,000 population in the State. 16 counties have more than 3 beds per 1,000 (26.5% of total popu- lation. 19 counties have 2.5 beds per 1,000 (21.1% of total population). 25 counties have i.t;6 beds per 1,000 (28.8% of total population). 6 counties have 0.68 beds per 1,000 (7.8% of total population). There is obviously an unequal distribution of hospital beds to the needs of the population. The American Hospital Association reports that the adequate num- ber of hospital beds in the nation should be 3 to 5 per 1,000. 73 The number of hospital beds in North Carolina for the Negro population, which is 982,108, is 1,631, giving a ratio of 1.66 per 1,000 of population. There are 41 counties which have no hospital beds for the colored race. Eighty-nine general hospitals in the State received aid from the Duke Foun- dation to the amount of $419,942.00. These hospitals comprise 84% of all gen- eral hospital beds in North Carolina. 15.8% of the days of care of all white patients were free, and 53.5 % of all days of care of Negro patients treated in 89 hospitals was free. This means that 69.3% of the hospital patients in North Caro- lina were unable to pay hospital bills. Eighty-four per cent of our population, or 3,015,639 people, live in 66 coun- ties and average 2.8 hospital beds per 1,000. Sixteen per cent of the State's popu- lation, or 555,984 people, live in 34 counties without any hospital facilities. These figures speak, for the need of more hospitals and hospital beds in North Carolina. The National Farm Foundation Conference which met in Chicago on April 11-13, 1944, and dealt with Medical Care and Health Service in Rural Areas, reached these conclusions: 1. Too few physicians, dentists, and other medical personnel in rural areas. 2. Relatively more old physicians in rural areas. (It is held that a physician past 65 years old in a rural area is only 33%% effective.) 3. Low ratio of hospitals and hospital beds in rural areas. 4. Preventive medicine is neglected because most physicians, under present con- ditions, have no economic incentive to give time and effort to that field. 5. Health education and organization in rural areas have been neglected. 6. Sanitation programs have not been carried far enough in rural areas. 7. A good medical care plan should include all types of medical care, surgery, dentistry, ophthalmology, general practice, prescribed drugs, hospitals, etc. 8. Rural people need most of all a good general physician, preferably not less than one physician for each 1,000 people. 9. The numher, size, type, and location of hospitals, clinics, and health centers should be determined on the basis of careful jilanning by public committees. The guiding goal is the maximum amount of service to the most people. Presumably there might be three size classes of hospitals: (1) Large central hospitals oi horn ^00 to i,ooo beds to serve a state or any large sub-area of a state. (2) Intermediate sized or district /(ospitals of from 50 to 100 beds to serve districts of from 15 to 30 thousand people. (3) Small community hospitals or health centers with a small number of beds for emergency cases and for cases not requiring specialized attention in a larger hospital. With the expansion of the tivo-year medical school at Chapel Hill '\nio ^ iouv- year school, a central hospital adequate for the needs of the State and for teaching medical students could be built. It seems to be the consensus that a certain num- ber of rooms should be set aside for private patients in an institution of this type. It is easier to hold a high-class teaching faculty if they are permitted to devote a certain allotted part of their time to private patients. It is desirable for interns and resident physicians to come in contact with some private patients. 74 A hiyh-class hospital, medical school and faculty is a necessity. Our popula- tion must be brought up to the level of the best in modern medicine and most cer- tainly our medical practice and physicians graduated at our State institutions must not and will not be brought down to a low level to meet certain sections of an un- trained public ignorant of medical progress. Rural medicine could be helped by the county or district hospital. The small clinic will fill the needs of many communities. The young physician who is well trained will be willing to go where he has the advantages of a hospital; otherwise he will not go. About lo per cent of the younger rural doctors emigrate yearly to the larger centers. Loan funds should be established to aid poor boys, especially in the rural areas, to enable them to get a medical education. Most of the doctors in the country districts were reared in the country. Loan funds should carry a direct obligation to return to their communities for a certain number of years. The responsibility for financing a rural hospital should belong in part to the community in which it is located. The interest in it is greater and as a consequence it gets better local support. In North Carolina, with a colored population of 982,108, there are 142 colored physicians. These physicians are located in 48 of our 100 counties. It is obvious that this is an inadequate number. Practically all of them are located in towns and cities. The State of Virginia, which has problems rather similar to our own, in 1944 voted to contribute to the cost of education of a ma.ximum of 25 medical and 10 dental students at Meharry Medical School located in Nashville, Tennes- see, the sum of $500 per year for each medical student and $400 per year for each dental student. Meharry has been envisioned as a future regional medical center where all southern states might place their Negro professional students for training. Meharry Medical School took a stride toward this goal recently when it was granted an endowment of $4,300,000 by the General Education Board. The col- lege already has contracts with the State of Tennessee for the training of 30 of its medical students. The faculty of approximately 90 is composed of both white and Negro department heads and instructors. Meharry is the largest and one of the two medical colleges for Negroes fully accredited by the Association of Amer- ican Medical Colleges and is rated as "Class A" by the American Medical Asso- ciation. North Carolina physicians and population: 1944 poptllation numbeb physicians The State in Active Pbactice Ratio 3,346,000 1,638 I to 1,938 Wake County 103,369 83 I to 1,245 Dare County 4,633 ■ I I to 4,633 Swain County 12,111 3 I to 4,037 75 Number of licensed physicians each year in North Carolina from 1940 through 1943: 1940 148 1 94 1 119 1942 138 '943 178 Average number of medical students graduated from medical schools in North Carolina each year who are residents of North Carolina: about 65; Duke, 20; and Wake Forest, 45. Average number of prospective medical students with sufficient or adequate premedical training to entitle them to admission to a Grade A medical school : 130. Average number of physicians who die or retire in North Carolina each year: 50. Average need for new physicians in order to maintain present ratio approxi- mates 100 each year. Many of these new physicians go into specialties and do not serve the general, especially the rural, public. There are 24 specialties listed in the Directory of the American Medical Association. The ideal prescribed by the AmericanM edical Association is one physician to every 800 to 1,000 patients. Our average at its very best before the war approxi- mated one physician to every 1,600 patients. Our two medical schools at their best do not take care of the education of our new physicians who are needed to supply our present medical needs and maintain our present ratio by at least forty to fifty new physicians each year. The majority of these men receive the first two years of their medical education at the Medical School of the University of North Carolina and go out of the State for the last two years of their medical education. The two schools in the State could not well absorb the fifty or more men who yearly graduate at Chapel Hill. A medical education out of the State is more expensive to a North Carolinian than one within the State. Thus many poor boys are denied the privilege. Many of the best graduates who go out of the State are offered attractive positions in other states and never return to North Carolina to practice. Good pre-medical preparation has reached such perfection that relatively few medical students are dropping out of medical schools. This causes a lack of va- cancies in good medical schools. This ultimately means the doom of the two-year schools because there will be no openings for their graduates in Grade A schools. The graduates of the school at Chapel Hill have been the backlog of the medical profession in North Carolina. Nationally it is known as a first-class school with good and modern equipment and an excellent faculty. There is a definite need in North Carolina for the 50 or more graduates of this school each year. If the school is abolished our medical deficit will increase. The school can readily be expanded into a four-year school of real excellence and dis- tinction. The State of Virginia to our north supports two state-aided medical schools, the State of South Carolina one, and the State of Tennessee one. 76 SUMMARY North Carolina population — 3,571,623. Present physician to population ratio — i to 1,938. Desirable ratio — i to 1,000. Colored population — 982,108. Colored physicians — 142. Ratio of colored physicians to population — i to 6,916. Total number of counties in North Carolina — 100. Total number of counties with hospitals — 66. Total number of counties without hospitals — 34. (Their population is 555,984) . Total number of hospital beds in North Carolina per 1,000 population — 2.37. (The ideal is 3 to 5 beds per 1,000.) The number of hospital beds for Negroes per 1,000 population — 1.63. There are 41 counties with no hospital beds for Negroes. Conclusions Increased hospital facilities are necessary. Increase in the number of physi- cians in North Carolina is a necessity. It would be a calamity to sit still and await the ultimate fate of the closing of the two-year medical school at Chapel Hill. One of our best sources of physicians in North Carolina would be lost. It is practical and necessary in order to meet our demands for physicians in North Carolina to expand it into a four-year school. The solution of this problem is bigger than the mere founding of hospitals and a medical school. It is one which profoundly af- fects the social and economic life of North Carolina. Signed : HUBERT B. H.aywood, Chairman. 77 VII Our Negro Population Asks Equal Opportunity to Get Hospital Serv- ice and Medical Training (Report on Special Needs of Our Negro Population, by Edson E. Blackman, M.D., Chairman.) Both in order to be fair and just to North Carolina Negroes and to meet the requirements of the Hill Burton Act, hospital facilities must be ample to meet the demands of both races. . . . Read also here discussion of the relative advantages of 1) a State Medical School for Negroes or 2) state participation in a Regional or South- eastern Medical School for Negroes which 3) might itself be located in Durham, Raleigh or Winston-Salem as here suggested. To THE Hospital and Medical Care Commission: The following recommendations are submitted by the Committee to study the special needs of our Negro population: First, That a unit be established for Negroes in connection with the proposed four-year Medical School at the University of North Carolina. Second, That hospital units be established for both races at ad- vantageous and convenient locations, and that both white and Negro physicians be available to their patients. Third, That hospital associations be encouraged to extend the Blue Cross program among Negroes. I. Training Negro Doctors: Three Suggestions I. In several meetings with small groups, three suggestions have been offered for consideration : (a) That a medical training unit be established at Durham within the Organi- zation of the North Carolina College for Negroes or affiliated with that institution. The library and the facilities for teaching the sciences and certain other subjects lend themselves to this kind of training to some extent at least. This institution is located near the University of North Carolina and Duke University, where al- ready, by a co-operative arrangement, these universities through their faculties and libraries are assisting in the graduate and professional training offered to Negroes in North Carolina. The expansion of the graduate program in this college to in- clude medicine might conceivably be worked out on standard levels and at reason- able costs. (h) That a ynedical unit be established in Winston-Salem where some assistance and co-operation might be secured from Wake Forest College (Bowman Gray Foundation) Medical School located there. It has been suggested that the present hospital for white people now located in a Negro section there might be available as a nucleus for a medical training unit for preparing Negro doctors — when a new hospital location is found and new buildings erected. Excellent hospital facilities for both races are available in Winston-Salem. The Winston-Salem Teachers' College, near to the location referred to, might offer some valuable services to such a medical training unit. (c) That a medical unit for training Negro doctors he developed in connec- tion with Shaiv University in Raleigh. The Leonard Medical School, formerly a part of the institution, trained a considerable number of Negro doctors who have rendered fine service to North Carolina. Some of these men are still in active service. It is suggested that aid — though a little farther removed from Durham and Chapel Hill — might be available from the medical schools in those two uni- versities — Duke University and the University of North Carolina. 80 Leaders among Negroes in the State believe that a "medical school in North Carolina would attract students from surrounding states ; and that the State would be discharging its own obligations in providing medical education for all its citi- zens. Further, the Old North State Medical Society endorses the establishing of a medical school for Negroes in the State." The Negro population of North Carolina in 1940 was 983,574. It is now prob- ably beyond i,(X)0,ooo. To serve this population, "the State has only 129 active Negro physicians, or 7,783 Negro people per physician."* The mininuim recommended by competent authorities is "one physician for each 1,000 people." On this basis the million Negroes in North Carolina would need about 1,000 doctors. However, if the need is estimated upon the basis of one doctor for 2,000 people instead of the minimum of one for 1,000 as recommended by competent authorities, the number needed is 500 Negro doctors in this State. According to the data secured by Dr. Hamilton, there are only 129 doctors now, or one-fourth the number actually needed on a basis of one for each 2,000 people (or twice the number of people "competent authorities" say is a doctor's popula- tion load). These figures greatly emphasize the very urgent need for more doctors if the Negro people in North Carolina are to receive even moderate medical atten- tion. 2. In view of the magnitude of this very important matter, we suggest the ap- pointment of a small committee of both races, including experts in the field of medical education, research, general graduate education, business and finance, race relations, who would study the problem carefully and thoroughly. The purpose of such exhaustive study would be to determine if, after investigating all the factors involved, it would be wise from all viewpoints to establish a medical unit for train- ing doctors for the million Negro people in the State — this to be operated in con- nection with the proposed four-year medical college at the University of North Carolina. Such a medical unit might well be established at one of the centers men- tioned above — Durham, Winston-Salem, Raleigh. The major point of this sug- gestion is that the persons interested in the proposed program of medical and hos- pital care in North Carolina, those in the leadership of the movement, the Legis- lature, and the citizenry of the State may all know that every possible effort has been made to provide, if possible, medical training for Negro doctors within the State. Such a complete study would include every phase of the problem, a realistic understanding of the need for 500 or more Negro doctors instead of only 129 as now, the cost of it, and the place to operate such a unit. This would make it pos- sible for the Legislature and other leaders to determine if the wisest solution of the problem is to establish such a medical unit in North Carolina as is desired by Negroes of the State, or, if, all things considered, the out-of-state fellowship plan would be best for both the young medical trainees themselves because of the stand- ard of services they would receive, or other reasons, and for the State because of the cost for standard training for one race of its citizens. * Summary Report of the Committee on Hospitals and Medical Care for Rural People. 81 II. Hospitalization for Negroes in North Carolina On the basis of the total Negro population in 1940, viz.: 983,574 with a total hospital beds of 1,760, it appears there are approximately 1.7 hospital beds per 1,000 population. This shows there are fewer than fifty per cent of the hospital beds per 1,000 of population among Negroes in North Carolina that the average American standard requires. This means that each hospital bed must serve 559 people, whereas, the American standard requires one hospital bed for approxi- mately each 250 people. The task of the State and the counties and cities is to provide two hospital beds where only one exists now. Perhaps the best thing that can be said in the beginning is to quote a statement recently prepared including the most accurate up-to-date data on this subject — for the whole State, and for both races, as follows: White and Negro Hospital Beds with Number of Beds per 1,000 population in each county. Compiled from 1940 United States Census and from hospitals registered by American Medical Association and those receiving assistance from the Duke En- dowment Fund.* Population Hospital Beds Ratio Pee 1000 counti' white negro white neqbo white negbo Alamance 46,835 io,952 36 6 0.75 0.47 Alexander 12,516 938 000 o Alleghany 6,032 309 000 o Anson 14,518 13,925 24 16 1.65 1.15 Ashe 22,189 475 26 I 1. 17 2.01 Avery 13,302 259 78 2 5.76 7.70 Beaufort 22,632 13, 799 71 '4 3-i4 i-02 Bertie 11,324 14)^77 000 o Bladen 16,101 ii)055 000 o Brunswick 11,331 5,794 40 10 3.53 1.75 Buncombe 92,604 16,151 381 31 4.14 1.92 Burke 35.444 3. 171 128 16 3.61 5.05 Cabarrus 49,612 9,781 106 24 2.14 2.46 Caldwell 33»037 2,768 38 4 1.76 1.45 Camden 3,195 ^'^+5 000 o Carteret ■ 15,986 2,698 31 5 1.98 1.85 Caswell 10,918 9,114 o 00 o Catawba 46,488 5,165 118 13 2.54 2.52 Chatham 16,814 7,912 18 o 1.06 o Cherokee , 18,631 182 23 2 1.24 10.99 Chowan 6,139 5,433 o 00 o Clay 6,326 79 o o o o Cleveland 45, 208 12,847 86 25 1.90 1.95 Columbus 3', 227 '4)43^ 4^ '3 '-47 ^-9' Craven 17,265 i4)033 4^ 59 2.67 4.20 * Compiled by Alexander Webb of the Hospital and Medical Care Commission. 82 Population County white negbo Cumberland 39)Oi5 20,305 Currituck 4,373 2,336 Dare S,57o 471 Davidson 47)4^4 5)^93 Davie 12,730 2,179 Duplin 25,576 izL,i63 Durham 5i)7i4 28,530 Edgecombe 22,495 26,667 Forsyth 85,318 41, ^57 Franklin i7)340 i3)042 Gaston 74)941 12,590 Gates 5,086 4,972 Graham 6,415 3 Granville 14,383 14,961 Greene 10,044 8,504 Guilford 121,761 32,155 Halifax 24,446 32,066 Harnett 32,237 12,002 Haywood 33,9i3 891 Henderson 23,917 2,132 Hertford 7,905 ii,447 Hoke 5,963 8,974 Hyde 4,618 3,242 Iredell 40,849 9,575 Jackson 18,757 609 Johnston 5o,349 ^3,449 Jones 6,127 4,799 Lee 13,395 5,348 Lenoir 23,399 17,812 Lincoln 20,892 3,295 jVIcDowell 21,166 1,830 Macon 15,4^5 465 Madison 22,300 222 Martin 13,429 12,682 Mecklenburg 108,523 43, 303 Mitchell 15,912 68 Montgomery 12,534 3,746 Moore 21,635 9,334 Nash 32,255 23,353 New Hanover 30,871 17,064 Northampton 10,766 '7,533 Onslow 13,077 4,862 Orange 15,911 7,i6i Pamlico 6,328 3,378 Pasquotank 11,804 8,764 Pender 9,49' 8,219 83 UOSPITAL Beds Ratio I'EH 1000 WHITE NEGRO WHITE NEGBO 175 46 4-49 2.27 63 9 1-33 '•53 665 48 520 164 15 279 11.28 2.13 6.69 5-75 0.56 6.78 I 12 22 1.49 '•73 35 16 2-43 1.07 375 75 3.08 233 n 23 3-15 0.72 53 •4 1-33 1. 17 75 6 2.21 6-73 93 9 4.09 4.22 213 18 5.21 1.88 27 35 I 1.44 0.69 ..64 38 12 2.84 2.25 84 28 6 4.91 4.02 1.88 37 5 '•75 2-73 79 6 3.12 1 2.90 31 708 8^ 2.31 6.52 0.32 2.01 68 •7 3-'4 1.82 145 48 4-49 2.05 294 .64 952 9.61 46 9 3-52 ..85 23 7 '■95 0.80 Population Hospital Beds Ratio Peb 1000 County white neoeo white negro white negro Perquimans 5,045 4,728 000 o Person 15,827 9,202 25 o 1.58 o Pitt 32,158 29,086 36 14 1. 12 0.48 Polk 10,231 1,643 22 4 2.15 2.45 Randolph 40,226 4,328 69 8 1.72 1.85 Richmond 24,570 12,240 45 20 1.83 1.63 Robeson 51,287 25,473 130 50 2.53 1.96 Rockingham 45,862 12,036 105 20 2.29 1.66 Rowan 56,240 12,966 100 20 1.78 1.54 Rutherford 39,445 6,132 60 10 1.52 1.63 Sampson 30,828 16,612 6 o 0.19 o Scotland 11,168 12,064 22 8 1.97 0.66 Stanly 28,919 3,915 84 18 2.90 4.61 Stokes 20,364 2,292 000 o Surry 39,252 2,531 104 16 2.65 6.32 Swain 11,797 3^0 28 o 2.38 o Transylvania 11,400 841 20 5 1.75 5.95 Tyrrell 3,545 2,011 15 5 4.23 2.49 Union 29,921 9,176 40 8 1.34 0.87 Vance 16,000 13,961 53 35 3.31 2.51 Wake 72,728 36,816 260 no 3.58 2.99 Warren 8,036 15,109 000 o Washington 6,857 5,4^6 000 o Watauga 17,75^ 358 o o o. o Wayne 33,027 25,301 97 33 2.94 1.30 Wilkes 40,177 2,826 56 4 2.41 1.42 Wilson 29,152 21,067 127 41 4.63 1.95 Yadkin 19,482 ^''7^ 000 o Yancey 17,044 158 o o o o Totals 2,588,049 983,574 7,036 1,760 As great as is the need for expansion of hospital services for Negroes in North Carolina, there will be some encouragement gained from the fact that in sixty-one counties there are 1,760 hospital beds — ranging from one each in two counties to 279 in one county, and 164 each in two other counties. These facts, hopeful as they are, will help stimulate other counties and communities to provide hospital beds for their Negro people. Also encourage raising the total number of hospital beds from 1,760 to from 3,500 to 4,000 for the million Negroes in the State. III. Negroes Need Expanded Health Insurance Program One of the ideas advanced by the "Hospital and Medical Care Commission is: More Doctors More Hospitals More Insurance 84 It is probably true that Negroes, for reasons which are well understood, for many years have used more widely than other people various types of commercial and fraternal insurance to help them in serious sickness and in death. True, many of these organizations are "Burial Associations" intended to provide respectable funerals and the actual interment of the deceased. It is also probably true that even those with the very lowest incomes have been forced to pay an exorbitant part of their small weekly or monthly wages in order to secure the protection they sorely needed for sickness and funerals. However, while the cost has been high in many instances there was nothing to do but "to pay" the charges — and the benefits have been a relief and a genuine satisfaction to thousands who had no other way to pro- vide for themselves and their loved ones, thus assuring at least minimum comforts, medical and hospital service, and when the end comes, a respectable funeral. The program proposed by the Governor, the State Medical Society, and this Commission will prove to be a real blessing to thousands upon thousands of Negroes, give them courage and determination to lift themselves gradually but surely out of a status of making a bare living into higher income groups, who can and will support themselves in all their needs, and, further will become contribu- tors to the support of their various communities and the State. For Negroes, as well as for all other people in North Carolina, adoption by the State of the program to provide: More Doctors More Hospitals More Insurance such as is proposed by the Hospital and Medical Care Commission will, accord- ing to the old adage, make them and us "healthy, wealthy and wise." Then, the Governor's declaration, "The ultimate purpose of this program should be that no person in North Carolina shall lack adequate hospital care or medical treatment by reason of poverty or low income," will become a reality in North Carolina. Edson E. Blackman, Chairman of the Committee on Special Needs of Our Negro Population C. C. Spaulding, Durham R. E. WlMBERLY, M.D., Raleigh Clyde Donnell, M.D., Durham N. C. Newbold, Raleigh Alexander Webb, Raleigh 85 VIII Competent Psychiatric Help Must Be Provided all the Way from Community Clinic to Teaching Hospital (Extracts from Report of Committee on Mental Hygiene and Hospital- ization, by Dr. Maurice H. Greenhill, Department of Neuro-Psychiatry, Duke University.) Nothing in this volume is more thought-provoking or more valuable than this remarkable chapter on North Carolina's psychiatric prob- lems — prepared by Dr. Maurice H. Greenhill of Duke University for our Committee on Mental Hygiene and Hospitalization. Especially highlighted are these facts: 1) The extremely poor medical care for North Carolina's mentally ill patients — at least until quite recently. 2) The actually insane compose only a small part of our mental problem. 3) "Acute receiving hospitals for the mentally ill" would save many citizens from prolonged or permanent confinement in hospitals for the insane — and thus be a good financial investment as well as a nobly humanitarian advance for our Commonwealth. To THE Hospital and Medical Care Commission: The mental health problem in North Carolina is a grave one. In a study some years ago North Carolina ranked forty-seventh among the states in the quality of its medical care for mentally ill patients in its hospitals — only 1 of the 48 states of the Union ranked loiver. Yet according to the Thompson Report ("A Study of Mental H ealth in North Carolina," 1937), only 3% of the expenditures from the North Carolina General Fund icent to the care of the mentally ill. All of this applies to State institutional care, which meani that North Carolina has not taken seriously enough its responsibility for its citi- zens with various types of insanity. This, however, is only a very small part of the problem. It is common knowl- edge to every physician that the number of patients who suffer from insanity com- prise a small group of the total number who are victims of mental illness. This pro- portion is estimated at 2%, therefore 98% of all individuals who have mental illnesses have no provisions whatsoever made for them for their care by the State. Because many individuals with insanity are chronic cases, the cost of care for this type of disorder is indeed high, and both the obvious need for the permanent care of such individuals and the high cost of their care has focused the attention of the State upon this particular problem. Insanity Only Part of Mental Illness Problem There is, however, a still greater problem related to the care of the citizens of the State with mental illnesses. This is the problem of those countless numbers who are involved in psychiatric illnesses which do not necessitate their commit- ment to a State institution but which constitute a sizable proportion of the practice of the average physician in the State. It has been estimated for many years by many authorities that 40 to 70% of the average physician's practice is devoted to the diagnosis and treatment of disorders at least partly psychiatric in nature. The cost of such treatment is high in terms of actual cost to the patient, cost of time of medi- cal personnel, cost in time in absence from and loss of employment, and general cost to many public institutions, including social service agencies, courts, churches, and correctional institutions. This problem spreads even further when it is real- ized that the families of these individuals suffering from the minor psychiatric dis- orders also become involved in the problem in terms of suffering and decreased work-efficiency. The 98% who suffer from mental disorders not listed among the insanities have such psychiatric illnesses as psychoneuroses, psychomatic disorders, and personal- ity disorders. In the main it is these disturbances which constitute half the aver- age physician's practice. An individual's income does not prevent him from hav- ing one of these illnesses. It may safely be stated that, as in all medical disease, there is a large proportion of patients who are indigent, so among the 98% of in- dividuals with mental disorders but do not need confinement in a State institution for the insane, there are many who are unable to finance the care of their health. 88 Certain facts may bring into sharper focus the importance of the problem of mental illness in North Carolina. These may be divided for the purposes of clarity into two sections, (i) the needs of North Carolina, and (2) possible solutions for these needs. Facts Pertaining TO Mental Health Needs in North Carolina (a) The scope of mental illness in North Carolina: Mental disorder is made up of the following types of illnesses: Psychoses or the insanities (2%), psychoneuroses, psychosomatic disorders, and personality dis- orders. The number of individuals in North Carolina who sufifer from insanity is known approximately and is made up of those patients in the State institutions, those who have been discharged from these institutions but still have some degree of insanity, and those awaiting admission to these institutions. The problems re- lated to this group of patients are now the responsibility of the State Hospitals Board of Control. Who should take the responsibility for the other 98% of mentallv ill patients who are indigent? It is hoped that the Governor's Aledical Care Program will help to handle this enormous problem. It is impossible at the present time to know the actual number of individuals in the State who have psychoneuroses, psychoso- matic disorders, and personality problems. The number treated in the few existing psychiatric clinics in the State does not represent the total number under treatment since the average physician always has some under treatment, nor does it represent the need of other individuals for psychiatric treatment who do not receive it. As a sampling of what the need is, it is found that of 97,446 patients seen at Duke Hospital in 1943, 8,283, or 8.5%, had a psychiatric diagnosis on their hospital records. It may then be estimated that 8.5% of all the patients diagnosed and treated under the proposed North Carolina Medical Care Program will be suffer- ing from some type of mental illness with or without other medical disorders. Experience and investigation from the literature tells us that this figure of 83^% is indeed small. The difference in part is accounted for by the fact many individuals with medical and surgical disease have emotional symptoms which de- mand attention and influence healing processes and which have to be treated by a physician although he may not put down a psychiatric diagnosis in the record. This type of problem is called "psychosomatic medicine." It must be noted that the 8^^% of all medical patients who have psychiatric diagnosis is a far larger percentage than many medical problems such as tubercu- losis, which are receiving considerable attention in the Medical Care Program. It follows that of the total population of North Carolina there will be in the course of its lifetime approximately 250,000 individuals upon whom a psychiatric diagnosis will be made. Who is going to take care of the indigents in this group? The number above this who will have some type of emotional problem which a physician will have to handle and upon whom psychiatric diagnosis will never be made, is indeed staggering. Proper facilities for handling this last group in the way of (i) psychiatric education for the medical students who will become the 89 doctors of the State, (2) for the training of the specialists in this field, and {3) for the promotion of psychiatric clinics — these will go far in improving the quality of medical care and toward eventually reducing its cost. (b) The cost of mental illness in North Carolina: It is well known that the cost of care for a patient with a psychiatric disorder is higher than for any other medical illness. The cost for the care of the insane is known to the Legislature, and the proposed cost which will be necessary to raise the level of the care of the insane person is pointed out by the State Hospitals Board of Control. It is a little more difficult to estimate the cost of care for the other mental illnesses besides the insane. However, under uninformed medical practices, the psychoneurotic goes from physician to physician, has innumerable laboratory tests needlessly done in order to rule out serious medical or surgical dis- ease before the diagnosis of psychoneurosis is made. All of this could be avoided by concentration upon the problem, by proper medical education, and by the setting up of more psychiatric clinics. As an example of the unnecessary expenses to which individuals with psychia- tric illnesses are put, the following study might be cited: Of 100 women who had been diagnosed by one or more physicians as having a purely menopausal disorder but who turned out to have psychoneuroses, it was found that the average cost to each one of these patients prior to the time that the correct diagnosis was made, was $225.00. This amount went for physical examination. X-rays, and injections of glandular products to counteract the menopause which was totally unnecessary, since many of these patients were not in menopause nor were they suffering from the effects of menopause. There will necessarily have to be an orientation to men- tal hygiene in the new North Carolina program to prevent such wastage of money and such injustices to the individual patient. (c) The present resources for mental hygiene in North Carolina: The available resources for the care of the mentally ill individual in North Carolina are infinitesimal in proportion to the need. To date most of the emphasis has been placed upon the insane which, as has been stated, comprises only 2% of the mentally ill patients. Those individuals with illnesses of a mental nature lying closer to the whole field of medicine have little opportunity for help and practi- cally no possibility for financial assistance should they come down with a psychia- tric disorder. For example, hospital care associations in the State will not pay for the hospitalization of their policyholders when they file a claim for treatment of any type of psychiatric illness. The poor suffer particularly and often become de- pendent upon the public welfare agencies at a tremendous cost to the State in terms of relief expenditures. At the present time there are only three clinics in North Carolina where these patients can get help. The Department of Neuropsychiatry at Duke Hospital sees approximatelv 3,000 of these patients per year, the Charlotte Mental Hygiene Clinic, 275, and the Mental Hygiene Clinic of Raleigh and Wake County, 130. In the private sanitaria devoted to mental illness there are facilities at any one time for a total throughout the State of 140 patients who can receive treatment for a 90 disorder other than insanity. In the entire State there are only twenty physicians outside of the State Hospitals who can devote most of their time to the treatment of these problems. Possible Solutions for These Needs (A) The Four-Year Medical School and General Hospital: It seems apparent that none of the health program of the State can be separated entirely from the proposed Medical Care Plan. Therefore it will be necessary to coordinate the activities of the State Hospitals for the Insane with the proposed Four- Year Medical School at the University of North Carolina and with what- ever mental hygiene program might be set up for the State as a whole in terms of medical care. The medical student in training at the proposed medical school will have to have psychiatry as an important part of his curriculum if he is to be prepared to meet the enormous mental hygiene need in North Carolina. This can best be carried out in the following ways : (1) There should he a strong modern Department of Psychiatry at the pro- posed Four-Year Medical School. This department should consist of a staff of five to ten psychiatrists who have had the highest training possible and the sala- ries of these should be sufficiently high to attract good men. Facilities should be available for the training of internes and residents for the field of psychiatrv so that these men in time will supply with psychiatrists both the medical care hos- pitals and clinics and the State hospitals for the insane. It should also have facil- ities to train psychiatric nurses and psychiatric social workers. It should be flexible enough to allow medical internes to rotate through it as part of their interneship training. (2) This department should be housed either in a wing of the General Hos- pital at the Four-Year Medical School or in an adjacent huildinc/. I know that 60 beds have been proposed for such a unit, but 100 or 120 would be ideal. There should be 60 beds for adult white patients, 20 beds for children, and 20 beds for Negro adult patients. Such a unit should have a good social service department, an occupational therapy department, and a physical therapy department. It should contain much laboratory space to attract good men for research opportunities. In this unit every type of modern psvchiatric treatment should be used, not only for the welfare of the patient but also for teaching purposes. The men in the State hospitals for the insane should have the opportunity of working for a brief period each year in this unit for purposes of stimulation and for education related to in- novations in treatment. (3) Since the above unit is connected with the General Hospital it follows that most of the patients will come from the 98% of individuals with minor psy- chiatric disorders. It has been the experience of certain other states that acute receiving hospitals for the mentally ill have proved to be the most economical financially for the State and of the most benefit to the individual patient. For this reason there is in existence the Boston Psychopathic Hospital which is operated jointly by the State of Massachusetts and the Harvard Medical School, and the Langley Porter Clinic in San Francisco which functions under the State of Cali- fornia and the University of California Medical School. These hospitals serve 91 both as teaching units such as the one proposed above and as receiving hospitals for the State hospitals for the insane. Under such projects the advantages are that a great amount of teaching material is available, many patients who would other- wise have to be committed are successfully treated without commitment of a per- manent nature, and the entire tempo of a receiving unit can be so much greater than that of an enormous State hospital that patients receive modern methods of treatment much more quickly than they would in a large State hospital, making for the eventual recovery of a greater number. // li'ould seem advisable under the Medical Care Prograiyi in this State to use the psychiatric unit of the proposed Four-Year Medical School as a receiving hos- pital and to establish one other receiving hospital in the State which is set up under a quality similar to that at the proposed medical school. Such a program would decrease the number of patients in the State hospitals for the insane, prevent many patients from becoming permanent wards of the State, and ultimately be a vast financial saving for North Carolina. (B) County and Community Hospitals and Clinics: So far the proposals have dealt with the mental health teaching program and handling of the care of the insane. Some of the larger proportion of individuals with minor psychiatric disorders would be cared for in the psychiatric unit of the General Hospital and in the other receiving hospital. But the problem might scarcely be touched through these measures unless the proposed county and commu- nity hospitals under the Medical Care Program are supplied with facilities for the care of the psychoneuroses, psychological disorders associated with medical and surgical disease, and personality problems. Every county hospital should have a small number of beds (5 to 10) for psychi- atric patients. Each one should also have in its out-patient organization a psychi- atric clinic. It should, if possible, have one psychiatrist and one psychiatric social worker. If this is impossible because of limited personnel there should be some system whereby the psychiatrists from the receiving units could be available for regular and frequent psychiatric consultation. Every small community hospital or community clinic under the Medical Care Program should have psychiatric facilities also. These smaller hospitals should have twf) or three beds at least for psychiatric patients and at these hospitals or clinics there should be held regularly a psychiatric clinic under the direction of psychiatrists from the county hospital or from the State receiving hospitals. Un- less psychiatric care permeates through the entire State system in this way. North Carolina will be sorely neglecting one of its large problems. North Carolina now has the opportunity of not only raising its own standards for the care of the indigent sick, but also of putting itself in the forefront of prog- ress in the solution of one of the great problems of our time, the care of the men- tally ill individual. Mental disorder is more prevalent than tuberculosis and poliomyelitis and it has too long been neglected. Its total cost to the State is as great as all other diseases put together, yet little attention is paid to it. Now per- haps something may be done. Maurice H. Greenhill, M.D. 92 IX Every School Child Must Have i) A Med- ical Examination With 2) Correction of Discovered Defects By Clyde A. Erwin, State Superintendent of Public Instruction and George M. Cooper, M.D., A^. C. State Board of Health The North Carolina Hospital and Medical Care Commission heartily approved the declaration in Governor R. Gregg Cherry's Inaugural Address that there should be medical examination of all school children and that "where parents are unable to finance the cost of remedying childhood physical defects, the State should make pro- vision for this remedial work to be done." Calling on State Super- intendent Clyde A. Erwin and Dr. George M. Cooper, a pioneer worker in this field, for special reports on this subject, they re- sponded with the following studies now just brought up to date (February, 1947). In his Inaugural Address, on January 4, 1945, Governor R. Gregg Cherry said : "I believe that an adequate medical examination, and care, should be provided for all the children in the State whose parents are not able to provide the same. This program is in no sense intended to be a plan of socialized medicine, but it is my belief that where parents are unable to finance the cost of remedying childhood physical defects, the State should make provision for this remedial work to be done. Only less sacred than the right of a child to obtain an education is his right to get a fair chance of health in his youth. The neglect of youth becomes the burden of age and a grievous loss to the State in earning power." The great possibilities of a program such as Governor Cherry proposes are clearly indicated by the excellent results which have been achieved under less ambitious efforts in earlier years. Dr. Cooper, who was the father of school-health work in this State and who secured astonishing results with a minimum staff during his 14 years as director ( 1917-3 1 ) , has summarized our past efforts admirably in the first part of this report, and there is no need for me to go into this phase. In the light of North Carolina's own past experience in this field, however, and of the experience of other states, it seems to me that the following health objectives are now highly desirable and necessary and can be attained during the present Administration : Basic Recommendations 1. Improvenienf of the extent and quality of health instruction in the public schools, includiny such important subjects as nutrition, first-aid and care of the sick, personal hygiene, alcoholism and narcotism, prevention and control of communi- cable diseases, cleanliness, social hygiene, and safety. 2. Improvement of the environmental conditions of the schools with respect to sanitation, lighting, and handicashing facilities. 3. Extensions of health services, including/ immunization, medical examina- tions and follow-ups for the correction of physical defects. 4. Special programs for children who are handicapped because of defective hearing, poor vision, and mental maladjustment. 5. A physical education program for all children from grades 1 to 12 as con- trasted with an athletic program for a few. •Need for Examination and Treatment The need for Governor Cherry's plan to examine and correct the defects of all school children — at private expense where possible and at public expense where necessary — is plain and urgent. When the United States entered the war, the schools promptly met with the re- quests of the Governor and the Department to make health and physical education compulsory for all boys in the two upper grades. 94 Almost half of the schools, with the aid of the State and local medical and den- tal societies, also gave physical examinations to such students, and the percentage of those with some defect was amazing in many cases: PER CENT Dental defects 85 Defective vision 16 Hernia 2 Diseased tonsils 14 Overweight 7 Underweight 16 Heart abnormalities 1.5 A majority of the children exainined in our preschool clinics each year are also found to have some defect. The percentage of "failures" in the school has been brought down in the last 10 years from 17.1 to 12.7%, but we feel that the wasted expenditure on "repeaters" might be cut another one-third with better enforcement of compulsory attendance and better school health. As Governor Cherry has said, "There are literally thousands of boys and girls in our schools who are not reaping the full benefits of educational opportunity be- cause they are suffering from physical defects." Difficulties in Way The major factors which make progress difficult in health programs for school children are familiar to many, but I want to list a few of them as background for the thinking and planning of our leaders. 1. There is an acute shortage of teachers who are adequately trained in health education. The colleges are also short on personnel to train them. 2. The State Department has only one man available from State funds to super- vise and advise with local school officials in regard to health education, safety, and physical education.* 3. The local pressure on school administrators to continue ofifering all the tradi- tional subjects makes it difficult to get health and physical education into the cur- riculum of small schools with present teacher allotments. 4. Health service to the schools is often the last item on the list of essential services of a local Health Department. One reason is that many funds to these departments are dependent upon the services rendered, such as venereal disease treatment or maternity and infant care. Another is that funds are not available either locally or from the State to carry on an adequate corrective program in the schools. * The SehooMIeiilth Coordiimtiiifr Servicp. a staff finaiicod by Stato. Federal, and Rockefeller funds, nlso loiiducts an experimental pnifjram in alxml tliree euuiities eacli .year. Imt this leaves !»" other counties under the sujiervisiou of one health educator. 95 5- Many of our small schools do not have indoor toilet facilities, and the pres- ent sanitary laws are either not adequate or not enforced. State- Local Co-operation In addition to the State-wide program suggested in the early part of this report, the Department would like to suggest for legislative consideration two other im- portant possibilities on a State-Local basis: 1. To amend the School Machinery Act so as to permit any city or county ad- ministrative unit to employ personnel for health instruction, health service, and physical education, in the same way that the local units are now permitted to hire extra teachers for vocational subjects. (Such applications would require the cus- tomary showing of necessity and approval of the State Superintendent, and the cost would be paid out of moneys which come to the county school fund, by law, from fines, forfeitures, penalties, dog taxes, poll taxes, and/or regular tax sources.) 2. It would also be much easier to get city and county administrative units to provide adequate health programs if the State would match the local funds as it now does in the case of vocational subjects. (Virginia now does this as to the em- ployment of doctors, nurses, and teachers of health and physical education.) Clyde A. Erwin. A School Child Health Program By Dr. George M. Cooper, N. C. State Board of Health Everyone interested in bettering North Carolina health conditions should re- joice in Governor Cherry's superb advocacy of a greatly enlarged and adequately supported health program for North Carolina school children. In view of this advocacy it should be perhaps equally helpful ( i ) to look, back at what has been done in a day of relatively small things and small support and then (2) look forward to the vaster possibilities of a really well-rounded child health program for North Carolina. Historically this movement goes back to the inaugural address of the late Governor T. W. Bickett in 1917 when he declared: "I have no genius for destruction. Sense and poetry agree that a man must follow his natural bent. It results that the activities of this administration must be exerted along constructive lines. If there be a man in North Carolina who desires to drain a swamp or terrace a hillside; if there be a farmer who is struggling to escape from the crop lien's deadly clutch; if there be a tenant who hungers for a vine and fig tree he may call his own, I want all such to know that the Governor of the State will count it honor and joy to rise up at mid- night and lend a helping hand." 96 And then coming especially to public health, he said: "If there be physicians who, with that divine self-forgetfulness that is the birthmark of their calling, arc willing to trace Disease to its most hidden laid and plant the banners of Life in the very strong- holds of Death, 1 want them to know that the State sees a new salva- tion in their sacrificial labors, and stands ready to clothe them with all needful authority, and place an unlimited armamentarium at their command." One of the measures Governor Bickett constantly advocated was medical ex- amination of school children, of which he said: "Every child has a natural right to have any mental or physical de- fect corrected, if it be in the power of medical or surgical skill. The incidental fact that the parents may not he able to pay for the neces- sary treatment in no way affects the riyhts of the child. We cannot claim to maintain an intelligent, much less a Christian civilization, if a child be allowed to stagger through life under the handicap of a mental or physical infirmity for the want of a few dollars. Indeed, it is an economical blunder for society to permit an adult to become a mental or physical derelict for want of proper surgical or medical treatment. It is cheaper to correct these infirmities than to pay for the upkeep of these derelicts in charitable institutions." In 1917 this writer as State Medical Inspector of School Children, with the aid and co-operation of Dr. W. S. Rankin, Secretary of the State Board of Health, and Hon. J. Y. Joyner, State Superintendent of Public Instruction, visited and participated in county institutes conducted for two weeks at a time representing 65 counties in North Carolina. Practically every teacher in those counties was pres- ent at the time of this visit. It was learned directly from the teachers that more than 75 per cent of the teachers had taught the previous year in schools including those in town and cities in this percentage without any sanitary facilities whatso- ever. At that time the State Board of Health was waging an intensive fight for eradicating typhoid fever, hookworm disease and other diseases due to insanitation. A strenuous efifort was then inaugurated to provide sanitary facilities in all the schools, together with a screening examination by teachers to locate children with remediable defects, a later examination to be followed by agents of the State Board of Health working in counties on a circuit basis. A visit and inspection was made by competent nurses specially trained for the business at least every three years. Following the inauguration of this program from 1917 until 1935 when the plan was discontinued, the writer worked out a plan utilizing appropriations made by the Legislature directly to the State Board of Health on the urge of Governor Bickett, to follow up the findings of the nurses and the local part time county phy- sicians who frequently rendered aid in this program. There were very few whole time health departments at that time in the State. The writer worked out a two- fold program, more fully described as follows: 97 The Dental Program First, was the Dental Pro(jram which was submitted to the North Carolina Dental Society on June i8, 1918, and unanimously endorsed. Following this meet- ing, six young dentists were employed, the first one beginning his work in Nash County on July 10, 19 18. Each one was assigned to a separate county. He was fully equipped with a portable outfit and assigned to work in the schools for school children, regardless of classification, between the ages of 6 and 13 years. The purpose was to teach oral hygiene as well as to do repair work as an educational demonstration. Efiforts had been made on an experimental basis running back into 1917 to establish the practicability of such a plan. A summary of the work done by these dentists in what was designated as "free dental clinics for school children" was published in The Health Bulletin for April, 1922. Up to that time nearly 70,000 children had been given free dental treatment in the five years embraced, 500,000 children had been examined by teachers searching for defects, and 240,128 children had been examined by school nurses, physicians and dentists. From that day to the present, there have never been fewer than a half dozen dentists employed on the State Board of Health stafT, continually doing work for the school children in every section of North Carolina. A number of permanent dental clinics have been established (for example, here in Raleigh), and a permanent whole time den- tist has been employed for many years. No dentist has ever been foolish enough to oppose this program, as it is a constant source of recruiting of patients who need treatment and who are able to pay for it for every dentist practicing in the State. It has been a godsend for more than a million school children in these 26 years since the work was inaugurated. The Medical and Surgical Program A companion piece to the provision for dental work was what we called The Medical and Surgical Division. Following the work of the nurses who in turn had followed the screening process of the teachers in 86 of our 100 counties, a pro- gram of tonsil and adenoid clinics was inaugurated. This followed an effort for two years, 1917, 1918 and 1919, to try to get the specialists in the State to take care of these needs. It was utterly impossible to do so without organized effort. Here again the approval of the Department of Eye, Ear, Nose and Throat of the State Medical Society was secured in 1918 and these tonsil clinics (called "tonsil clubs" at the time) were inaugurated in 1919 following experimental clinics in three or four counties. To make a long story short, these clinic facilities were set up in schoolhouses, beginning immediately on the close of school along in May, ending in September, and every summer from 1919 to 1931, inclusive, from 2,000 to 2,300 children were operated on successfully for the removal of tonsils and adenoids. A total of 23,211 children received operations with only two deaths in the whole series, one death occurring in Moore County in a child who was operated on under private auspices, having been refused as a bad risk by the clinic physicians. The other child in Alleghany County went in swimming the week following the operation contrary to advice and received a pneumonic infection. The mortality records have never been approached anywhere in the United States. 98 A group of competent graduate nurses were in charge of this program under the specific direction of the writer during all of the first years of the work. The best operators in the State were secured for the operations. They were paid an adequate per diem from small funds collected from some of the patients. These funds also paid for additional nurses, for the equipment and supplies, a special truck being made to order and complete equipment of the very best, including cots, blankets, sheets, etc. The children were grouped in sections of 25 carefully selected according to their grave needs for such operations and of the safety with which it could be performed. They were kept over every night and sent home next morning. As stated in the beginning of this article, this work was on a demonstration basis. It introduced good operators of established practice here in North Caro- lina to the people in their own sections and it has meant prosperity ever since to this group of specialists, besides the thousands upon thousands of children who se- cured better health as a result. Five Features of a Future Program In view of this writer's experience in the practice of medicine for nearly ten years and the following thirty years experience in an intensive study of this whole field, the following outline of procedures necessary for success may be set forth with faith and confidence in the efifectiveness of such a program: First, an appropriation by the State Legislature directly to the North Carolina State Board of Health is the first requisite, the appropriation to be earmarked and specifically provided for this purpose under the directorship of a physician who must be a crusader for the public interest and who is willing to fight for the under- privileged children in North Carolina, but at the same time who is a qualified, trained physician and who has common sense and initiative and the ability to do creative thinking as occasion demands. Second, the co-operation between the State Board of Health and the State De- partment of Education must be re-established on the basis that it was so happilv and satisfactorily carried out in those years between 1917 and 1931 in which (i) the Department of Education assumed responsibility for the teaching in the class- room of all public health subjects (just as they would mathematics and English), and (2) in which the State Board of Health has full and complete jurisdiction over the physical defects found in school children and in all matters of epidemi- ology and disease control. Third, it is absolutely necessary for all local principals and teachers of all the schools to be in wholehearted sympathy with this pror/ram. It is hardly necessary to say that a strict enforcement of the attendance law is necessary and sympathetic co-operation of all classroom teachers is an absolute necessity. Fourth, a strict system of annual inspection of every school child enrolled in the schools of every county must be provided under the leadership of the State Board of Health co-operating with the local health departments in each city and county which must provide the personnel to do the examinations following the screening 99 process first done by the teachers under the guidance of the State and local health departments. Fifth, it is utterly useless to make these examinations, to do all this teaching, to make all the efforts that so-called public health education in the schoolroom or in the deportments of health require unless organized plans for follow-up are pro- vided. These plans must be submitted and followed through by the State Board of Health and the director selected to carry on this program. A co-operative plan with practicing physicians, including every specialty group and the general prac- titioners known as family doctors, is necessary. This can be very well arranged. Four imperative needs are these: 1. It is an absolute necessity that the State own, operate, and control a Four- Year Medical School in order to assure the proper distribution of physicians in the State. 2. It is equally as necessary to have hospital facilities and medical centers in every section of the State easily available to these children and their parents. 3. Provision must be made to take care of the big majority of the children who cannot pay top prices for medical and surgical work but who can pay something, and of course for the lesser group who cannot provide anything that costs money for themselves. 4. Defects constantly located will run the whole scale of human diseases en- countered in this climate, from pediculosis to one or the other of the many hun- dreds of forms of eczema. Nutritional deficiencies will be rampant. Intestinal diseases are still highly prevalent in most of the rural sections of the State. A sympathetic and co-operating medical profession is an absolute necessity, together with the provision of hospital facilities to cope with the situation. The program can be put on a practical basis and carried through icith promise of 100 per cent success just as our tonsil clinics from 1919 to 1931 were carried on and just as our dental clinics have been carried on successfully for 26 years. The Legislature can provide the money but the leadership must be provided in the Health and Education Departments, including State and local and professional co-operation by physicians, dentists and hospital tnanagers which must be forth- coming. How Much Would It Cost? The cost of such a program as is here set forth would depend entirely on what the people wanted done for their children. A conservative estimate of the cost of setting up the administrative machinery and getting the program under way for the first two years, if placed exclusively in the hands of the State Board of Health, would be about $300,000 a year. This estimate is based on the very successful pro- gram of diagnosis and treatment of crippled children carried on by the State Board of Health for the past eight years with the co-operation of every one of the ortho- pedic surgeons practicing in North Carolina. George M. Cooper, M.D. 100 X Both the Counties and the State Should Better Support An Enlarged and Adequate Pubhc Health Program By Carl V. Reynolds, M.D., Secretary, State Board of Health One way to make our distressing shortage of doctors and hospitals somewhat less distressing is to decrease the number of sick or ailing persons who need doctors and hospitals — Preventive Medicine. Here the public health activities of our State (in co-operation with the Federal government) have a tremendous part to play — as here set forth by our veteran State Health Officer, Dr. Carl V. Reynolds. There arc two forms of viedicine — the curative and preventive — the over-all plan of caring for and rehabilitating our people, and making medical and hospital services available to all uho need them, regardless of their economic or wage-earning status. The successful promotion of both curative and preventive medicine must rest upon the realization that these are interdependent, and that the success or failure of one means the success or failure of the other. Public Health Funds: State, $543,234; Other, $2,124,913 It is an established fact that it is necessary to have $1 per capita in order to maintain a minimum public health program. Many years have elapsed since 1877, when the State Board of Health was created by legislative enactment, with an annual appropriation of $100. During the present fiscal year, ending June 30, 1947, there has been available to the State Board of Health, for all purposes, the sum of $2,668,147. This sounds like a huge sum, but is dwarfed by expenditures for many other purposes, none of which could be more important than public health — and some not nearly so basically important. Of this, only $543,234, incliid- inc/ the Laboratory fund, came from State appropriations, the remaining $2,124,913 from the Federal Government. The State has lost $200,000 a year by reason of the transfer of the Reynolds Fund to Wake Forest College. For the present fiscal year the counties and cities of the State are contributing $1,815,910 to the co-operative public health program, while Federal funds are budgeted in the amount of $2,124,913 while the State appropriation stands at only $543,234 — general fund, $462,991; Laboratory, $80,243. What Public Health Service Can Do The standard maximum State allotment for a full-time local health unit during the depression year of 1932-33, when there were only 43 such units in North Caro- lina, was $2,400. At the present time, there is available only $175,000 in State appropriated funds, to be spread over 94 counties with full-time health depart- ments. If this were prorated on a basis of too counties, it would mean only $1,750 a county, in the face of growing needs and added responsibilities to our people. Already the local health units are serving over 95 per cent of the entire population. It is felt, that an additional new appropriation of $425,000 (including $350,000 special V. D. Aid) for each year of the coming biennium would be a fair figure, and that by providing it the State would be assuming only its rightful responsi- bility in supporting the public health organization. An appropriation from the State of a much larger amount would be but a fraction of the amount being con- tributed by the counties for local health services. Tuberculosis control, cancer control, nutrition and crippled children's work also warrant additional State funds, if this work is to be expanded to meet necessary requirements. Approximately $10,000,000 for tiiberculosis control has been appropriated by the Federal Government, and North Carolina has set up a definite bureau to direct 102 these funds, in order to receive $261,995 this fiscal year. The last Lej;islature (1945) appropriated ,^20,000 to administer the Federal funds above referred to. What we need now is an appropriation suflicient to pay experienced personnel commensurate with services rendered. Special funds have become available for ranrcr control, but we were only able to secure these ($71,772) through a philanthropic gift of $25,000 as the last (1945) Legislature appropriated nothing. But for this benefaction, we would have lost the $71,772 Federal grant. It would be an outstanding advance in cancer control to make available at the State Laboratory of Hygiene a tissue examination for diagnostic purposes. This is essential to the success of the program, as biopsies are now outside the financial reach of many. Nutrition must play an important part in the post-war maintenance and reha- bilitation of our people. While we have made a good start with the means avail- able — coming for the greater part from outside sources (the Rockefeller Founda- tion) — State funds should be provided for a long-range program, as nutrition plays and will continue to play a very definite role in preventive medicine. The Rocke- feller Foundation funds will cease after November, 1947. The State shouhi, there- fore, make an appropriation to keep this important program going. Thousands of children already have been reclaimed through the work of the Board of Health's Crippled ChilJren's Department. Corrections are constantly be- ing made for hare lips, cleft palates, bone diseases, burns, injuries at birth, congen- ital joint trouble, club feet, bowed legs and many other conditions which will con- tinue to call for remediable measures. Many children needed and have been given orthopedic treatment as the result of the 1935 poliomyelitis epidemic in North Carolina. We have just passed through an epidemic of even larger proportions, the crippling results of which have not yet been fully appraised. We should be prepared to meet whatever added responsibilities this imposes upon us, and this can be done only with sufficient funds. During the past two vears, the State Board of Health has supervised 420 clinic sessions for crippled children, 1,395 were admitted to 21 selected hospitals for treatment; and, on June 30, last year 23,688 children in need of orthopedic serv- ices had been located and their names placed on the State register. Beyond question, one of the most important links in the public health chain in North Carolina is the State Laboratory of Hygiene. For the fiscal year ending June 30, 1946, the cost of operating the Laboratory was only $147,239.26, though this institution saves the taxpayers of North Carolina an estimated $2,500,000 a vear, based on what they would have to pay at commercial prices for the services it renders them. Yet of this total the Laboratory itself earned $71,359-63, leaving onlv $75,879.63 coming from the State appropriation. Recent Pur.Lic Hf.m.th Achievements Let us consider briefly some of the advances we have made through mass pro- tection. Death rates from controllable and preventable diseases in North Caro- lina fell last year to new levels — diphtheria to i.o, typhoid fever to 0.3, tubercu- losis in all forms to 37.4, pellagra to 1.9, malaria to 0.6 (all per 100,000). Com- 103 pare these with the death rates from the same diseases a generation or even a decade ago, and the results in some instances will prove nothing short of amazing. The 1945 crude rate of 7.6 — White, 6.9, and Negro 9.4 — per 1,000 population was an all-time low and around 3 points below the rate for the U. S. Although the rates still are too high, there seems to be a sustained downward trend in both maternal and infant mortality. Public health takes a justifiable pride in this, because it operates, at strategic points throughout the State, 200 ma- ternal and child health clinics, where during the past two years, 13,433 babies were examined and 8,341 pre-school examinations were made. There were, in addi- tion, 15,687 prospective mothers examined, approximately 9 per cent of whom were found to be syphilitic, compared with 13 per cent 6 years ago. Also, during the two-year period ending June 30, 1946, the State Board of Health's Oral Hygiene Division gave 2,061 classroom lectures in the schools of the State on mouth health. These were attended by 92,616 children. Of these more than 57,085 who were underprivileged were treated and 34,845 whose parents were able to pay were referred to practicing dentists. We now have only seven school dentists, as compared with 34 at the beginning of the war. We cannot olTer salaries commensurate with what dentists are making in private practice. Hence, the distressing shortage. Public health is keeping track of North Carolina's venereal disease incidence with increasing efficiency. For two years prior to June 30, 1944, the State Labora- tory of Hygiene made 1,095,000 serologic tests, and 1,049,000 during the previous biennium. The number of treatments given in the State's 310 public health clinics since 1939 has totaled 3,304,000, compared with approximately 1,500,000 the pre- ceding four years. Health Service Needed in 100 Counties We take pride in the manner in which our State health organization mobilized for war, after a period during which preparedness was emphasized and re-empha- sized, beginning in earnest in May, 1940, when it appeared inevitable to many that we were headed toward active participation in the world conflict. We should also mobilize for the peace that has followed, which will be marked by added, and often heart-rending problems. We must meet this situation, prepared to cope with it, both financially and in the matter of trained personnel. North Carolina in 1945 recorded a crude death rate of only 7-6 (per 1,000), being the lowest in our history despite conditions, and more than three points below the death rate for the United States as a whole. This has been accomplished through mass protection, and it is logically sound to assume that this is the proper procedure to follow. ^'Is previously stated, we now have 94 counties in North Carolina with qualified health organizations, either on a unit or a district basis. It is high time the Legis- lature consider the enactment of a law requiring all of North Carolina's 100 coun- ties, through some form of taxation, to provide funds for a minimum health organ- ization, either on a unit or district basis. Carl V. Reynolds, M.D., Secretary, State Board of Health. 104 XI The Origin, Progress and Statutory Organization of the Movement for Better Hospital and Medical Care In this final section of our volume we summarize Governor Cherry's Special Message to the General Assembly February 27. 1945 . . . reproduce the Medical Care Commission Act ratified March 21, 1945 . . . present a concise history of the 1944-5 movement for better hospitals and medical care for our people . . . and conclude with a re-statement of the high hopes and ideals toward which our Com- monwealth will move "as the thoughts of men are widened with the process of the sun." Extracts from Governor Cherry's Message February 27, 1945 Mr. President, Mr. Speaker and Members of llie General .issembly of North Carolina: In my Inaugural Address reference was made to the Report of a Commission recommending further steps to be taken in medical care and public health in North Carolina. Through the courtesy of Dr. Clarence Poe, the chairman, every member of the General Assembly has been furnished with a copy of the Report, together with a collection of pamphlets and statements from interested and capable persons sup- porting the findings of the distinguished group of North Carolina citizens who served on the Commission and made the Report. . . . Since such information has been furnished to you in a clear and convenient form, this is no occasion for me to restate the conclusions and findings of the Report and the reasons therefor, except as may be incident to my recommendations to you as hereinafter set out in this message. . . . After innumerable conferences I have decided to recommend to you for your favorable action, the general principles of the Medical Care Program as embodied in a bill introduced in the Senate and House last night and which is now before you for consideration. In brief outline, the subject of the bill before you, the fun- damental outlines and general principles of which 1 strongly recommend to you for favorable consideration, involves and sets forth the following: FIRST: The estahlishment of a "North Carolirm Medical Care Commission," by the present General Assembly, and in order to effectuate the same, I further recommend that you appropriate and make available the sum of $50,000 for each year of the biennium for the operating expenses of the Commission and the performance of such other duties as may be required of the Commission under the terms of the pending act. SECOND: Thai you adopt the principle of Stale conlrihutions for the hospitalization of indi- gent patients and that the Commission shall be authorized to promulgate rides and regvlations for determining the indigency of persons hospitalized and the basis upon which hospitals and health centers shall qualify to receive contributions for indigent patients and the Commission is authorized and empowered to contribute not exceeding $1 per day for each indigent patient hospitalized in each hospital ajiproved by it. To effectuate this provision, I recommend that you appropriate the sum of $500,000 for each year of the biennium; provided, however, that this appropriation shall not be available until all provisions of the General Appropriations Bill of 1945, including those relating to the emergency salary for public school teachers and state employees shall have been completely provided for. THIRD: That you authorize and direct the Commission to be created under the pending Act to mal'e surveys of each county in the Stale to determine the need for some hind of state aid for construction and enlargement of local haspitals, and make a report of their findings and recommendations. FOURTH: That you authorize and direct the Commission to he created under the pending Act, and in accordance with rules which the Commission may promulgate, to mal-e loans to worthy students in need of financial assistance who may wish to become physicians. 106 FIFTH: That i/oii adapt the prtiiclpic iiud declare the pidtcij of expniidiiif/ Ike two-year medi- cal scIkwI of the I'nirernit!/ of Sorth Varoliiia into a xtaiulanl four-year medical School, together with necessary hospital fai ilities, homes for nurses, internes anil resi- dent physi(Unis as may he reipiired for the expansion of such Medical School. It is not coiitcniplateil that uuy couslruction of buildings or acqiiisilioii of c(|ui|)nii'nt to effi'ctuatt' the dt'clarcij jiolicy of cxpausioii of such medical .school can he perfornied during the war period. SIXTH: That you authorize and direct the Conmission to be created hy the pending act to make careful investigation of the necess^ity and methods of providing medical train- ing for Negro students, and make a report of their findings and recommendations. ^ ^ ^ Many desirable services, riclily deserved by our people, must be postponed for the duration of the war. ... In like manner, much of the proposals of the Hos- pitals and medical Care Commission must be postponed to some future date. But Senators and Lady and Gentlemen of the House, a most comprehensive plan of hospitalization and medical care has been laid before you and is contained in the report (of the Hospital and Medical Care Commission) now on your desks. The bill before you and now under consideration endorses the principles and par- tially efifectuates the plan outlined in such report. 1 personally favor and sin- cerely believe that improvement in medical care in North Carolina is sure to come and that it is dehnitely on the way. Just when the capstone will be Hnally laid for a comprehensive and adequate plan of medical care in North Carolina is a matter for future legislators — but we here today and in the succeeding days of this General Assembly, ought to lay the cornerstone and the broad foundation upon which we can build such program as our people seek to obtain and ought to have. The people of our State at decisive times in our history have made the great decision to build a more enlightened and productive State. In our poverty we built a great school system; in spite of debts and deficits we built a great public highway system. In these days, we shall not be afraid to lay the foundations for proper medical and hospital care needed by our poorer and less fcjrtunate fellow citizens. The voices of the sick, the suffering and even the dying cry out to us at this time for help. These voices which we hear, and voices too long unheard, come to us across the plains and hills of every part of our State. It is my belief that we should answer their calls and minister to their needs by laying the founda- tion of a balanced and humane program for more adequate medical care for the people of this Commonwealth. As members of this General Assembly, you have the responsibility and privi- lege of making another decisive decision in the history f)f our State. I ask you to believe with me that "Better Schools, Better Roads and Better Healtii" constitute the three main high roads for the advancement of North Carolina. 1 have confi- dence that you, in this Hour of Destiny, will make the decision embracing a pro- gram for the future happiness and welfare of North Carolina. 107 Act Establishing the Medical Care Commission H. B. No. 594 An Act to Provide a State-wide Program of Hospilal and Medical Care . . . to Create the North Carolina Medical Care Commission . . . to Make Contingent Appropriations for Contributions for the Care of Indigent Sich in Approved Hospitals . . . io make Surveys and recommen- dations for the Construction of Necessary Hospitals and Health Centers . . . to Provide for the Expansion of the Medical School of the University of North Carolina . . . to provide for the Construction of a Central Hospital as a Memorial to North Carolina Dead of World War I and World War II . . . and Other Provisions Relating Thereto. The General Assembly of North Carolina do enact: Section 1. That Chapter one hundred and thirty-one of the General Statutes of North Caro- lina be, and the same hereby is, amended by adding the following articles and sections. Article 12. Sec. 131-117. North Carolina Medical Care Commission. There is hereby created a State agency to be known as "The North Carolina Medical Care Commission," which shall be composed of 20 members nominated and appointed as follows : Three members shall be nominated by the Medical Society of the State of North Carolina; one member by the North Carolina Hospital Association; one member by the North Carolina Dental Society; one member by the North Carolina Nurses' Association; one member by the North Caro- lina Pharmaceutical Association; and one member by the Duke Foundation, for appointment by the Governor. Ten members of said Commission shall be appointed by the Governor and selected so as to fairly represent agriculture, industry, labor, and other interests and groups in North Carolina. In appointing the members of said Commission, the Governor shall designate the term for which each member is appointed. Four of said members shall be ajjpointed for a term of one year; four for a term of two years ; four for a term of three years ; five for a term of four years ; and thereafter, all appointments shall be for a term of four years. All vacancies shall be filled by the Governor for the unexpired term. The Commissioner of Public Welfare, and the Secretary of the State Board of Health shall be ex-officio members of the Commission, without voting power. The Commission shall elect, with the approval of the Governor, a chairman and a vice chairman. All members, except the Commissioner of Public Welfare, and the Secretary of the State Board of Health, shall receive a per diem of seven dollars ($7.00) and necessary travel expenses. Sec. 131-118. Commission Authorized to Employ Executive Secretary. The North Carolina Medical Care Commission is authorized and empowered to employ, subject to the approval of the Governor, an Executive Secretary, and to determine his or her salary under the provisions of the Personnel Act. The Executive Secretary may employ such additional persons as may be required to carry out the provisions of this Act, subject to approval of the Commission, and the provisions of the Personnel Act. Office space for the Commission shall bp provided by the Board of Public Buildings and Grounds, in Ealeigh. Sec. 131-119. Contribution for Indigent Patients. The North Carolina Medical Care Com- mission, in accordance with the rules and regulations promulgated by it, is hereby authorized and empowered to contribute not exceeding one dollar ($1.00) per day for each indigent patient hos- pitalized in any hospital approved by it, provided the balance of the cost shall be provided by the county or city having responsibility for the care of such indigent patient, or from other sources. The Commission shall promulgate rules and regulations for determining the indigency of the per- sons hospitalized and the basis upon which hospitals and health centers shall qualify to receive the benefits of this section. For the purpose of carrying out the provisions of this section, there is hereby appropriated from the General Fund to the North Carolina Mrdiral Care Commission for the fiscal year ending 108 June 30, 1946, the sum of $500,000; aiul for the fiseal year ending June 30, 1947, the sum of $500,000, provided that the benefits of tliis section shall ai>))ly only to ii()s|)ituls publicly owned, or owned and oj)erated by charitable, non-[)rofit, non-stock coiporations, and provided further that these appropriations provided in this section shall not be available until all provisions of Section 231/2 of the Committee Substitute for House Bill Xnnd)er 11, the (ieneral A])propriations Bill of 1945, relating to the emergency salary for public school teachers and State enii)loyces shall have been completely and fully provided for. Sec. 131-120. Construction and Enlari/ement of Local Jlospitah. The North Carolina Medi- cal Care Commission is hereby authorized and empowered to begin immediate surveys of each county in the State to determine: (a) The hospital needs of the county or area; (b) The economic ability of the county or area to support adequate hospital service; (c) What assistance by the State, if any, is necessary to supplement all other available funds, to finance the construction of new hospitals and health centers, and necessary equipment to provide adequate hospital service for the citizens of the county or area; and to report this information, to- gether with its recommendations, to the Governor, who shall transmit this report to the next session of the General Assembly for such legislative action as it may deem necessary to effectuate an ade- quate State-wide hospital program. The North Carolina Medical Care Commission is hereby authorized and empowered to act as the agency of the State of North Carolina for the purpose of setting up and administering any State-wide plan for the construction and maintenance of hospitals, public health centers and related facilities, which is now or may be required in order to comply with any Federal law and in order to receive and administer any funds which may be j)rovided by an Act of Congress for such pur- pose; and the Commission, as such agency of the State of North Carolina with the advice of the State Advisory Council set up as hereinafter provided, shall have the right to promulgate such state-wide plans for the construction and maintenance of hospitals, medical centers and related facil- ities, or such other plans as may be found desirable and necessary in order to meet the require- ments and receive the benefits of any Federal legislation with regard thereto. The said Commission shall be authorized to receive and administer any funds which may be appropriated by any Act of Congress for the construction of hospitals, medical centers and related activities or facilities, which may at any time in the future become available for such purposes; and said Commission shall be further authorized to receive and administer any other Federal funds, which may be available, in the furtherance of any activity in which the Commission is authorized and empowered to engage in under the provisions of this Act establishing said Commission, and in connection therewith, the Commission is authorized to adopt such rules and regulations. Sec. 131-121. Medical Student Loan Fund. The North Carolina Medical Care Commission is hereby authorized and empowered, in accordance with such rules as it may promulgate, to make loans to students who may wish to become physicians and who are accepted for enrollment in any standard four-year medical school in North Carolina, provided such student shall agree that upon graduation and upon being licensed, to practice medicine in some rural area in North Carolina for at least four years. Rural area, for the purpose of this section, shall mean any town or village hav- ing less than 2,500 population according to the last decennial census, or area outside and around such towns or villages. Such loans shall bear such rate of interest as may be fixed by the Commis- sion, not to exceed 4 per cent per annum. For the purpose of carrying out the provisions of this section, there is hereby appropriat» _ s^.\Mi:^jb. ' :-J . A«.. — Governor J. Melville Brouyhton, January 31 , 1944. II. An adequate medical examination should be provided for all children. . . . ff'here parents are unable to finance the cost of remedying childhood physical de- fects, the state should make provision for this remedial u'ork — the Sacred Ritjlit of Every Child to Health. . . . The neglect of Youth becomes the burden of Age and a grievous loss to the state in earning power. — Governor R. Gregg Cherry, in Inaugral Address, 1945. III. We must noiv strive toward the ultimate fulfillment of this great new ideal of American democracy : For every person, rich or poor, high or low, urban or rural, white or black, an equal right to adequate hospital and medical care whenever and wherever he makes the same grim battle against ever-menacing Death which sooner or later we must all make for ourselves and see our loved ones make. — Conclusion of Address in support of Hill-Burton Bill by Chairman Clarence Poe, Before U. S. Senate Committee, Washington, March 12, 1945. IIS LIST OF CHARTS AND TABLES /. Hoic North ('(iiolitdi lOinkx in ('Dniixiri.son With Other States — General Table: How North Carolina Ranks in Health and Medioul Care and in Social and Economic Conditions Affecting Health, 18 Hospital Beds per 100,0()0 Population, 20 Physicians per 10<»,000 Popnhition. 28 Days Hospitalization, 21 Maternal and Infant Mortality Rates, 33, 34, 36 Births and Deaths in Hospitals, 38, 39, 40 Income per Capita, 43, 44 Rejections for Military Service, 45, 46 Mortality Rates: Adjusted, 31; Rural White, 30 //. How Your County Ranks in Comparison With Other Counties — Hospital Beds: White, 22-3; Negro, 23-4 Deaths in Hospitals, 40, 41 ; Births, 41-42 Physicians, Per 100,000 Population, 28 Death Rates, 19, 30, 37; Infant, 36 Midwives, Births Attended by, 41-42 Rejections for Military Service, 44, 47, 48 Public Health Expenditures, 51-53 Hospital Beds Needed by Counties and Communities, 2.">-27 Deaths, Principal Causes of, 32 Maternal Deaths, White and Negro, 35 Effective Buying Power Per Capita, 49, 50 INDEX OF OTHER ARTICLES, CHARTS, ETC. Cost of Medical and Hospital Care, $100 per familv. 64 Crippled Children, 103 Dental School, 73 Diseases, Numljer and Types per 1000 persons, 63 Farm Foundation Recommendations for Rural Health and Hospitals, 74 Good Health Association, 114 Health Centers, 66 Hospitals: III Eastern and Western Counties, 3 Wlio Should Pay for Hospital CareV 6 Duke Foundation Contributions, 12, 74 How Many Beds? 57 Rmal Hospitals. 62-3 Rural Clinics, 63 'J'ypes of Hospitals, 66. 74 Central or Teaching Hospital. 72 Hill-Burton Bill, 114 Insiiranee: Hospital and Health, 6, 63, 66 Loan Fluids for Medical Students, 4, &'i, 75 Maternity Beds, must be near people, 58 Medical Care Commission Appointed. 113 Medical Education Out of State. 76 Medical Students: Duke, Bowman C.rav. r.X.C, 71. 76 Mental and I'siii-hintrie Problems, 1.5. 72 Illnesses. Extent and Cost, 88-90 Clinics, L(K'ation of. 90 Features of Four-Medical Schools, 91, 92 5 to 10 Beds Needed Each County, 92 Acute. Receiving Hospitals for. 91 Military Rejection.s, North Carolina. 12; Orphanage Boys, 12, 13 National Commission on Hospital Care. 114 Negroes: Hospitals for. 58, 74. 82-84 Medical Training for. 4, 73, 75. Ml. SI Insurance for. 85 North Carolina Death Rale. M Nursing. School of, 72 Pharmacy, School of, 73 Public Healtli Funds, 102-3 Public Health Work, 6; Ex])en(li(ures, 65 Rural Physicians, Present Situation .ind .Need. 61 School Children: Examination of. 6. 15 Health Instruction. 94 Percentage Defects. 95 Dental Treatments. 9S E.ve, Ear, No.se and Throat. 98 Complete School Health Program for. .f.SOO.OOO, 100 Socialized Medicine, 3 Two- Year Medical Schools, 76 116 HOO WA 900 AN8 P743 1947 c.2 W North C2rolina. Hospital and Medical Care Co mm i s s i o n . Hospital and me d i c a I care A 900 AN 8 P74 3 1947 c.2 North Carolina. Hospital and Medical Care Commission. Hospital and medical care for all our people K This book circulates for a 3-week period and Is due on the last date stamped below. It may be renewed for one additional 3-week period. The fine for late return is 25(C a day. Charles R, Jonas, Executive VIce-Prealdent Harry B. Caldwell, Executive Secretary James E. Lambeth, Jr., Treasurer Regional Vice-Prcsldenta D. Hlden Ramsey Irving Carlyle James S. Picklen Henry L. Stevens Directors: Josephus Daniels William B. Umstead W. M. Copprldge. M.D. George Watts Hill R. Flake Shaw Mrs. Harry B. CalJv.-oII Bon (^one Julian Price Thomas J, Pearsall Hyman Battle Charles A. Cannon Irving (^arlyle