Principles of

Public Health Administration
Principles of
Public

 

The C. V. Mosby Company

 
Health Administration

John J. Hanlon, M.S., M.D., M.P.H.

Director of Public Health Services, City of
Philadelphia, and Professor and Head,
Department of Preventive Medicine and Public
Health, Temple University School of

Medicine, Philadelphia, Pa.

Illustrated Third Edition

1960 St. Louis
PUKLTC HEALTH BIB,

THIRD EDITION
COPYRIGHT @© 1960 BY
THE C. V. MOSBY COMPANY

All rights reserved

Previous editions copyrighted 1950, 1955

Printed in the United States of America

Library of Congress Catalog Card Number 60-6192
Distributed in Great Britain by Henry Kimpton, London
To

FLORENCE LIVINGSTON HANLON

864
 
 
Foreword

 

The methods of providing our people and the communities in which they
dwell with adequate health services are never static. They must ever be reconciled
with the changing patterns produced by social, economic, educational, and pro-
fessional characteristics. Man constantly adjusts to the environment in which he
lives. He is affected by the health status ol his family and neighbors. Changes in
the way of life and the new aspects ol an industrial age demand a continuous
evaluation of methodology in the creation and functioning of agencies, both
official and voluntary, personal and collective, which serve to prevent disease
and accident and to promote positive health. The type ol agency required will
change with new problems. Trained man power must be made available with
which to staff such agencies, including private enterprise and industry. Costs
must be considered in relation to goals and results; duplication of effort must be
avoided. Public and family wants and needs must be studied in relation to the
mores and attitudes of society. Economy demands maximum results compatible
with the trend toward a longer and more wholesome life span.

It is therefore most appropriate that our distinguished author, fortified with
a vast and impressive service in the health sciences, should review and reconcile
his text with the scientific, educational, and political aspects of a fast-moving
world, seeded by an ever-enlarging population, alert to the needs and fruits of
an environment in which man can live best with himself and his fellowmen.

HENRY F. VAUGHAN, Dr.P.H.
Preface to third edition

 

 

Many significant changes have occurred since the publication of the last edi-
tion of Principles of Public Health Administration. One of the most significant
has been the sustained increased birth rate in the United States, as well as else-
where, and the recognition that public health workers had best brace themselves
for the impact of a tremendous population expansion. Closely allied with this
has been the continued concentration of people in urban settings with an ever
more rapid pace of life. Significantly affecting this has been a spiraling rise in
the standard of living and a fantastic increase, far exceeding all expectations, in
the numbers and types of material advantages which have accrued to the entire
population. While many benefits have resulted from these changes, they have
brought with them some problems. In the revision of the previously existing
material and in the selection of new material for this edition, an attempt has
been made to reflect both types of changes. Based upon a more direct considera-
tion of the phenomenon of social pathology, recognition has been given to the
increasingly important problems of chronic diseases, accidents, mental health, and
addictive diseases and to the significantly increasing needs for social services and
medical care. Beyond this, the obvious risk has been taken of concluding the
volume with an attempted look into the future. This is done with the feeling that
what has gone before probably is but little compared to what the future holds
in terms of man’s success in coping with his environment.

As in the case of the previous editions, it is incumbent upon the author to
express most sincere thanks and appreciation to a number of individuals who
have been of assistance. A blanket statement of thanks should be expressed to all
those who teach public health administration in the various schools of public
health in the United States. At one time or another they have all made helpful
suggestions. Dr. Garold L. Faber has been extremely kind in a meticulous review
of the second edition. Particular thanks is also expressed to a number of splendid
co-workers in the Public Health Services of the Philadelphia Department of Pub-
lice Health who have assisted in innumerable ways, impossible to itemize. Out-
standing among them have been Mrs. Adele S. Hebb, Miss Erleen F. Jamison,
and Mr. William J. Wolf. Finally, sincere thanks is given for the devoted and
capable help of my secretaries, Miss Bette L. Geist and Miss Lillian Willier.

JOHN J. HANLON, M.D.
Philadelphia, Pa.
Preface to first edition

The policy which has developed in the United States and elsewhere is to
place at the executive helm of organizations conducting public health programs
individuals whose primary qualification is the possession of a medical educa-
tion. Time was, in the formative days of the profession and in a less complex
society, when that single qualification perhaps sufficed. But neither public health
thought nor society has been static. Remarkable and intimately interrelated
changes and progress have occurred at a rapid pace containing far-reaching im-
plications for those who would successfully strive for the protection and promo-
tion of the public health. No longer is it adequate merely that the health
officer be a good diagnostician and therapist. If his ability and inclination are
restricted to these, his most fruitful and satisfactory work will be performed in
the private practice of medicine.

Should the physician, on the other hand, have a deep-seated wish to par-
ticipate in the promotion of the well-being of the public en masse through the
work of the increasing numbers of public health agencies, he soon finds himself
involved in fields and problems, the importance, even the existence, of which he
was hardly aware throughout the period of his medical education. In discussing
the role of the govermental executive, Donald C. Stone, while Assistant Director
of the Bureau of the Budget, pictured the problems in a manner worth repeating
here.

The specialized conditions surrounding governmental programs put extraordinary
demands on their directors in terms of knowing how to weave the competing and dis-
parate elements into a unified whole and producing an organization capable of accom-
plishing its mission. Public pressures, the need to adjust to the views of legislative
bodies, the rigidities in procedures attendant upon management according to law and
executive regulation are elements present in any public service enterprise. All of these
are related to that central characteristic that distinguishes executive positions in the
public service from those in private management—the fact that the government executive
is the guardian of the public interest and is accountable to the electorate, directly or in-
directly, for what he does. This is very different from the concern for the public which

the private executive has in relation to the marketability of his product and the good
name of his firm. *

*Stone, Donald C.: Notes on the Government Executive: His Role and His Methods, New
Horizons in Public Administration, A Symposium, University, Alabama, 1945, University of
Alabama Press, pp. 47-48.

10
PREFACE TO FIRST EDITION 11

In a more specific sense, the neophyte in public health administration, when
he first opens the door providing entry to the organization for which he is to pro-
vide leadership, finds himself face to face with a series of problems of quite un-
expected types and for which he usually has been unprepared. His record of
clinical prowess and acumen may be excellent, but he will find it of little value
in solving these particular problems. When he pulls on the knob and enters,
his first problem is always one of personnel management. In rapid succession he
finds himself concerned with problems implying an understanding of the prin-
ciples of organization, government, and law. Before much of his first day is
passed, he is certain to have participated in a number of situations requiring
personal relationships with the public, the press, the medical profession, and
others. He then realizes that while a satisfactory bedside manner is one thing,
an acceptable public manner is another. Sooner or later he awakens to the fact
that the program and the personnel he is directing involve the expenditure of
money. Where does it come from? How to go about obtaining it? The probability
is that his acquaintance with the word “budget” was in connection with his per-
sonal financial struggles at the end of each month. Now demands are made upon
him to produce in some baffling manner what seems to him a complicated docu-
ment depicting the financial working, past, present, and future, of the agency
he directs.

These are but a few of the unforseen and unprepared-for headaches which
are encountered by the man who decides to devote his professional life to the
field of public health administration. What is expected of him appears to be the
impossible. Physician, engineer, lawyer, political scientist, economist, sociologist—
must he be all of these and more? In the literal sense this, of course, would not
be possible. It is not too much to expect, however, that he have at least an under-
standing of the fundamental principles involved in the various fields related to
his office. Experience will teach him much, but at least a modicum of information
beforehand might be helpful. It is with this in mind and with the hope of stimu-
lating an interest for further study that this book is presented.

He who writes a textbook is one of the most indebted of men. So many
persons contribute and assist in so many direct and indirect ways that complete
recognition and repayment becomes an impossibility. Who can ever adequately
evaluate the influence of past friends, associates, and teachers? Yet their influence
upon us and anything we undertake is deep and lasting. For most, all that can be
done is humbly to acknowledge their value and influence.

There are always a few, however, who stand out—those without whose help
and encouragement the immediate task would not have been possible. In the
case at hand, the writer wishes to express particular thanks to a few such specific
individuals: to Dr. Henry F. Vaughan for his many years of professional guidance
and inspiration, and for critical review of many of the following chapters; to Dr.
Carl E. Buck, long-time Field Director of the American Public Health Associa-
tion, for many valuable suggestions concerning the contents of this book; to Dr.
Louis I. Dublin, Dr. Joseph W. Mountin, Professors F. Alexander Magoun and
12 PREFACE TO FIRST EDITION

Leonard D. White for their kind permission to make generous use of much of
their material. Much credit is due the writer's wife not merely for her many sug:
gestions but for her constant prodding and encouragement. Finally, no small
measure of thanks is given to Miss Virginia Meredith who put so much patient,
untiring effort into the preparation of the manuscript. Many thanks to you all.

JOHN J. HANLON
Ann Arbor, Mich.
Contents

 

 

part 1 Introduction

chapter 1. The philosophy of public health ........... ........ .. .. .... .....

Public Health as a Profession, 21; Definition, 22; Therapeutic Medicine, Preventive
Medicine, and Public Health, 24; Health and Government, 26; Scope of Public
Health, 26; Public Health and Population Increase, 27; Public Health Versus
Natural Selection, 32.

chapter 2. The background and development of public health in the United States

Reasons for Review, 36; The Pre-Christian Period, 37; The Middle Ages, 38; The
Black Death, 39; Other Diseases, 40; The Renaissance, 41; The Eighteenth and
Nineteenth Centuries; The Plight of Children, 42; Sanitary Conditions, 43; English
Sanitary Reforms, 45; English Influence on America, 46; Colonial America, 47; The
Nineteenth Century in America, 48; City Health Departments, 49; The Shattuck
Report, 49; The First State Health Department, 51; The Quarantine Conventions
and the American Public Health Association, 52; The National Board of Health,
53; The United States Public Health Service, 54; The Children’s Bureau, 61; The
Department of Health, Education, and Welfare, 64; The Voluntary Health
Agencies, 65; County Health Departments, 65; Development of Professional Train-
ing, 66.

chapter 3. World health problems ....... ................... ....

Inadequacy of Data, 69; Some General Observations, 70; Extent of World Health
Problems, 72; Economic, Social, and Political Relationships of World Health Prob-
lems, 76.

chapter 4. The economic justification of public health activities ...............

Inevitability of Health Costs, 80; Economic Value of Life, 81; Savings Effected by
Public Health Measures, 90; Potential Savings by Public Health Expenditures, 93.

chapter 5. Behavioral science and pubic health ...............................

Introduction, 99; The Meaning of Health to Society, 99; Social Analysis and Com-
munity Organization for Health, 102; Society and Culture, 104; Effect of Cultural
Patterns on Health, 109; Effect of Cultural Patterns on Public Health Activities and
Programs, 112; Effect of Public Health Activities on Cultural Patterns, 122; Con-
tributions of Behavorial Scientists to Public Health, 125.

13

36
14

CONTENTS

 

chapter 6. Social pathology and public health . .. ....... ... .......... ..... ..

Introduction, 130; Definition, 133; Man and Environment, 134; Modern Develop-
ment, 140; Interrelationship of Social Problems, 143; Multiproblem Families, 147;
Points for Action, 151.

part 2 Administrative considerations in public health

chapter 7. Governmental aspects of public health ... = Co

Governmental Structure, 159; Federal and State Government, 159; Local Govern-
ment, 161; Municipal Government, 161; County Government, 164; Township Gov-
ernment, 169; Revenues and Expenditures on Each Level of Government, 170; In-
terlevel Relationships and Trends, 175; Centralization, 177; Grants-in-Aid, 180.

chapter 8. Legal considerations in public health ... Co

chapter 9. Organizational considerations in public health . .....

chapter 10. Personnel factors in public health

Definition of Law, 194; Characteristics of Law, 194; Purpose of Law, 195; Systems
of Law—Development, 196; Statutory Law, 197; Common Law, 197; Stare Decisis,
197; Equity or Chancery, 198; Administrative Law, 201; Classification of Law, 201;
Courts, 202; Sources of Public Health Law, 203; Eminent Domain, 204; Laws of
Nuisances (noscitur ad sociis), 205; Police Power, 207; Police Power, Administra-
tive Law, and Judicial Presumption, 209; Licensing, 210; Basic Public Health Laws
Necessary, 211; Writing and Passage of Laws and Regulations, 213; Liability and
Agency, 216; Extent of Use of Law in Public Health, 218; Court Procedure, 220;
Expert Witness, 222.

Introduction, 225; Purposes of Organization, 226; General Principles of Organiza-
tion, 227; Levels of Organization, Policy Making, 229; Boards, 229; Advisory Com-
mittees, 232; Administrative Level, 232; Functional Level, Delegation, 235; The
Scalar Principle, 236; Organizational Structure, 241; Staff Services, 245; Decentral-
ization, 249; Coordination and Control Measures, 251.

Introduction, 257; Personnel Management, 264; Recruitment and Employment,
Merit Systems, 264; Compensation, Tenure, and Promotion, 267; The Executive and
His Personnel, 269; Delegation, 271; Morale and Discipline, 274; Conditions of
Work, Job Appeal, 281; Overtime, 284; Leaves, 284; Inservice Training, 286; Retire-
ment, 287.

chapter 11. Fiscal management in public health

Introduction, 290; Fiscal Policy Making, 291; Financial Operations, 292; Budgeting,
292; Unit Cost Accounting, 305; Purchasing, 306; Fiscal Responsibility, 307.

chapter 12. Public relations in the public health program ........... Co

Purposes and Objectives, 311; General Considerations, 312; Obstacles to Good Public
Relations, 313; Methods in Public Relations, 314; Personal Contacts, 315; Appear-
ance, 315; Behavior, 316; Capability, 320; Private Life, 321; Telephone, 322; Corre-
spondence, 323; Employee Training, 324; Quarters and Equipment, 325; Avenues of
Publicity, 326; The Press, 326; Audio-visual Methods, 329; Community Groups, 332.

159

. 225
CONTENTS

part 3 Pattern of public health activities in the United States

chapter 13. Present organization of official public health programs ........ . ...

Introduction, 339; Local Health Organization, 339; State Health Organization, 346;
Federal Health Organization, 351; General, 351; Public Health Service, 357; Chil-
dren’s Bureau, 359; Other Federal Agencies, 361; Federal Agencies in International
Health Affairs, 362; International Health Organization, 363; Introduction, 363;
World Health Organization, 363; Pan-American Health Organization, 365; United
Nations Children’s Fund, 365; International Cooperation Administration, 366; Non-
governmental Agencies, 367; Conclusion, 368.

chapter 14. Vital statistics .......................... 0.

Introduction, 369; Sources of Public Health Statistics, 370; Administrative Uses of
Vital Statistics, 377; Organization of Statistical Activities, 392.

chapter 15. Laboratory services ...................................  .... .....

Development of Public Health Laboratories, 395; Functions of Public Health Lab-
oratories, 395; Laboratory Organization, 399.

chapter 16. Health education ........... ..

Scope of Health Education, 402; Personnel in Health Education, 405; Functions in
Health Education, 405; School and Health Department Relations, 408; Organiza-
tion of Activities for Health Education, 409.

chapter 17. Environmental health .....

Background, 411; Regional Differences, 413; Sanitation Needs, 415; Water Supplies,
417; Stream Pollution Control, 419; Waste Disposal, 421; Food and Milk Sanitation,
424; Atmospheric Pollution, 428; Housing and City Planning, 434; Vector Control,
439; Miscellaneous Sanitation Activities, 441; Personnel in Environmental Health,
441; Present Organization of Environmental Health Programs, 444.

chapter 18. Public health nursing ......... ............ ..... .. .........  ...

Introduction, Historical Development, 449; Number of Public Health Nurses, 451;
Field Nursing Agencies, 453; National Level, 453; State Level, 453; Local Level, 454;
Functions and Responsibilities, 455; Qualifications of Public Health Nurses, 458;
Administrative Relationships, 458; Relationships Within the Health Department,
459; Relationships With Other Nursing Agencies, 460; Consolidation of Nursing
Services, 460; Medical Relationships, 461; Community Nursing Council, 463; Public
Health Nursing and Social Work, 463; Administrative Aides in Public Health Nurs-
ing, 464; Supervision, 464; Standard Procedures, 464; Clerical Staff, 465.

chapter 19. Social services and public health .. .......... ....... ........ .

Introduction, 466; Background, 466; Role of the Social Worker in Public Health,
467.

chapter 20. Maternal and child health activities .

Introduction, 470; Background of Maternal and Child Health Programs, 471; State-
ment of the Problem, 472; Maternal Mortality, 472; Infant Mortality, 474; The Pre-

13

. 369
16 CONTENTS

school Child, 475; The School Child, 477; The Approach to the Problem, 478;
General, 478; The Maternal Health Program, 479; Preconceptional Aspects, 479;
Antepartum Period, 480; Intrapartum Period, 481; Postpartum Period, 482; The In-
fant and Preschool Program, 483; The School Health Program, 484; The School
Environment, 485; Health Protection and Promotion, 486; Health Instruction, 489;
Special Problems, 489; Responsibility for the School Health Program, 490; School
Health Councils, 491.

chapter 21. Public health nutrition ............. ... ........ 493

Food and the Health of Nations, 493; Recent Trends in the United States, 497;
Relation of Nutrition to Selected Health Problems, 500; The Place of Nutrition
in the Public Health Program, 506; Organization and Functions of State Nutrition
Program, 507; Legislation for Enrichment of Foods, 510.

chapter 22. Public health dentistry ....... .. 513

Magnitude of the Problem, 513; Factors Involved in Caries, 517; Recent Develop-
ments, 520; Pulbic Health Dental Programs, 524.

chapter 23. The control of communicable diseases .......... ... .. .. ......... 534

The Biological Significance of Infection, 534; General Requisites for Microorgan-
ismal Survival, 535; General Principles of the Control of Communicable Diseases,
540; Prevention of Spread, 541; Measures Aimed at the Organism, 541; Measures
Aimed at the Sources of Infection, 541; Eradication of Sources, 541; Reduction of
Communicability of Sources of Infection, 541; Treatment of Sources of Infection,
543; Measures Aimed at Transmitters of Disease, 543; Increasing the Resistance of
the Potential Host, 544; Maintenance of General Health and Nutrition, 544; Pro-
duction of Passive Immunity, 544; Production of Active Immunity, 544; Prevention
of Complications, 544; Administrative Aids in Communicable Disease Control, 545;
Legislation, 545; Reporting, 546; Isolation and Quarantine, 549; Compulsory Im-
munization, 551; Compulsory Examination, 554; Compulsory Treatment, 555; Reg-
ulation of Vehicles of Disease Transmission, 556; Material Aids in Communicable
Disease Control, 556; Consultation Service, 557; Graphic Aids, 557; Registers, 559;
Administrative Programming in Communicable Disease Control, 559.

chapter 24. Addictive diseases

Introduction, 570; Alcoholism, 571; Definition, 571; Extent of Problem, 572; Cost
of Alcoholism, 572; Effects of Alcohol, 574; Types of Alcoholics, 575; What Can
Be Done, 576; Content of Programs, 578; Prevention, 580; Drug Addiction, 581;
Definition, 581; Extent and Cost of the Problem, 582; Effects of Narcotics, 582;
Causes of Drug Addiction, 583; Epidemiology, 584; Approach to the Problem, 585.

chapter 25. Chronic diseases and adult health

Emergence of the Problem, 589; Extent of the Problem, 590; Are Chronic Diseases
Increasing? 592; Aging Versus Senescence, 594; The Solution of the Problem, 594;
Handicaps to Solution, 595; The Role of the Health Department, 596; Develop-
ment of Public Programs, 597; Content of a Chronic Disease Program, 598; Re-
search, 598; Early Diagnosis, 598; Hospitalization and Treatment, 599; Follow-up,
599; Rehabilitation, 600; Education, 600; Custodial Care, 600; The Role of In-
dustry, 601; Recent Events on the National Level, 602.
CONTENTS

chapter 26. Occupational health and private enterprise ............. ........ ..

General Considerations, 604; Background, 606; Benefits, 607; Industrial Health Pro-
grams, 609; The Role of Government, 611.

chapter 27. Accidents—a public health problem .......... .....................

Emergence of the Problem, 614; Extent of the Problem, 615; Reasons for Public
Health Concern, 617; Poison Control, 618; Sheet Plastic, 619.

chapter 28. Mental health ....... ... ......................

Introduction, 621; Extent of Problem, 622; Definition and Goal of Mental Health,
623; Mental Health Programs, 624.

chapter 29. Rehabilitation ................

Introduction, 626; Source of the Problem, 627; Magnitude of the Problem, 628;
Economics of the Problem, 630; Program Needs and Goals, 631.

chapter 30. Public health, the private physician, and medical care ..... ...

Relationship Between Public Health and Private Medicine, 635; Evolution of Mod-
ern Medicine and Society, 636; Economic Factors Influencing the Need for Medical
Care, 641; Expenditures for Medical Care, 643; Attempts to Solve the Problem,
648; Developments in the United States, 652; Voluntary Medical Care Insurance,
655; The Future, 656.

chapter 31. The voluntary health agencies ..... .. .. ... .... .. . .. ... ........  ..

Introduction, 660; Number and Type, 661; Functions and Activities, 662; Pioneer-
ing, 662; Demonstration, 662; Education, 663; Supplementation of Official Activi-
ties, 663; Guarding of Citizen Interest in Health, 663; Promotion of Health Legis-
lation, 663; Group Planning and Coordination, 664; Development of Well-Rounded
Community Health Programs, 664; Financing, 664; Desirable and Undesirable Char-
acteristics, 665; Current Trends and the Future, 666.

part 4 The future

chapter 32. The past as prologue .... ... ............ .. ............... ......

Introduction, 673; A Look at the Past, 673; Our Exploding Era, 675; The De-
mographic Revolution, 675; The Economic Revolution, 676; Social and Political
Revolution, 676; The Cultural Revolution, 678; The Scientific and Technological
Revolution, 678; Course of Action, 679; Consolidation of Past Successes, 679; Remedi-
ation of the Backlog of Disabilities, 682; Attack on New and Unsolved Old Prob-
lems, 683; Conclusion, 685.
 

   

- . oo . Sg
os Read ren aii rg ce i a a tis ca Eh tes a Le Tine So
part |

introduction

Before embarking on the main purpose of this book, it is
perhaps worth while to consider certain fundamental and back-
ground aspects of public health. It has been interesting and en-
lightening to hear the replies of fellow workers and particularly
students when they are asked why they are in or planning to enter
the public health profession. It must be admitted that the fre-
quency of vague, indeterminate replies has been most discourag-
ing. It is believed desirable, therefore, to admonish students to
question seriously the advisability of their becoming public
health workers, as, of course, they should question the pursuit
of any calling. The disadvantages should be considered as well as
the advantages which are honestly believed to exist. Each of us
has but one life to live and, for practical if not selfish reasons,
we should each exercise jealous care of what we do with it. It is
foolish indeed for any individual to cast away his one great ex-
perience in a field for which he is unsuited or unhappy, or to
work for a cause in which he does not sincerely believe. Any en-
terprise requires understanding and belief to be satisfying and
fruitful. Part of the purpose of these introductory chapters is to
indicate the high degree of satisfaction and fruitfulness to be
found in public health work.

An acquaintance with the history of society, its health prob-
lems, and its attempts to solve them contribute to greater under-
standing and satisfaction. Similarly, an awareness of the relation-
ship between man’s behavior and his state of illness or health is
important. An appreciation of the significant contribution which
improvement of the public health makes to the general economy
is also of use. These are a few of the phases of the subject which
are presented in brief form. This is done in the hope of stimulat-
ing interest in more extensive reading, analysis, and thought.

19
chapter 1

The philosophy of public health

 

 

Public Health as a Profession. It is not without significance that there have
been, and are now, many persons who devote their lives to the public health
movement and who are genuinely outstanding by any measure. Many of them
unquestionably could have gained far more personal, material benefits had they
pursued some other type of activity or enterprise. One of their predominant
characteristics is enthusiasm for their work. One might ask what it is that makes
such ardent proponents of those who give sincere thought and effort to the public
health movement. Is there a unique challenge to be found in this profession? It
is perhaps that here, more than in any other field of human endeavor, be it of a
professional, economic, or artistic nature, man is for the first time successfully
adapting the creatures and environment of nature to himself and his welfare
rather than submitting himself to them.

But, the reader may ask, can a sincere and honest person hope to accomplish
much in the face of superstition and ignorance of a large part of the people,
political interference, inadequate funds, and sometimes personnel of poor quality?
Should we not be justifiably impatient? One is reminded of a statement once made
by the famous Irish parliamentarian Edmund Burke (1729-1797) in the face of
repeated criticism: “Those who carry on great public schemes must be proof
against the most fatiguing delays, the most mortifying disappointments, the most
shocking insults, and what is worst of all, the presumptuous judgments of the
ignorant.” Sir Henry Cole once showed this statement to his good friend and
public health pioneer Edwin Chadwick and told him that he ought to have it
pinned to his sleeve as an epigraph. Yet, despite these handicaps, it is possible to
point to great and spectacular successes that have been accomplished during but
a short period of time. When Chadwick received the foregoing advice, the average
age at death in large English cities was 36 years for the gentry, 22 years for trades-
men, and 16 years for the laboring class! More than one half of the children
of the working class and one fifth of the children of the gentry died before their
fifth birthday. During the century and a quarter since then, the average life ex-
pectancy at birth has been increased in the United States to about 70 years, and
deaths before the fifth birthday have decreased about 95 per cent.

21
22 INTRODUCTION: PUBLIC HEALTH

 

The cause for patience was sometimes propounded by the late Milton J.
Rosenau in terms of the relatively few generations that have existed throughout
the recorded history of our western civilization. Briefly, his reasoning was that
only 3,500 years have passed since the time of Moses, and if the average length
of a generation were considered to be approximately thirty-five years, there have
been only about one hundred successive generations or direct steps back to the
time of Moses. To pursue this reasoning further, when it is considered that the
majority of those generations might be ignored on the basis of their failure to
contribute to the knowledge and social advancement of man, there are left per-
haps a scant dozen, most of them in the immediate past, to which we owe a real
debt.

The practice of medicine is commonly referred to as one of the oldest pro-
fessions. Yet, modern medicine, as we now know it and benefit from it, can hardly
be considered more than a century old. Still more recent in origin is the public
health movement which, though presaged by occasional sporadic earlier glim-
merings, dates back but a brief half century. We are naturally led to a considera-
tion of the significance and purpose of this public concern for health. Far from
being a thing apart, it is intimately related in its conception and development to
a broad philosophical and social revolution of many facets which has as its driving
force a growing appreciation of the innate dignity of man. It has been an accom-
paniment of social reforms which include public education, public welfare, the
rights of labor, the humane care of the mentally ill, and penal management, to
mention but a few of the more outstanding.

Definition. There have been many attempts to define public health. When
the various definitions are arranged chronologically it is interesting to observe
how they present a word picture of the evolution and progress of the field. Earlier
definitions restricted public health to sanitary measures invoked against health
hazards with which the individual was powerless to cope and which when present
in one individual could adversely affect others. Insanitation and, later, com-
municability were the criteria followed in deciding whether a problem fell within
the public health jurisdiction or sphere of interest. Following the great bacteri-
ological and immunological discoveries of the late nineteenth and early twentieth
centuries and the subsequent development of techniques for their application,
the concept of prevention of disease in the individual was added. Public health
then came to be regarded as an integration of the sanitary sciences and the medi-
cal sciences. As far back as 1847 Solomon Neumann in Berlin had propounded
that “medical science is intrinsically and essentially a social science, and as long
as this is not recognized in practice we shall not be able to enjoy its benefits and
shall have to be satisfied with an empty shell and a sham.” Despite this, it is only
realtively recently that medicine and, indeed, public health have become widely
recognized as social sciences. Numerous current writers still find it necessary to
emphasize this relationship.?2 The enigma of the delay in acceptance of the rela-
tionship has been particularly well analyzed by Rosen? in the following manner:

In Great Britain, as in the United States, interest in the development of a concept
of social medicine is a recent phenomenon. The social relations of health and disease
PHILOSOPHY 23

had been recognized by physicians and laymen, but owing to a number of causes no
concerted effort had been made to organize such knowledge on a coherent basis and
thus make it available for practical application. In part this was due to the dominant
role that laboratory sciences and techniques had come to play in medicine, in part to
the concurrent rise and expansion of medical specialism, and in part to the limited
view of public health that had been current in both countries. Furthermore, the bias
created by these factors was reinforced by powerful social ideologies still rooted in the
nineteenth century version of natural law.

During the past few decades, however, influences within medicine itself and in
society as a whole have acted to overcome these factors. The development of such
branches of medicine as endocrinology, nutrition and psychiatry tended to break down
the compartmental thinking of the physician, and to bring back into mental focus the
sick person, the patient. Moreover, within society as a whole, the ideology of the com-
placent individualism was wearing thin, and the consciousness of social problems, includ-
ing those involving health, became exceedingly acute.*

One of the most forceful recent advocates of this point of view has been
Winslow* who crystallized his thought into what has become perhaps the best-
known and most widely accepted definition of public health and of its relation-

ship to other fields. For analytic purposes it may be presented in the following
manner:

Public Health is the Science and Art of (I) preventing disease, (2) prolongirg life,
and (3) promoting health and efficiency through organized community effort for

(a) the sanitation of the environment,

(b) the control of communicable infections,

(c) the education of the individual in personal hygiene,

(d) the organization of medical and nursing services for the early diagnosis and
preventive treatment of disease, and

(e) the development of the social machinery to insure everyone a standard of living
adequate for the maintenance of health,

so organizing these benefits as to enable every citizen to realize his birthright of health
and longevity.t

This definition certainly cannot be criticized for lack of comprehensiveness.
It includes almost everything in the fields of social service and reform. In addi-
tion, it provides a rather complete summary not only of public health and its
administration, but also of the sequence of its history and development as well
as present-day and probable future trends.

I have tried to stress the multifaceted relationships of health and of public
health in the following terms.

Health is a state of total effective physiologic and psychologic functioning; it has both a
relative and an absolute meaning, varying through time and space, in both the individual and
in the group; it is the result of the combination of many forces, intrinsic and extrinsic, inherited
and contrived, individual and collective, private and public, medical, environmental, and social;
and it is conditioned by culture and economy, and by law and government.

*Rosen, G.: Approaches to a Concept of Social Medicine, Milbank Mem. Fund Quart.
26:7, Jan. 1948.

Winslow, C.-E.A.: The Untilled Field of Public Health, Mod. Med. 2:183, March 1920.
24 INTRODUCTION: PUBLIC HEALTH

 

Accordingly:

Public health is dedicated to the common attainment of the highest level of physical, mental,
and social well-being and longevity consistent with available knowledge and resources at a given
time and place. It holds this goal as its contribution to the most effective total development and
life of the individual and his society.

There are two more recent definitions to which attention should be called.
The first is the official statement of the House of Delegates of the American
Medical Association, formulated in 1948. It defines public health as “the art anc
science of maintaining, protecting and improving the health of the people
through organized community efforts. It includes those arrangements whereby
the community provides medical services for special groups of persons and is
concerned with prevention or control of disease, with persons requiring hos-
pitalization to protect the community and with the medically indigent.” The
American Medical Association has always given strong support to public health
programs and activities. The statement above, however, is of particular interest
and significance in view of recent social and legislative trends.

The other definition is the one adopted by the World Health Organization
and included in its constitution: “Health is a state of complete physical, mental
and social well being and not merely the absence of disease or infirmity.” In a
sense, this may be considered not so much a definition as a statement of aims and
principles.

In summary, therefore, there is evident, from the definitions themselves, a
gradual extension of the horizons of public health. In conformity with the ad-
vances of medical and scientific knowledge and keeping pace with social and
political progress, public health work has expanded from its humble concern
with gross environmental sanitation to add in sequence, sanitary engineering,
preventive physical medical science, social science, preventive mental medical
science, and more recently the positive or promotive and behavioral aspects of
personal medicine.

An appropriate note of caution has been voiced by Mountin® with regard
to the question of definition. He pointed out:

The progressive nature of public health makes any restricted definition of the func-

tions and responsibilities of health departments difficult. More than that—there is a

real danger in attempting to narrow down a moving and growing thing. To tie public

health to the concepts that answered our needs 50 years ago, or even a decade ago, can
only hamstring our contribution to society in the future.*

Therapeutic Medicine, Preventive Medicine, and Public Health. A question
sometimes arises with regard to the distinctions among medicine, preventive
medicine, and public health. To a considerable degree, the private practice of
medicine customarily deals with the repair of damage already done: the realign-
ment of a broken limb, the healing or removal of a diseased organ, or the readjust-
ment of an unsettled mind. By virtue of the nature of the problems involved,
its concern is necessarily highly personalized and individualized. Preventive medi-

*Mountin, J. W.: The Health Department’s Dilemma, Pub. Health Rep. 67:223, March 1952.
PHILOSOPHY | 25

cine goes a step further but in itself still represents a negative ideal with disease
to be prevented in the individual as its primary goal. In this sense, preventive
medicine has been outlined to consist of three phases or areas of activity®:
1. The prevention by biological means of certain preventable diseases such as acute com-
municable and deficiency diseases.
2. The prevention of some of the consequences of preventable or curable chronic diseases,
such as syphilis, tuberculosis, cancer and diabetes.
3. The prevention or retardation of some of the consequences of nonpreventable and non-
curable diseases, such as many cardiac ailments.

It is becoming increasingly obvious that as the number of possible applica-
tions of preventive care to the treatment of incipient or established diseases are
multiplied, preventive medicine becomes all but indistinguishable {rom good
clinical medicine in general. Among the results have been the increased teaching
of “comprehensive medicine” and the growing tendency of private physicians to
incorporate preventive medicine in their private practices.

In public health we must go still further and develop constructive and pro-
motive medicine in which the center of interest is still the individual but now
as a social or community integer, a member of a group. We must not be content
with the mere preservation of his health but must strive for the development of
its maximum potentialities. Referring again to Professor Winslow's definition,
it is of interest to note how the emphasis in public health has changed from the
physical environment or sanitation to preventive medicine, and more recently
back to the individual and his environment, but now in terms of his relationship
with his complex social environment. With this change in emphasis has come
a more mature realization both on the part of organized medicine and of public
health workers that each is an adjunct to and a true partner of the other.
Murphy,” in attempting to answer whether health is a public or a private mat-
ter, indicates that “it is neither and it is both.” In considering the many and
complex health and medical problems that challenge us, he argues that “their
effective resolution will be hastened as we blend public and private effort on
the basis of logic and need.” Appropriately, he concludes that, “There may be
times when we can afford the luxury of foolish, unproductive infighting, but this
is not one of them.” Vaughan,® while extolling the striking success of various
types of public health programs nevertheless cautioned:

Notwithstanding these reasonable and warranted activities, supported in the main
by tax funds cheerfully and eagerly appropriated by our elected officials, public health
will never rise higher than the level of health established for the individual. The health
of the many is but a summation of personal health. A nation can never be healthier
than its citizens, and it is upon the welfare of the latter that our effort must be con-
centrated.*

In the final analysis, the family physician should be the family health officer,
acting on the individualized level in all three areas of therapeutic, preventive,
and promotive medicine. This shift also has brought with it a re-evaluation of

*Vaughan, H. F.: The Way of Public Health, Tr. & Stud., Coll. Physicians, Philadelphia
9:86, June 1941.
26 INTRODUCTION: PUBLIC HEALTH

 

health which until recently has been pursued by many, including not a few
public health workers, as an ultimate goal in itself. Increasingly it is being
realized that health in itself has real value only as it promotes efficiency and hap-
piness. After all, it is the quality of life that counts and not the quantity. Health
in and of itsell is valueless. The true value of health depends on the activities en-
gaged in by virtue ol it.

Health and Government. There is occasional objection to health promotion
as a governmental responsibility and activity. It should be realized that social
philosophy was not always such as to lead to the acceptance of this type of
activity as appropriate for a government. Among earlier civilizations, the Roman
Empire was notable in its concern for the protection and enhancement of the
well-being of its citizens in health as well as in other matters. During most of the
period since, however, the prevailing attitude has been to regard any such prop-
osition as constituting either unnecessary and dangerous pampering of the masses
or, later on, as unwarranted and improper interference on the part of the govern-
ment in the private rights of the individual. Also, as Shryock? reasons, medicine
had little tangible impact upon society prior to 1875. Since then, however, medi-
cine and related fields, either by their presence or absence, have had increasingly
significant effects on the problems and very nature of society. This, no govern-
ment can afford to ignore.

In our society there are numerous reasons for governmental action in public
health. Many public health activities can be carried out only by group or com-
munity action. This is particularly true in urban areas which are so characteristic
ol our increasingly mechanized, industrial societies. A few of the many examples
that may be mentioned are sanitary water systems, sewage disposal [acilities, and
communicable disease hospitals. Furthermore, many public health activities must
have an authoritative and legal basis ol a nature available only to governmental
agencies. Isolation and quarantine regulations and many phases of an industrial
hygiene program offer examples in this category. Still other activities, of which
the collection of vital statistics is an example, can be carried on only through
well-organized and well-staffed, stabilized and continuing governmental agencies.

Scope of Public Health. What then are the justifiable fields of activities in
public health? In view of the foregoing discussion of definition, they may be
considered potentially to fall into four categories:

1. Those fields in which activity must be on a community basis:

(a) The supervision ol the food, water, and milk supplies of a com-
munity
(b) Insect control
(c) Prevention of atmospheric and stream pollution
2. Those fields dealing with preventable illnesses, disabilities, or premature
deaths:
(a) Communicable diseases, including infestations
(b) Dietary deficiencies
(c) Effects of drugs and narcotics habitually used
(d) Allergic manifestations and their community sources
PHILOSOPHY 27

 

(e) Certain mental, personality, and behavior disorders
(f) Occupational health
(g) Cancer (primarily avoidance of progression; prevention to some de-
gree)
(h) Cardiovascular diseases
(i) Conditions associated with the risks of maternity, growth, and de-
velopment
(j) Certain hereditary conditions
(k) Home, community, and industrial accidents
(I) Rehabilitation of victims of accidents and disease
(m) Dental caries
3. Those fields of medicine which need organized official leadership:
(a) Facilitation of pregraduate and postgraduate education
(b) Promotion of equitable distribution of personnel and facilities
4. Research—no health department can ignore scientific investigation and
evaluation and remain progressive

Obviously few if any public health agencies will find it possible or necessary
to engage in all of these activities. In every case it is desirable to determine and
adapt the program of the community to its needs and capabilities. Of great as-
sistance in the definition and analysis of these is the Evaluation Schedule for
Local Health Work of the American Public Health Association.

Public Health and Population Increase. An increasingly common criticism
leveled at public health workers is that they are multiplying the problems of
the world by causing widespread overpopulation through their dramatic saving
of lives. Public health workers, sociologists, political scientists, and others have
long been aware of a relationship between public health activities and increases
in the populations of nations and of the world.!” Awareness has been sharpened
more and more by recent world events, especially by the sustained postwar rise
in birth rates and by the growth and success of international technical assistance
programs in health and sanitation. This awareness has reached the point of acute
concern which is voiced in part by more and more vocal questioning, indeed, even
condemnation of the activities of the dangerous doctor, the heedless hygienist,
and the cynical sanitarian.!11213.14 In view of this, it may be of value to consider
some of the facts, some of the problems and interrelationships, and some of the
pros and cons of the question.

On the basis of anthropologic and archaeologic researches, it would appear
that man has existed as a distinct species for at least a hall million years. It is
logical to assume that throughout this long period, and in fact during any par-
ticular interval of it, he multiplied to the extent to which his way of life and
his environment allowed. The best available evidence indicates a gradual increase
to an asymptote of about 450 million, a level which still prevailed by the mid-
seventeenth century.'® During the comparatively brief period of 300 years since,
there has occurred what is probably the most significant and far-reaching bio-
logical phenomenon in the history of our planet. Man's numbers multiplied
fivefold to about 215 billion. The current rate of increase is about 100,000 per
28 INTRODUCTION: PUBLIC HEALTH

day, or about 3614 million per year. This is equivalent to adding a Madison, Wis-
consin, each day or a new nation larger than Mexico, Spain, or Korea, each
year to the population of the world.

If population growth data are studied, it soon becomes apparent that forces
in addition to public health have been at work. This is indicated also by the
fact that the inception of the recent marked upswing in the world’s population
actually antedates the modern public health movement. Beginning in about
1650, a significant quickening in the rate of population increase can be ob-
served. It is difficult to determine the relative importance of the various factors
that must have been involved in the reduction of mortality and in the resulting
increase in population. It is evident, however, that the changes during the first
part of this period were not due to public health measures because few, if any,
existed. Rather, it would appear that the determining roles during that period
were played by changing social organization, a rising standard of living, im-
proved work conditions, and the appearance of certain social reforms.

In Europe, a significant excess of births over deaths was already well estab-
lished by the eighteenth century, producing a steady population increase despite
fluctuations due to frequent epidemics and occasional famine. Then, in the mid-
nineteenth century, there began a marked decrease in mortality with a consequent
upsurge in the rate of population increase which reached a peak in the early
twentieth century, despite the large number of emigrees. This upsurge may be
attributed to the development of new means of transportation, which facilitated
a wider distribution of goods and people; to technological progress manifest by
the Industrial Revolution which ensured a means of living for greater numbers
of people; and particularly more recently to the widespread application of newer
knowledge concerning the causation and prevention of disease en masse. Sub-
sequently, despite continued decrease in death rates, the rate of population
growth in Europe slowed down because birth rates began to fall rapidly.

The picture of population growth in the United States differed from that
of Europe in three respects. First, during the early nineteenth century, the rate
of natural increase was much higher than in Europe, probably because of the
young average age of those who came to America. Then, throughout the rest
of the century, the rate of natural increase underwent a rapid decline due to
rapidly dropping birth rates. Thus in the United States, births per thousand
women aged from 15 to 44 years dropped from 276 at the beginning to 208 at the
mid-point and to 130 at the end of the nineteenth century. Finally, despite this
marked slowing in natural increase, the flood of immigrants prevented a drop
in the rate of total population growth.

We are fortunate in having available a recently published review of studies
on the relationship between population changes and economic and social con-
ditions, The Determinants and Consequences of Population Trends,'® issued by
the Population Division of the United Nations Department of Social Affairs.
This extensive review indicates not only that many basic aspects of the problem
have been scarcely considered, but also that much disagreement exists over the
interpretation of a large part of what has been studied. One thing appears
obvious: no single factor, such as public health activity, can be considered alone
PHILOSOPHY 29

in relation to population change, as if it existed in a social and historical
vacuum. Indeed, an exceedingly complex series of interrelationships is involved
in the dynamics of population growth, stability, or retrogression. An elementary
list of factors to consider includes areal limitations; climate; the present size,
spatial distribution, and age structure of the population; the present and po-
tential resources for food; availability and use of efficient agricultural imple-
ments, machinery, and techniques; the quality of housing; policies and practices
with regard to public health and education; the existence, availability, and
utilization of natural resources and of sources of energy; means of verbal and
physical communication with special emphasis on farm-to-market roads; trends
toward urbanization and industrialization; the tax and financial structure, espe-
cially the availability of short-term and long-term loans at reasonable rates of
interest; policies relating to the composition, full employment and adequate
compensation of the labor force; and a multitude of cultural factors.

Space does not permit adequate consideration of these factors. A few ex-
amples, however, may illustrate the manner and extent to which some of them
may increase a population. It is well known that the addition of new sources or
types of nutrient will result in increased bacterial growth or increased size of
a herd. That this applies also to human beings is not surprising. Thus, in the
eighteenth century, the sweet potato was introduced into China as a cheap,
easily grown, rich source of carbohydrate in place of or to supplement grain.
As far as is known, no other significant factor was changed. Certainly no pub-
lic health or sanitary activities were pursued. Within fifty years, the popula-
tion increased from an estimated 60 million to 160 million. It is interesting to
note that the inception of the population spurt in Europe dates from about the
time of the introduction of the white potato from the Andean region of South
America.

It is also accepted that the larger the area effectively available to a species,
the more it tends to move and increase. Thus an inoculum multiples and spreads
throughout a container of broth. This has been the experience of our species,
too, most noticeably when it discovered or developed new lands. It was obviously
more than chance that caused the beginning population upswing in the world
to coincide with the great period of discovery, settlement, and exploitation, and
with more widely available and more rapid means of transportation.

Life, in the final analysis, depends upon energy. Some members of the de-
terminant school of sociology have analyzed the history of man from this view-
point and have found that each time a new source of power or energy has been
discovered, there has occurred a period of unrest and strife resulting in a smaller
number of units of people—clans, tribes, nations, or alliances. There then has
followed an increase in production and a marked upsurge in population.'?

Unquestionably, public health measures have contributed to the population
increase of the past century. It has done so in four ways: (1) by improving the
chances of fruitful conception; (2) by greatly increasing the chances of survival
among infants and young children; (3) by preventing the premature deaths of
many young adults who represent the most fertile component of our population
and the group with the longest period of future fecundity; and (4) by greatly
30 INTRODUCTION: PUBLIC HEALTH

reducing the number of marriages dissolved by the death of one partner. This
has allowed a longer period of effective married life.

Among the social and economic factors related to the dynamics of popu-
lation, consideration must be given to the degree of urbanization and industrial-
ization. These are two of the most striking phenomena of our time and, of course,
are closely linked. They have a curious two-phased effect upon population growth
—initial encouragement followed by secondary retardation. The sequence of
events is complex but basically appears to be about as [ollows. Industry, concen-
trated in centers of population and offering a means to obtain cash income,
attracts especially the more vigorous and adventurous young adults. At first they
tend to follow the old established essentially rural customs of their kind—marry
young and aspire to large families. Sexual union among them is more fruitful
because of their youth and because of the long average remaining period of
fecundity. To this extent, industrialization and urbanization result in a sub-
stantial initial increase in the rate of population growth.

However, with improved education, growing sophistication, stabilization of
the labor force, the wish for an improved standard of living, social rivalries, and
competition for their time, energy, and income, there occurs an emphasis on
rationality and independence of tradition, with a breaking away from the old
conservative cultural ties. Marriages are delayed and families are kept small for
the sake ol more education, increased income, or improved social position. Chil-
dren come to be considered less an economic asset and more an economic burden.
Family life becomes less cohesive because individuals participate in many other
institutions and have many contacts outside the home. Since life becomes in-
creasingly complex, sexual intercourse becomes less frequent. Hence, industrial-
ization and urbanization result eventually in a decreased rate of reproduction
and population growth. This has been found to hold true in Eastern as well as
in Western civilizations.!$

Reference has been made to the lesser developed areas. Understandably
there is concern over the rapidly declining death rates occurring in these areas
in the face of high birth rates. Certain considerations should be borne in mind,
however. There are a number of reasons for their rapid mortality decreases at
this time. They have the benefit of technical knowledge which required a long
period of experimentation and trial and error in the presently advanced areas.
The practical application of this knowledge is now possible for them at low per
capita cost because of the development of relatively simple and inexpensive tech-
niques and because of the present achievement of international cooperation and
assistance on the basis of mutual long-term benefit. Another important reason
is the great historical striving for independence and national identity throughout
the world with stress on “catching up” as quickly as possible in education, health,
and technical, industrial and economic progress. Because so much needed to be
done, achievements have been rapid and dramatic. It would be unrealistic how-
ever to expect improvements in health or other fields to continue indefinitely at
the same rate. In the field of health, preventable communicable diseases have
accounted for a large part of the illness and death, and it is in this area that
practically all the gains have occurred. Other gains will be more time consuming

)
PHILOSOPHY J!

and more difficult to achieve. This is borne out by the slowing in the rate of
mortality decline in some countries, such as Ceylon, British Guiana, Japan, and
others.1?

After studying many aspects of this question with particular reference to its
relationship to population, the Woytinskys®® concluded:

The growth of world population in the past three hundred years obviously does
not express the secular trend and cannot be projected indefinitely into the future.
Rather, it has been a unique, unprecedented and unrepeatable phenomenon of limited
duration. It had a beginning in the not too distant past, and it will have an end,
perhaps, in the not too remote future. The slowing down and levelling off of growth
in world population seems unavoidable. The question is only when will growth stop
and at what level .*

The possibility of a reversal must always be kept in mind. Despite the marked
improvements that have occurred in the mortality picture, if concurrent progress
in fields other than health does not occur, a slump in the curve of health progress
may be anticipated. Thus Stolnitz,?t who refers to social and economic factors
“more as permissive elements than as precipitating factors,” states: “It is obvious
that the impact of medical skills on today’s underdeveloped areas can be enor-
mous. Whether the permissive elements will also be adequate is perhaps the
foremost problem confronting half the world’s population.” It should not be
overlooked that some of the same social and economic factors that affect mortality
also affect fertility. Their relationship to mortality is not necessarily the same as
their relationship to other factors that contribute to population change. Thus
factors that contribute to the decline in mortality may not necessarily raise the
rate of population growth, since they may also contribute to a decline in the
birth rate. In this regard we have seen public health activities contribute to
improved school attendance and cerebration, to industrial development and
urbanization, to a higher general income level and the improvement in the
standard of living, to an understanding of man’s physiological and reproductive
functioning, and to a better appreciation of his place in society. Beyond this, it
is reasonable to expect that some of the same forces which have been speeding
the decline in mortality will also effect a speeding of a lowered birth rate, hence
a deceleration of population growth. In other words, it is possible that the
so-called dangerous time lag between lowered mortality and lowered fertility may
be telescoped.

Of necessity, much has been left unsaid. No mention has been made of the
great possibilities of more efficient land use, development of new agricultural
techniques, improvement of plant and animal strains, application of nuclear
energy to power development, irrigation, water distillation, food preservation,
more adequate utilization of solar energy, reduction of food wastage by insects and
vermin, chemical soil treatment, hydroponics, the release of land for food use as
a result of inexpensive artificial fibers and plastics, the food value of algae, the
possibilities of sea farming and sea breeding, the possibility of more artificially

*Woytinsky, W. S., and Woytinsky, E. S.: World Population and Production; Trends and
Outlook, New York, 1953, The Twentieth Century Fund, p. 261.
32 INTRODUCTION: PUBLIC HEALTH
manufactured foods, the need for less energy food as a result of increasing mech-
anization on farms as well as in industry. The technological possibilities of the
future seem vast indeed and give additional cause for reasonable optimism and
hope.

What may be concluded? First, that public health effort has saved lives and
has contributed to population increase; second, that public health is only one of
many factors involved in social improvement and population increase; third,
that public health measures tend to be more rapidly successful than activities in
other fields; fourth, that the interrelationships of these fields and ours in terms
of the effects are relatively little understood; fifth, that technical assistance to
underdeveloped communities or areas should be multidisciplinary and never
limited exclusively to public health or any other single field of endeavor; and
sixth, that in carrying out public health programs anywhere, rather than to at-
tempt the impossible of bringing about public health changes entirely within
existing cultural patterns, as if they were static, we should encourage changes
which are consistent with the realities of desirable dynamic, social, and public
health improvement.

Public Health Versus Natural Selection. A final question that calls for an
answer deals with the objection that public health is dangerous on the grounds
that it promotes the survival of the unfit. Advocates of this viewpoint claim that
public health activities interfere with or negate the forces of natural biological
selection which in a coldly impersonal manner supposedly weeds out “the lame,
the halt, and the blind” as well as protoplasm of poor quality. Thus referring to
public health as unnatural, Aldous Huxley? calls it the very essence of the myth
of progress. In general, the arguments he and others propound are that public
health and preventive medical measures serve to protect and promote the unfit
at the mental, moral, physical, and financial expense of the fit, and particularly
jeopardize future generations by interfering with the process of natural selection.
One British writer?® concludes that while modern public health measures will
continue to make life comfortable during the few remaining generations of our
western civilization, a few good old-fashioned epidemics such as the Black Death
might be desirable because they tend to wipe out many mental and physical
weaklings who at present are coddled through life. Other examples among many
that might be cited are those ol a sociologist? on the one hand and a physician?
on the other who point to the public health efforts which protect the unfit while
more desirable human specimens are sent off to war.

To answer these arguments in the most selfish manner possible, one may
ask how the “fit” (whoever they may be) can survive if disease is allowed to run
rampant among the “unfit.” It is true that uncontrolled disease tends to eliminate
those who appear to be inferior from certain viewpoints. Those who are chron-
ically tired, hungry, and cold are often more apt to succumb. In the majority of
instances, however, uncontrolled disease strikes blindly, producing malaria, tu-
berculosis, or other diseases in the most vigorous specimens of humanity, if they
are unprotected, as well as in the so-called inferior. Disease and death have often
entered palaces and mansions through the back door. A normal, or for that
PHILOSOPHY 33

matter an unusual, infant may be disastrously affected by the presence of disease
in the group. Generally speaking, the use of the terms unfit, undesirable, or in-
ferior represents psychological, socially produced, blind spots.

The risk involved in uncontrolled disease is strikingly exemplified by the
entries on the church register at Stratford-on-Avon. At that shrine of civilization,
enclosed in a carefully guarded glass case, is a church register opened at the page
on which is entered the statement of birth of William Shakespeare. Several lines
above may be seen the entry “juli 11, 1564, Oliverus Gume—hic incipit pestis.”
All together, during the year 1564, that little village suffered 242 deaths from
plague. This probably represented from one third to one half of the population
at that time. During the upswing of the epidemic there was born a helpless in-
fant who easily could have been one of those affected but who, by chance alone,
was spared to give us subsequently some of the most choice literary treasures of
our civilization. If he had become infected and had died, would that infant
have been considered unfit or inferior?

The question arises, therefore—just who are the fit and the unfit? Close obser-
vation indicates that the definition varies by time and place. Steinmetz was a
congenital cripple, Toulouse Lautrec was afflicted with hereditary osteochondritis
tragilitas, Mozart and Chopin died at early ages from tuberculosis,* and Schu-
mann from typhoid fever. Would anyone dare label these and thousands like
them unfit? Americans can least afford to point the finger. A majority of the
citizens of this great nation are descendants of persons who by one standard or
another have been considered undesirable or unfit. The reasons have varied—
religious, national, economic, social, political, and cultural-whatever reason has
been most expeditious for those on top at the moment. Recognition of this is
given by the statement enshrined in the Statue of Liberty:

Give me your tired, your poor,

Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these the homeless, tempest-tossed to me,
I lift my lamp beside the golden door.

While certain individuals or even groups admittedly may suffer from physical
or other handicaps, it is false reasoning to suppose that they are necessarily stig-
matized for all time. No public health worker would deny that his field of pro-
fessional choice now makes it possible for many to live who otherwise would have
died. These beneficiaries have lived, and, while much yet needs to be done, they
have prospered. Each new Olympic Tournament sees the establishment of new
records of physical prowess. The descendants of immigrants are taller and of
greater physical stamina than were their forebears or are their counterparts in
the old country. One cannot help but ponder the potential magnitude of the
benefits that would accrue to the human race from a truly vigorous application of

*For a long list of notable persons who were tuberculous, see Tuberculosis and Genius by
Moorman.*
34 INTRODUCTION: PUBLIC HEALTH

 

just the public health knowledge we have at the present time. Rosenau had this
in mind when he wrote concerning preventive medicine and public health:

It dreams of a time when there shall be enough for all, and every man shall bear his
share of labor in accordance with his ability, and every man shall possess sufficient for
the needs of his body and the demands of health. These things he shall have as a matter
of justice and not of charity. It dreams of a time when there shall be no unnecessary
suffering and no premature deaths; when the welfare of the people shall be our highest
concern; when humanity and mercy shall replace greed and selfishness; and it dreams
that all these things will be accomplished through the wisdom of man. It dreams of these
things, not with the hope that we, individually, may participate in them, but with the
joy that we may aid in their coming to those who shall live after us. When young men
have vision the dreams of old men come true.

Some may easily dismiss all this as representing starry-eyed, impractical ideal-
ism. But to achieve the greatest success and satisfaction in a social field, such as
that represented by public health, demands a full share of idealism. This must,
by elimination, be the answer, since it can be said fairly that public health
officials through their efforts have rarely aimed at the improvement of their
own personal fortunes or the creation of new positions in which they have a
private, personal interest. But, after all, idealism and practicality are not neces-
sarily immiscible as are oil and water. In fact, their admixture is sorely needed
now more than ever before, in this newborn atomic age. The prefacing statement
of A. Lawrence Lowell?” in his book entitled Conflicts of Principle is as timely
and as pertinent now and to our present public health purpose as when he
wrote it.

People often call some men idealists and others practical folks as if mankind were
by natural inclination so divided into these two groups that an idealist cannot be prac-
tical or a man of affairs have a lofty purpose whereas in fact no man approaches per-
fection who does not combine both qualities in a high degree. Without either he is
defective in spirit and unscientific in method; the idealist because he does not strive
to make his theory accurate, that is consonant with the facts; the so-called practical
man if he acts upon the impulse of the occasion without the guidance of an enduring
principle of conduct. Hence both lack true wisdom, the idealist more culpably for he
should be diligent in thought and seek all the light he can obtain. It is useful to repeat
that many men have light enough to be visionary, but only he who clearly sees can
behold a vision. *

REFERENCES

I. Bock, W. E., and Boek, J. K.: Society and Health, New York, 1956, G. P. Putnam’s Sons.

2. Terris, M.: Social Medicine as an Academic Discipline, J. M. Ed. 33:565, Aug. 1958.

3. Rosen, G.: Approaches to a Concept of Social Medicine, Milbank Mem. Fund Quart. 26:7,
Jan. 1948.

4. Winslow, C.-E. A.: The Untilled Field of Public Health, Mod. Med. 2:183, March 1920.

5. Mountin, J. W.: The Health Department’s Dilemma, Pub. Health Rep. 67:223, March 1952.

6. Smith, G., and Evans, L. J.: Preventive Medicine, Attempt at Definition, Science 100:39,
July 21, 1944.

7. Murphy, F. D.: Health—Public or Private? Am. J. Pub. Health, 46:15, Jan. 1956.

*Lowell, A. Lawrence: Conflicts of Principle, Cambridge, 1932, Harvard University Press,
Pp. V-vi.
PHILOSOPHY 35

 

11.
12.
13.
14.
15.

16.

17.
18.

20.

21.

22.

23.

24.

26.
27.

Vaughan, H. F.: The Way of Public Health, Tr. & Stud., Coll. Physicians, Philadelphia
9:86, June 1941.

Shryock, R. H.: The Interplay of Social and Internal Factors in the History of Modern
Medicine, Scient. Month. 76:221, April 1953.

. Hanlon, J. J.: The Public Health Worker and the Population Question, Am. J. Pub. Health

46:1397, Nov. 1956.

Vogt, W.: Road to Survival, New York, 1948, William Sloane Associates, Inc.

Osborn, F.: The Limits of the Earth, Boston, 1953, Little, Brown & Co.

Cook, R. C.: In Russell, P. F.: Public Health Practice and Population Pressure in the
Tropics, Am. J. Trop. Med. 1:177, March 1952.

Rolph, C. H.: The Human Sum, New York, 1957, The Macmillan Co.

Pearl, R.: The Natural History of Population, London, 1939, Oxford University Press.

United Nations Department of Social Affairs: The Determinants and Consequences of
Population Trends, New York, 1953, United Nations.

White, L.: Man's Control Over Civilization, Scient. Month. 66:235, March 1948.

Tauber, I. B.: Population and Labor Force in the Industrialization of Japan, 1850-1950;
Economic Growth, in Brazil, India, and Japan, Princeton, 1955, Princeton University
Press.

. Bourgeois-Pichat, J., and Pan, Chia-lin: Trends and Determinants of Mortality in Under-

developed Areas, New York, 1956, Milbank Memorial Fund.

Woytinsky, W. S., and Woytinsky, E. S.: World Population and Production; Trends and
Outlook, New York, 1953, The Twentieth Century Fund.

Stolnitz, J.: Comparison Between Some Recent Mortality Trends in Underdeveloped Areas
and Historical Trends in the West. In Trends and Differentials in Mortality, New York,
1956, Milbank Memorial Fund.

Huxley, Aldous: Brave New World, Life 25:63, Sept. 20, 1948.

Bowes, G. K.: Epidemic Disease; Past, Present, and Future, J. Roy. San. Inst. 66:174, July
1946.

Gillette, J. M.: Perspective of Public Health in the United States, Scient. Month. 53:235,
Sept. 1941.

. Johnson, A. S.: Medicine's Responsibility in the Propagation of Poor Protoplasm, New Eng-

land J. Med. 238:715, May 27, 1948.
Moorman, L. J.: Tuberculosis and Genius, Chicago, 1940, University of Chicago Press.
Lowell, A. Lawrence: Conflicts of Principles, Cambridge, 1932, Harvard University Press.
chapter 2

The background and development
of public health in the United States”

Reasons for Review. Although the primary purpose of this book is to con-
sider the various administrative factors involved in the practice of public health,
it is believed to be none the less desirable to devote some attention to historical
background. This is done not merely to pay intellectual tribute to the memory
of the great contributors to the profession, although this in itself would be com-
mendable, but also for a number of very practical reasons. Along the line of
paying tribute, Osler? once claimed it to be a sign of a dry age when the great
men of the past are held in light esteem. One of the practical reasons for his-
torical review is that we might thereby grasp the social signifiance of the public
health movement. As has been noted, this accounts largely for the ardent en-
thusiasm of many of those who give sincere thought and effort to the movement.

Another reason for considering the background of public health is that we
may achieve a better understanding of where we are and in which direction we
should be going, if we occasionally glance backward to see whence and how we
came. Many circumstances and events that have occurred in the past help to
explain some of the present-day administrative problems which might otherwise
be puzzling. As with all other constructive social movements, numerous difficul-
ties have been encountered in the field of public health; superstition, public
apathy, political interference, inadequate funds and, to often, personnel of poor
quality, are but a few that have been mentioned. One sometimes hears short-
sighted, impatient and intolerant persons, even within the public health pro-
fession itself, condemn much of past and present public health practice in terms
of these factors or because progress appears to be slow. The suggestion is made
that these persons should learn something of the backgrounds of our social struc-
ture and of the public health movement so that they may better understand the
relative importance of these factors and the reasons why they may yet exert some

*For two extensive and scholarly presentations of this subject see 4 History of Public
Health by Rosen and The History of American Epidemiology by Top?

36
BACKGROUND AND DEVELOPMENT 37

 

influence. This is not meant to condone or encourage an attitude of complacency
or comfortable self-satisfaction, but is intended merely to point out that sound
planning for the future is best accomplished by an honest evaluation and under-
standing of the past and present.

The Pre-Christian Period. Little is known concerning the prehistoric origins
of either personal or community hygiene. Some hints may be gleaned, however,
from a study of the customs and tribal rules of contemporary groups low in the
scale of civilization. With few exceptions, notably the Eskimos, primitive tribes
have a certain amount of group and community hygienic sense. Rules against
the fouling of family or tribal quarters are almost universal. Many tribes of
American Indians, for example, have a long-standing custom of using the down-
stream side of the camp site for excretory purposes. Burial of excreta is not un-
common. However, this practice often is based more on superstition than on
sanitary intent. Many groups have elaborate provisions for the burial or burning
of the dead. Practically all primitive people recognize the existence of disease and
engage in forms of voodoo, quarantine, tribal dancing, and the use of smoke and
noise to drive away the evil spirits of disease. With this in mind it is difficult to
resist calling attention to the burning of pitch and the firing of cannon as means
of combating yellow fever in American communities as recently as the end of
the nineteenth century.

Passing to civilizations concerning which archaeological or other records
exist, it is found that the Minoans, about 5000 B.c., and the Cretans, 3000 to
1800 B.c., had advanced to the point of constructing drainage systems, water
closets, and water flushing systems. The Egyptians of about 1000 B.c., as de-
scribed by Herodotus, were the healthiest of all civilized nations. They had
a marked sense of personal cleanliness, possessed numerous pharmaceutical prep-
arations and constructed earth closets and public drainage pipes. The Jews ex-
tended Egyptian hygienic thought and behavior by including in the Mosaic law
what is considered to have been the first formal hygienic code. It dealt with a wide
variety of personal and community responsibilities including cleanliness of the
body, protection against the spread of contagious diseases, isolation of lepers,
disinfection of dwellings following illness, sanitation of camps sites, disposal of
excreta and refuse, protection of the water and food supplies, and the hygiene of
maternity.

The Grecian civilization is of particular interest for two reasons. It was here
that personal hygiene was developed to a degree never previously or subsequently
approached. Much concern was given to personal cleanliness, exercise, and die-
tetics rather than to matters of environmental sanitation. Another point of in-
terest is that®n contrast with present-day public health thought, the weak, the
ill, and the crippled were ignored and in some instances deliberately destroyed.

The Roman Empire is well known for its administrative and engineering
achievements. At its zenith, this civilization had laws providing for the regis-
tration of citizens and slaves; the taking of a periodic census; the prevention of
nuisances, ruinous buildings, dangerous animals, and foul smells; the destruction
of unsound goods; the supervision of weights and measures; the supervision of
public bars, taverns, and houses of ill fame; and the regulation of building con-
38 INTRODUCTION: PUBLIC HEALTH

struction. Steps were taken by the government to ensure an uninterrupted supply
of good and cheap grain to the population. Many public sanitary services were
provided. Many streets were paved, some even had gutters and were drained by
a network of drains. Provision was made for the cleaning and repair of streets and
the removal of garbage and rubbish. Numerous public baths were constructed.
An adequate and, for that time, a relatively safe public water supply was made
available by the construction of magnificent aqueducts and tunnels to transport
water. It is of interest to note that several of the aqueducts and subsurface drains
(cloacae) constructed by the Romans are actually still in use having been in-
corporated in the present-day water and sewerage systems of Rome.

The Middle Ages. With the dawn of the Christian era there developed a re-
action against anything reminiscent of the Roman Empire and its attendant
paganism. The early Christian Church, representing the consensus of thought of
the period, took the attitude that the Roman and Grecian ways of life pampered
the body at the expense of the soul. Accordingly, belittlement of worldly and
physical matters and “mortification of the flesh” became the preferred patterns of
behavior. This philosophy expanded to such an extent that there resulted the
prolonged intermission in the progress of civilization known as the Dark Ages
which was marked by superstition, mysticism, and the rigorous persecution of
freethinkers.

So intense was the reaction that it even included a marked change in attitude
toward sanitation and personal hygiene. It was considered immoral to see even
one’s own body, therefore people seldom bathed and were clothed in notoriously
dirty garments. This is said by some to have been partly responsible for the
eventual widespread use of perfume in the latter part of this period. Diets in
general apparently were poor and consisted of badly prepared or preserved foods.
This contributed to the eventual great interest in the use of spices and in the
development of trade routes for obtaining them. There was utter disregard for
sanitation, refuse and body wastes being allowed to accumulate in and around
dwellings. Slops were customarily emptied out of windows, giving rise eventually
to the familiar password Gardez l'eau. These and other customs lasted until
relatively recent times, as evidenced by Hogarth’s prints of life in eighteenth
century England.

Some important medical and hygienic developments did occur, however,
during this period. Generally speaking, they were forced upon the people by the
untoward effects of an uncontrolled nature and as fruits of their self-made, ill-
conceived habits and customs. Terrifying pandemics of disease ocurred which
were among the most commanding and intense experiences in the entire history
of the human race. During the sixth and seventh centuries, a new religion, Mo-
hammedanism, had arisen. The philosophy of Isalm spread and gathered many
followers in Africa, the Near East, Asia, and to some extent the Balkans and the
Iberian peninsula. Following the death of Mohammed it became a religious
custom to make a pilgrimage, usually in the company of a large number of people,
to Mecca, the birthplace of the prophet. During each great pilgrimage, among the
many thousands converging on the small city were some from far-off Asia, espe-
cially India, which was and still is the endemic center of cholera. The disease
BACKGROUND AND DEVELOPMENT 39

 

naturally spread rapidly throughout the thousands of pilgrims, who on turning
homeward disseminated it along their routes of travel and throughout their re-
spective homelands. Thus each great pilgrimage was almost invariably followed
by a pandemic of cholera. Added to this were the hordes of Christian crusaders
from all parts of Europe whose wanderings inevitably resulted in periodic seeding
of the European continent with the vibrio of cholera as well as other agents of
disease. The seed prospered in a gradually urbanizing Europe, whence centuries
later it was transferred to America by the invading settlers. During the period
from 1830 to about 1880, cholera repeatedly re-entered America, spreading along
the water routes, and accompanying the forty-niners to the gold fields of Cali-
fornia. At one time or another most settlements were affected by cholera, which
often resulted in the death of one third to one half of the population.

Returning to the earlier Dark Ages, leprosy spread, probably from Egypt
to Asia Minor, whence it was broadcast throughout Europe, aided again by the
crusades and other great migrations. It apparently was a far more acute and dis-
figuring disease than that presently observed in the Western world and, because
of the terror to which it gave rise, laws were passed all over the continent regu-
lating the conduct and movement of those afflicted. In many places lepers were
declared civilly dead and were banished from human communities. They were
compelled to wear identifying clothes and to warn of their presence by means of
a horn or bell. This had a twofold result in that it was a most effective isolation
measure and usually brought about a relatively rapid death from hunger and
exposure, as well as from lack of treatment and care. These measures, inhuman
as they were, practically eradicated leprosy in Europe, but by no means in the
world, by the sixteenth century and may be regarded as the first great, although
unplanned, victory in epidemiology.

The Black Death. No sooner had leprosy passed its zenith and begun to de-
cline than an even deadlier menace appeared in the form of bubonic plague. Its
spread was largely the result of the development of trade contacts between
Europe, the Near East and Asia. It has been said with considerable justification
that nothing before or since so nearly accomplished the extermination of the
human race. To quote a few historical figures,* during the 1340's more than 13
million are said to have died from it in China. India was practically depopulated.
Tartary, Mesopotamia, Syria, and Armenia were literally covered by dead bodies.
When the disease was raging in its greatest violence, Aleppo lost about 500 and
the larger city of Cairo from 10,000 to 15,000 daily. In Gaza 22,000 people and
most of the animals were carried off within six weeks. When Pope Clement VI
asked for the number of the dead, some said that half of the population of the
known world had died. The figure he was finally given was about 43 million.
The total mortality from the Black Death is thought to have been over 60 million.
Striking further, Cyprus lost all of its inhabitants and ships without crews were
often seen in the Mediterranean, as afterward in the North Sea, drifting about
aimlessly, spreading the plague wherever they were driven ashore.

Europe, particularly during 1348, was devastated. Florence lost 60,000, Venice
100,000, Marseilles 16,000 in one month, Sien 70,000, Paris 50,000, St. Denys
40 INTRODUCTION: PUBLIC HEALTH

 

14,000, Strasbourg 9,000, and Vienna 1,200 daily. In many places in France not
more than two out of twenty people were left alive.

In Avignon where 60,000 people died, the Pope found it necessary to con-
secrate the Rhone river in order that bodies might be thrown into it without
delay, the churchyard no longer being able to hold them. In Vienna, burial
within churchyards or churches was prohibited. The dead were arranged in layers
by thousands in six large pits outside of the city as had already been done in Cairo,
Paris, and other cities. Crossing the channel, it destroyed one half of the popula-
tion of medieval England, at least 100,000 in London alone.

Altogether it is estimated that Europe’s tribute in the pandemic of the mid-
fourteenth century was about 25 million. Furthermore, this one horrifying visita-
tion was just the beginning. Plague continued to ebb and flow like a tide peri-
odically sweeping over the dirty, miserable European continent. Using the city
of London as an example, in 1603 over one sixth of the population succumbed
to the disease, in 1625 another sixth, and in 1665 about one fifth. During 1790
Marseilles and Toulon lost 91,000; in 1743 Messina 70,000; and in 1759 about
70,000 died on the island of Cyprus. The idyllic story of the dying poet Shelley
requesting that his body be burned on a funeral pyre on the Italian coast he
loved so well makes romantic reading. More truthful, however, is the circum-
stance of his falling victim to plague in 1843 resulting in an order by the Italian
authorities that his body be destroyed on a deserted stretch of beach.

Growing out of these terrifying experiences, and despite the then current
views of the divine or cosmic causation of disease, certain groping attempts were
made to forestall the apparent inevitability of epidemic disaster. In 1348, the
great trading port of Venice banned entry of infected or suspected ships and
travelers. In 1377 at Rogusa it was ruled that travelers from plague areas should
stop at designated places outside the port and remain there free of disease for two
months before being allowed to enter. Historically, this represents the first quar-
antine measure, although it involved a two-month interval rather than the literal
forty days. This procedure is of particular interest in that it implied a vague
realization of the existence of an incubation period for a communicable disease.
Six years later, in 1383, Marseilles passed the first actual quarantine law and
erected the first quarantine station. These are historical landmarks in public
health administration and epidemiology but unfortunately their effectiveness
was impaired by the fact that though great attention was paid to humans, the
role of the rat and the flea was not discerned.

Other Diseases. Some mention, even if necessarily inadequate, should be
made in passing to the rapid dissemination of syphilis throughout Europe and
the Near East following the discovery of America. Some measure of its incidence
and devastation is obtained by considering the name, “the great pox,” which was
applied to it in order to distinguish it from the smallpox which we now con-
sider serious enough even in its present generally milder form. Incidentally, it is
curious that little historical reference is made to many of the other diseases which
are known to have existed with incidences far exceeding any now occurring. In
mind are diphtheria, the streptococcal infections, the dysenteries, typhoid, typhus,
and others. The most probable reasons for the paucity of mention of them are
BACKGROUND AND DEVELOPMENT 41

that in the first place people undoubtedly became accustomed to their inevitable
endemicity and accepted them as part of the routine risk of life, and second, that
they were so dramatically overshadowed by the tremendous impact of the great
periodic pandemic killers as to merit relatively little mention in the historical
writings of the times. In summary, therefore, the peoples of Europe emerged from
the Middle Ages and, as a matter of fact, came all the way to very recent times
with little or no comprehension of any principles of public health other than
those of crude, inhuman and inefficient isolation and quarantine.

The Renaissance. In a period of history marked by increasing tendencies
toward social concentration, expanding trade, and population movement, the
risks involved in pursuing these trends in the face of rampant disease were neces-
sarily great. The great pandemics of the Middle Ages, therefore, must have caused
considerable social and political frustrations which could lead only to attitudes
of fatalism and general disregard for the welfare of individuals. Hecker,* phi-
losophizing along these lines, commented:

. The mind of nations is deeply affected by the destructive conflict of the powers
of nature, and . . . great disasters lead to striking changes in general civilization. For
all that exists in man, whether good or evil, is rendered conspicuous by the presences
of great danger. His inmost feelings are aroused—the thought of self-preservation masters
his spirit—self denial is put to severe proof, and wherever darkness and barbarism pre-
vail, there the affrighted mortal flies to the idols of his superstition, and all laws, human
and divine, are criminally molested. *

The way of life of a people likewise has a marked effect on their state of
health or illness. In this respect it is of interest to learn from a letter of Erasmus
to the personal physician of Cardinal Wolsey, the manner of life in the average
English household of the sixteenth century as quoted by Winslow’:

As to floors, they are usually made with clay, covered with rushes that grow in the
fens and which are so seldom removed that the lower part remains sometimes for twenty
years and has in it a collection of spittle, vomit, urine of dogs and humans, beer, scraps
of fish and other filthiness not to be named.

Winslow, in his incomparable presentation of the development of the modern
public health movement, points out how long it has taken the human race to
improve such conditions, presenting examples even more disgusting than the
above from England of 1842 and New York City in 1865. As a matter of fact,
even at the present time it is necessary to work but a short time in a sociological
field, in either urban or rural areas, in order to see conditions not far different
from those to which reference is made.

There gradually developed in the minds of a few some doubt of the teleolog-
ical origin of disease as a punishment for sin. It might be noted in passing, how-
ever, that this stigma has only recently been removed from cancer and tuberculosis
and that venereal infection is still considered by many as a punishment for

*Hecker, I. F.: The Epidemics of the Middle Ages, Philadelphia, 1837, Haswell, Barrington
and Haswell, p. 25 ff.

Quoted by Winslow, C.-E.A.: The Evolution and Significance of the Modern Public Health
Campaign, New Haven, 1923, Yale University Press, pp. 8-11.
42 INTRODUCTION: PUBLIC HEALTH

 

immorality. By the end of the Middle Ages, differentiation of a number of dis-
eases had been accomplished. Among the conditions recognized as distinct en-
tities were leprosy, influenza, ophthalmia, trachoma, scabies, impetigo, erysipelas
(St. Anthony's fire), anthrax, plague, consumption, syphilis (the great pox), small-
pox, diphtheria and scarlet fever considered as one, and typhus and typhoid
fevers also considered together.

The people of Europe, coming out of this dreadful, depressing period of
history, slowly and cautiously began to open their eyes and to think as free in-
dividuals. There began to appear a few outstanding thinkers, the number in-
creasing with the passage of time. Among them are found the names of Descartes,
Lyell, Lamarck, Cuvier, Boyle, Bentham, Smith, Voltaire, and Darwin, to mention
but a few. Each in his own way hammered at the bars imprisoning the minds
and bodies of men. Their combined efforts resulted in remarkable accomplish-
ments especially in the late eighteenth century and throughout the nineteenth
century. The concept of the dignity of man began to be emphasized more and
more. The search for scientific truth was at last advocated for its own sake.

The Eighteenth and Nineteenth Centuries; The Plight of Children. How-
ever, other changes were occurring at the same time. Among them was the de-
velopment of nationalism, imperialism, and industrialization with their tragic
and degrading influences. The false gods of power and profit were placed on
higher pedestals than they had ever before occupied, and individual liberties,
labors, and lives were sacrificed on a scale probably unprecedented since the
building of the pyramids. As an example, in one of the most shameful actions in
the history of the human race, there came about in England a legally condoned
practice of apprentice-slavery whereby pauper children were indentured to the
owners of mines and factories. The socially accepted pattern was for parishes to
assume responsibility for orphans and pauper children. This responsibility was
met at first by paying private “nurses” for taking the infants and younger children
into their homes for a few years, putting them out to work as apprentices when
they became older. Partly because of the increasing numbers and partly as a
remedy for frequent abuse of the young children, parish workhouses began to
be established in the late seventeenth and early eighteenth centuries as a sub-
stitute for parish nurses.

Theoretically the workhouses were also intended to provide some training
for the children but this was kept at a minimum and was largely concerned with
inculcating the ideals of labor and industry, virtue and religion. It was hoped
that the workhouses would “. . . cure a very bad practice in parish officers, who
to save expence, are apt to ruin children by putting them out as early as they can
to any sorry master that will take them, without any concern for their education
and welfare.”®

Dorothy George, in her authoritative review of life in England in the eight-
eenth century gives a picture of these methods and ideals in practice by describing
the London Workhouse in Bishopsgate Street in 1708.

. . . thirty or forty children were put under the charge of one nurse in a ward, they
lay two together in bunks arranged round the walls in two tiers, “boarded and set one
BACKGROUND AND DEVELOPMENT 43

 

above the other . . . a flock bed, a pair of sheets, two blankets and a rugg to each.”
Prayers and breakfast were from 6:30 to 7. At 7 the children were set to work, twenty
under a mistress, “to spin wool and flax, knit stockings, to make their linnen, cloathes,
shooes, mark, etc.” This work went on till 6 p.m. with an interval from 12 to 1 for
“dinner and play.” Twenty children were called away at a time for an hour a day to
be taught reading, some also writing. Some children, we are told, “earn a halfpenny,
some a penny, and some fourpence a day.” At twelve, thirteen or fourteen, they were
apprenticed, being given, at the master’s choice, either a “good ordinary suit of cloaths
or 20s. in money.” *

When children reached an age when they might be apprenticed, their lot
became infinitely worse. “A most unhappy practice prevails in most places,”
said a writer on the Poor Laws in 1738, “to apprentice poor children, no matter
to what master. Provided he lives out of the parish, if the child serves the first
forty days we are rid of him for ever. The master may be a tiger in cruelty, he
may beat, abuse, strip naked, starve or do what he will to the poor innocent
lad, few people take much notice, and the officers who put him out the least
of anybody. . . . The greatest part of those who now take poor apprentices
are the most indigent and dishonest, in a word, the very dregs of the poor of
England, by whom it is the fate of many a poor child, not only to be half-starved
and sometimes bred up in no trade, but to be forced to thieve and steal for his
master, and so is brought up for the gallows into the bargain. . . .” Children
apprenticed to chimney sweepers fared among the worst. Hanway, a leading re-
former of the period, in protesting against this in 1767 described the miseries of
their neglect and ill-treatment, of their being forced up chimneys at the risk of
being burnt or suffocated, and of their being forced to beg and steal by their mas-
ters. “Chimney-sweepers,” he says, “ought to breed their own children to the busi-
ness, then perhaps they will wash, clothe and feed them. As it is they do neither,
and these poor black urchins have no protectors and are treated worse than a
humane person would treat a dog.” In apprenticing children in large groups, the
provision was not uncommon to require that for every thirty normal children
one idiot would have to be taken. These unfortunates, forced to work from
fifteen to eighteen hours a day, sometimes literally chained to their machines,
fed a minimum of food scarcely fit for consumption, and housed under the most
crowded and filthy conditions, usually were released from their sufferings and
abuse by early death.

As recently as 1842, Edwin Chadwick pointed out that more than one half
of the children of the working classes died before their fifth birthday and that in
cities such as Liverpool the average ages at death of the various social classes were
35 years for the gentry, 22 years for the tradesmen, and 15 years for laborers!” The
breakdown for London, obtained by the Sanitary Commission for the Metropolis
in 1843, is given in Table 1.

Sanitary Conditions. During this period, the condition of the streets became
deplorable, due in part to nightmen and scavengers emptying their carts in the
streets instead of in the places assigned for the purpose. The accumulated filth

*George, M. Dorothy: London Life in the XVIIIth Century, New York, 1925, Alfred A.
Knopf, p. 218.
44

INTRODUCTION: PUBLIC HEALTH

 

Table 1. Deaths by Social Class, London, 1840*

 

 

 

 

 

 

 

Proportions Proportions Proportions | Mean Age
% of Deaths | of Deaths of | 9, of Deaths of Death | Mean Age
from Epi- Children of Children of All of All
Class demics to Under 1 Year | Under 10 Yrs.| Who Have | Who Died
Total Deaths to Births to Total Died, Men Above
of Each in That Deaths of Women and | Twenty-
Class Year Each Class Children One
——
: Years Years
Gentry, professional
persons, and their 6.5 1to 10 24.7 44 61
families
Tradesmen, shop-
keepers, and 20.5 1to6 52.4 23 50
their families
Wage classes, artisans,
laborers, and their 22.2 1to4 54.5 22 49
families

 

 

 

 

 

*Adapted from Chadwick as quoted by Richardson, B. W.: The Health of Nations, A
Review of the Works of Edwin Chadwick, London, 1887, Longmans, Green & Co., vol. 11, p. 80.

of the eighteenth century house was in many cases simply thrown from the
doors or windows.

Although eighteenth-century London was incredibly dirtier, more dilapidated and
more closely-built than it afterwards became, was there no compensation in its greater
compactness, the absence of straggling suburbs, the ease with which people could take
country walks? This is at least doubtful. The roads around London were neither very
attractive nor very safe. The land adjoining them was watered with drains and thickly
sprinkled with laystalls and refuse heaps. Hogs were kept in large numbers on the out-
skirts and fed on the garbage of the town. A chain of smoking brick-kilns surrounded
a great part of London and in the brick-fields vagrants lived and slept, cooking their
food at the kilns. It is true that there was an improvement as the century went on. In
1706 it was said of the highways, “tho” they are mended every summer, yet everybody
knows that for a mile or two about this City, the same and the ditches hard by are
commonly so full of nastiness and stinking dirt, that oftentimes many persons who have
occasion to go in or come out of town, are forced to stop their noses to avoid the ill-
smell occasioned by it.*

These conditions under which so many hundreds of thousands of people
lived and worked had dire results indeed from a hygienic standpoint. Smallpox,
cholera, typhoid, tuberculosis and many other diseases reached exceedingly high
endemic levels, and the contamination of sources of water became so extensive

*George, M. Dorothy: London Life in the XVIIIth Century, New York, 1925, Alfred A.
Knopf, p. 218.
BACKGROUND AND DEVELOPMENT 45

as to prompt that famous statement in parliament on the condition of the empire
in 1859: “India is in revolt and the Thames stinks.” Southwood Smith pointed
out at the time that the annual slaughter in England and Wales from typhus and
typhoid fevers was double the number of lives lost by the allied armies in the
battle of Waterloo.

English Sanitary Reforms. Concern with the economic consequences of ex-
isting social and sanitary conditions began to appear, providing leaders in sani-
tary reform with forceful arguments. Thus Chadwick reported:

This depressing effect of adverse sanitary circumstances on the labouring strength

of the population, and on its duration, is to be viewed with the greatest concern, as it is
a depressing effect on that which most distinguishes the British people, and which
it were truism to say eomstitutes the chief strength of the nation—the bodily strength
of the individuals of the labouring class. The greater portion of the wealth of the
nation is derived from the labour obtained by the application of this strength, and it
is only those who have had practically the means of comparing it with that of the pop-
ulation of other countries who are aware how far the labouring population of this
country is naturally distinguished above others. . .. The more closely the subject
of the evils affecting the sanitary condition of the labouring population is investi-
gated, the more widely do their effects appear to be ramified. The pecuniary cost of
noxious agencies is measured by data within the province of the actuary, by the charges
attendant on the reduced duration of life, and the reduction of the periods of work-
ing ability or production by sickness. The cost would include also much of the public
charge of attendant vice and crime, which come within the province of the police,
as well as the destitution which comes within the province of the administrators of
relief. Of the pecuniary effects, including the cost of maintenance during the pre-
ventible sickness, any estimate approximating to exactness could only be obtained by
very great labour, which does not appear to be necessary.*

In a legal sense, public health went unrecognized in England until 1837
when the first sanitary legislation was enacted. It established a National Vaccina-
tion Board, appropriating 2,000 pounds for its support. As a result, a few vac-
cination stations were set up in the city of London. This modest beginning was
followed shortly, in 1842, by Edwin Chadwick’s momentous Report on an In-
quiry into the Sanitary Condition of the Laboring Population of Great Britain,
one of the results of which was the establishment in 1848 of a General Board of
Health for England. Significantly, the same year saw the appointment, as the
first medical officer of health for London, of John Simon, who seven years later
was to assume that office for the nation as a whole. Improvements rapidly followed
one another. These advances in sanitation and hygiene did not go forward alone.
Legislation was passed concerning factory management, child welfare, the care
of the aged, the mentally ill and the infirm, education, and many other phases
of social reform.

It was not long before the horrors of previous conditions were forgotten, and
the standards of order, decency, and sanitation began to be taken for granted.

. . . pride was based on real achievements, which had an undoubted effect on the

health of the town, and in which London was a pioneer among large cities. The foot-
pavements, the lamps, the water-supply, the fire-plugs, the new sewers, defective

*Richardson, B. W.: The Health of Nations, A Review of the Works of Edwin Chadwick,
London, 1887, Longmans, Green & Co., vol. II, pp. 100-102.
46 INTRODUCTION: PUBLIC HEALTH

enough by later standards, were admired by all. . . . Beneath the pavements are vast
subterraneous sewers arched over to convey away the waste water which in other
cities is so noisome above ground, and at a less depth are buried wooden pipes that
supply every house plentifully with water, conducted by leaden pipes into kitchens
or cellars, three times a week for the trifling expense of three shillings per quarter.
. . . The intelligent foreigner cannot fail to take notice of these useful particulars
which are almost peculiar to London.*

The seeds of sanitary and social reform spread rapidly to the other large
urban centers of England. However, participation in these benefits by the smaller
towns and rural areas was understandably slower. Chadwick, as early as 1830,
had recommended the employment of a large number of local sanitary officers
including medical personnel for the adequate coverage of the nation. As might
be expected, his proposals originally met with considerable opposition, some of
which continued, even when he subsequently was able to demonstrate the eco-
nomic soundness of the costs incurred.

English Influence on America. It may appear to the more casual reader that
conditions and developments in Great Britain have been unduly stressed. Con-
sidering the primary concern of this book, any discussion of backgrounds must
necessarily emphasize those extraterritorial developments which have exerted
the greatest influence upon America. It is quite true that many advances had
been made elsewhere, notably in the low countries, Germany, and on the Scan-
dinavian peninsula. By mid-nineteenth century, France had long since embarked
on significant studies and activities relating to public health and sanitation and
many scientific papers were being published. The very establishment of the
Annales d’Hygiene Publique gives testimony to this. The work of the Belgian,
Quételet, was already widely known, and Pettenkofer in Munich, and Virchow
in Berlin already had far-reaching influences.

Nevertheless, the early intimate ties, social, economic and otherwise, between
the North American continent and Great Britain made happenings in the latter
of particular significance to the former. The relationship was aptly described
by Dr. Henry I. Bowditch,® the first president of the Massachusetts State Board of
Health.

But by far the greatest influence has been exerted upon us in America by England,
who, by her unbounded pecuniary sacrifices and steady improvement in her legislation,
and her able writers, has far outstripped any country in the world in the direction of
State Preventive Medicine. . . . The consumate skill in the discovery, removal, and
prevention of whatever may be prejudicial to the public health, shown under the ad-
mirable direction of Mr. Simon, late Medical Officer of England’s Privy Council, by his
corps of trained inspectors is wholly unequalled at the present day, and unprecedented,
I suspect, in all past time in any country on the globe.t

Furthermore, while scientific researchers may have progressed further in
some other countries, the application of the new knowledge, especially in terms

*George, M. Dorothy: London Life in the XVIIIth Century, New York, 1925, Alfred A.
Knopf, p. 218.

tBowditch, H. I.: Address on Hygiene and Preventive Medicine, Transactions of the Inter-
national Medical Congress, Philadelphia, 1876, pp. 11-12.
BACKGROUND AND DEVELOPMENT 47

 

of administrative organization and procedure, occurred more rapidly and more
successfully in England than elsewhere. Since the administrative organization de-
pends to a considerable degree upon legal procedure, it is of additional signifi-
cance that America, from the beginning, followed the pattern set by English law.
Thus, when the time came for American cities to pass sanitation ordinances, they
did so in the tradition of the English common law.

Colonial America. Transferring attention to the newly developing North
American continent, it appears that certain public health problems were soon
recognized by the colonists. They had good reason for being conscious of the
threat of disease. Many of the early settlements had been completely obliterated
by epidemic diseases, particularly smallpox. Among these were the colonies at
Jamestown and undoubtedly that at Roanoke Island. On the other hand, it was
probably due to disease that the colonists were able to establish their eventual
footholds in the new continent. The settlers of the Massachusetts Bay Colony, for
example, came to a territory the natives of which were by no means of a peaceful
nature. Yet, by the time the Pilgrims landed at Plymouth, the hostile natives
of the surrounding countryside had been all but eliminated, apparently by small-
pox introduced by the Cabot and Gosnold expeditions. Smallpox also appears
to have played a role to some degree in the weakening of the Aztec Empire and
its eventual conquest. In this instance it is known to have been introduced by a
servant of Narvaez who joined Cortez in 1520.2 It has been estimated that during
the early periods of colonization of Central and North America, the Indian popu-
lation was decimated by diseases introduced by the invaders, whether peaceful
or otherwise.”

The registration of vital statistics is generally considered to be one of the
essential cornerstones of sound, efficient public health awareness and practice.
It is not without interest that the recording of these data was a very early con-
cern of the New England colonists. As early as 1639, an act was passed by the
Massachusetts colony ordering that each birth and death be recorded, subsequent
acts outlining the necessary administrative responsibilities and procedures. Not
only was the information made available locally, but copies had to be made by
the town clerks and transmitted to the clerks of the county courts. The law also
provided for fees and penalties. Similar laws were enacted at about the same time
~ by the Plymouth colony.!t

Most of the early activities of a public health nature in America were con-
cerned with gross insanitation and attempts to prevent the entrance of exotic
diseases. For example, as early as 1647, the Massachusetts Bay Colony passed a
regulation dealing with the prevention of the pollution of Boston Harbor. Be-
tween 1692 and 1708, Boston, Salem, and Charleston passed acts dealing with
the nuisances and trades offensive or dangerous to the public health. In 1701,
Massachusetts passed laws providing for the isolation of smallpox cases and for
ship quarantine, to be used whenever necessary. The difficulty with these and
other early measures was that no continuing organization or even committee
existed in order to assure ready recognition of undesirable situations or com-
pliance with the requirements of the legislation enacted.
48 INTRODUCTION: PUBLIC HEALTH

 

In the century during which the American colonies developed, drew to-
gether, and eventually formed a federation of states, very little progress of a
public health nature was made. Following the American Revolution, the threat
of various diseases, particularly yellow fever, led to a widespread interest in the
development of legislation for the establishment of permanent boards of health.
Permissive legislation of this type was passed in 1797 by both the states of New
York and Massachusetts, followed in 1805 by Connecticut. In the matter of a
permanent local board of health, there is some controversy concerning priority.
Boston is commonly said to have organized the first in 1799 with Paul Revere
as its chairman. However, this has been contested by the cities of Petersburg,
Virginia (1780), Philadelphia (1794), New York (1796), and Baltimore (1793).
The latter claim has been supported more or less by the American Public Health
Association.12

By the end of the eighteenth century New York City, with a population of
75,000, had formed a public health committee which was concerned with the
“quality of the water supplies, construction of common sewers, drainage of
marshes, interment of the dead, planting of trees and healthy vegetables, habi-
tation of damp cellars, and the construction of a masonry wall along the water
front.” In July, 1798, the new American Congress created a Marine Hospital Serv-
ice in order to provide for the care of sick and disabled merchant seaman. This
service later was to become of interest and significance for three reasons. First, it
was the origin of what eventually became the United States Public Health Serv-
ice; second, it was to furnish the organization for effecting national quarantine;
and third, it represents one of the earliest examples of prepaid medical insurance.
For twenty cents per month, each merchant seaman was provided with medical
and hospital care. As early as 1800, the first marine hospital was constructed in
Norfolk, Virginia. :

The Nineteenth Century in America. Between 1800 and 1850 the United
States underwent great expansion, but public health activities remained station-
ary. What did not remain stationary, however, was the development of threats
to the public health and welfare and the resulting incidence of disease. Many
epidemics, especially of smallpox, yellow fever, cholera, typhoid and typhus, re-
peatedly entered and swept over the land. Tuberculosis and malaria reached high
levels of endemicity. In Massachusetts in 1850, for example, the tuberculosis death
rate was over 300 per 100,000 population, the infant mortality was about 200
per 1,000 live births, and smallpox, scarlet fever and typhoid were high on the
list of leading causes of death. As a result, by 1850 the average length of life in
Boston and most of the other older cities in America was less than in London
which at that time was itself the object of wide criticism for its sickening scenes
of misery and depravity. The American social scene was the subject of scathing
comments by visitors from abroad who were impressed with the crudity and
“barbarism” of life in the United States and the generally unkempt appearance
of its communities. As so often has happened, improvements in sanitation and
public health were delayed by lack of progress in other fields. Sir Arthur News-
holme,!3 the noted British hygienist, in describing this period of American social
history stated:
BACKGROUND AND DEVELOPMENT 49

 

The rapid growth of cities tended to out run the forces of law and order and to
smother under the weight of numbers any attempts at civic reform. Before public health
measures could be adopted or enforced, other more pressing problems had to be solved.
An effective police force, the first requisite of community life, did not make its appear-
ance in the Atlantic seaboard cities until 1853, and satisfactory fire prevention came even
later. Protection against the dirt and filth of human aggregation, which threatened the
life of every man, woman, and child, had to wait upon the adequate enforcement of
law and order.*

The inadequacies of the times were reflected in the low quality of medical
care available to the people. Professional teaching facilities were few and in-
adequate. Many “physicians” were sell-designated and itinerant. The prestige of
the medical profession was at its lowest ebb and its ranks were disorganized and
split by the development of numerous healing philosophies and cults. One writer!*
has summarized the situation by saying, “the doctors were victims of their own
want of knowledge, of the absence of adequate medical standards and of a chaotic
educational system.” Healing agents used included not only empirical remedies
left over from medieval Europe, but, in addition, many newly discovered ‘“reme-
dies” often borrowed from the native American aborigines. This state of thera-
peutic affairs led Oliver Wendell Holmes'® to remark that “if the whole materia
medica as now used, could be sunk to the bottom of the sea, it would be all the
better for mankind,—and all the worse [or the fishes.”

City Health Departments. The first half of the nineteenth century saw a
gradual trend toward the more or less full-time employment ol persons to serve
as the functional agents of local boards of health which now were increasing in
number. This represented the first step in the formation of full-time local health
departments. Some of the earlier of these organizations were established in Bal-
timore (1798) Charleston, South Carolina (1815), Philadelphia (1818), Provi-
dence (1832), Cambridge (1846), New York City (1866), Chicago (1867), Louis-
ville (1870), Indianapolis (1872), and Boston (1873). The last is of interest in
illustrating the lag, in this instance of three-quarters of a century, that occurred
between the formation of many local boards of health and the establishment of
functional health departments. As might be expected, the activities of these
health departments were determined by the current epidemiologic theories which
placed particular emphasis on the elimination of sanitary nuisances. For ex-
ample, at the mid-point of the nineteenth century, the population of New York
City had reached 300,000. Its board ol health was concerned only with crowded
living conditions, dirty streets and the regulation of public baths, slaughterhouses,
and pigsties.

The Shattuck Report.'® In terms of American public health history, the mid-
nineteenth century is most notable for the extraordinary Report of the Sanitary
Commission of Massachusetts.t Lemuel Shattuck (1793-1859), a most unusual

*Newsholme, Sir Arthur: The Ministry of Health, London, 1925, G. P. Putnam’s Sons, Ltd.,

pp. 1-3.
fMassachusetts Sanitary Commission, Report of a General Plan for the Promotion of Public
and Personal Health. . . . Boston, Dutton and Wentworth, state printers, 1850. Fortunately, this

noteworthy report has been made available again in Report of the Sanitary Commission of
Massachusetts by Shattuck.
50 INTRODUCTION: PUBLIC HEALTH

 

man, led the diversified life of teacher, historian, book dealer, sociologist, statis-
tician, and finally a legislator in the state assembly. Although in a medical sense
a layman, he had a keen interest in sanitary reform, originating apparently with
his work when gathering and tabulating the vital statistics of Boston. Because of
his persistent complaints regarding the current lack of sanitary progress, he was
appointed chairman of a legislative committee for the study of health and sani-
tary problems in the commonwealth. From this committee, and essentially from
Shattuck’s pen, there issued the report to which reference is made. With remark-
able insight and foresight, the report included a detailed consideration not only
of the present and future public health needs of Massachusetts, but also of its
component parts and of the nation as a whole. This most reimarkable of all
American public health documents, if published today, in many respects would
still be ahead of its time.

The content of this report may be appreciated in its true light when it is
realized that, at the time it was written, there existed no national or state public
health programs and such local health agencies as by that time had been organ-
ized were still in an embryonic stage of development. Medical practice in general
was then far from scientific, facilities for medical training were few and in a most
confused state and for nursing training entirely lacking, and almost another
half century was to pass before the spectacular era of Pasteur, Koch, and the other
contributors to the golden age of bacteriology. Among the many recommenda-
tions made by Shattuck a century ago were those for the establishment of 'state
and local boards of health, a system of sanitary police or inspectors, the collection
and analysis of vital statistics and a routine system for exchanging data and
information, sanitation programs for towns and buildings, studies on the health
of school children, studies of tuberculosis, the control of alcoholism, supervision
of mental disease, the sanitary supervision and study of problems of immigrants,
the erection of model tenements, public bathhouses and washhouses, the con-
trol of smoke nuisances, the control of food adulteration, exposure of nostrums,
the preaching of health from pulpits, the establishment of nurses’ training schools,
the teaching of sanitary science in medical schools, and the inclusion of preventive
medicine in clinical practice with routine physical examinations and family
records of illness.

Unfortunately, while this document laid down the principal ideas and modes
of action which ultimately formed the basis of much of today’s public health
practice, its importance was not appreciated at the time it was submitted and it
was destined to lie dormant for nearly a quarter of a century. One of the earliest
appraisals of it was given by Henry I. Bowditch, the first president of the State
Board of Health of Massachusetts, in an address before the International Medical
Congress at Philadelphia in 1876.8

The report fell flat from the printer's hand. It remained almost unnoticed by the
community or by the profession for many years, and its recommendations were ignored.
Finally, in 1869, a State Board of Health of laymen and physicians, exactly as Mr.
Shattuck recommended, was established by Massachusetts. Dr. Derby, its first secretary,
looked to this admirable document as his inspiration and support. In giving this high
honor to Mr. Shattuck, I do not wish to forget or to undervalue the many and persistent
BACKGROUND AND DEVELOPMENT 51

 

efforts made by a few physicians, among whom stands pre-eminent Dr. Edward Jarvis,
and occasionally by the Massachusetts Medical Society, in urging the State authorities
to inaugurate and to sustain the ideas avowed by Mr. Shattuck. But there is no doubt
that he, as a layman, quietly working, did more towards bringing Massachusetts to cor-
rect views on this subject than all other agencies whatsoever. Of Mr. Edwin Chadwick,
I need say nothing. You all know him. Fortunately for himself, he has lived to see rich
fruits from his labors. That was not granted to Mr. Shattuck.*

The comparison of Shattuck, the American, and Chadwick, the Englishman,
is of more than passing interest. Some lessons may be learned by comparing the
effects of the work of the two men. Shattuck’s report consisted essentially of
straightforward, unembellished, unillustrated statements of fact followed by
specific and detailed recommendations. This is in contrast with Chadwick’s
report on “The Sanitary Condition of the Laboring Population of Great Britain”
which included many vivid descriptions of the appalling conditions in existence.
The latter caused an immediate emotional response on the part of all those who
read or heard of the report. One is lead to wonder if Shattuck’s report might
have had a more immediate effect had it provided the reader with mental images
of existing conditions for contrast with further mental images of desirable con-
ditions attainable. Another point of contrast is that although Chadwick’s report
brought about a prompt reaction resulting in the establishment of a General
Board of Health in 1848, the response was not long lasting. Chadwick’s over-
enthusiasm and impatience demanded immediate action, for which the British
people were not yet ready. Considerable antagonism and resistance was generated
in many quarters, resulting in the early demise of the General Board of Health
after only four years of existence. This reversal caused an unfortunate delay in
the ultimate development of a sound national health program in Great Britain.
These two reports of Chadwick and Shattuck therefore, remarkable as they were,
both provide us with examples of administrative failure, one because of under-
promotion and the other because of overpromotion.

The First State Health Department. The repeated introduction of yellow
fever and other epidemic diseases caused the state of Louisiana in 1855 to set
up a board or commission to deal with quarantine matters in the port of New
Orleans. This has led some to claim priority for Louisiana in the establishment
of a state board of health. However, in terms of the more usual concept of the
general functions of a state board of health, it is generally considered that Mas-
sachusetts, despite its lack of response to Shattuck’s recommendations, merits
recognition for establishing the first true state board of health in 1869. The act
creating it directed:

The board shall take cognizance of the interests of health and life among the citizens
of this Commonwealth. They shall make sanitary investigations and inquiries in respect
to the people, the causes of disease, and especially of epidemics, and the sources of mor-
tality and the effects of localities, employments, conditions and circumstances on the
public health; and they shall gather such information in respect to those matters as they
may deem proper, for diffusion among the people.i

*Bowditch, H. I.: Address on Hygiene and Preventive Medicine, Transactions of the Inter-
national Medical Congress, Philadelphia, 1876, p. 11.
tAct of 1869, General Court of Massachusetts.
52 INTRODUCTION: PUBLIC HEALTH

 

In determining policy at early meetings, the board, under the leadership of
Dr. Henry I. Bowditch, decided to concern itself with public and professional
education in matters of hygiene, various aspects of housing, investigations of
various well-known diseases capable of partial or entire prevention, prevailing
methods of slaughtering, sale of poisons, and conditions of the poor. It was de-
cided also to send a circular letter to local boards of health in order to inquire
about their powers and duties and in order to collect for publication the number
and prevailing causes of deaths in the most populous cities and towns in the
state. The board requested that each community designate a physician to act as
correspondent. Patterson and Baker!? in discussing the early history of this
board, made the pertinent observation that “one by-product of this correspond-
ence was the beginning of a productive cooperation between the state and local
authorities.” One reads with annoyance of the merger in 1878 of the Massa-
chusetts Department of Health with the Department of Lunacy and Charity
as a result of political pressure and a desire for “economy.” As might have been
anticipated, matters dealing with the public health were effectively submerged
by the weight of the other two interests. Eventually the light was seen and a
sound program was made possible by re-establishment of the health agency as
an entity.

The Quarantine Conventions and the American Public Health Association.
Other activities of great public health potentiality were taking place at about
the middle of the nineteenth century. The small but increasing number of those
interested in the promotion of public health were realizing more and more the
desirability of maintaining contact with one another in order to gain strength for
the solution of problems which were of common interest and concern. Due par-
ticularly to Wilson Jewell, the health officer of Philadelphia who had recently at-
tended the Conference Sanitaire held in Paris in 1851-1852, there was called a
series of National Quarantine Conventions.'S The first, a three-day meeting, was
held in Philadelphia in 1857. It concerned itself with its own name and form of
organization, followed by discussions by the fifty-four in attendance on matters of
common interest. Much attention was given to the prevention of introduction of
epidemic diseases such as typhus, cholera, and yellow fever, to port quarantine,
and to the importance of stagnant and putrid bilge water, droppings or drainage
[rom putrescible matters, filthy bedding, baggage and clothing of immigrant
passengers, and air that has been confined. It recommended that immigrants
not previously protected against smallpox should be vaccinated. The second con-
vention held in Baltimore in 1858 was noteworthy for proposals for a uniform
system of quarantine laws and the organization of a Committee on Internal
Hygiene or the Sanitary Arrangement of Cities. It is interesting that forty-two
of the eighty-six persons attending the second convention were not physicians.
After two more conventions, New York in 1859, and Boston in 1860, the out
break of the American Civil War precluded further meetings.

The seed planted by the quarantine conventions by no means died. On
April 18, 1872, following the termination of the war, ten men, including Elisha
Harris and Stephen Smith, met informally in New York City for the purpose
of reactivating interest in national meetings for the consideration of public health
BACKGROUND AND DEVELOPMENT 53

 

 

matters. Meeting again at Long Branch, New Jersey, in September with several
additional répresentatives, a name was chosen, a constitution adopted, and Dr.
Stephen Smith was elected the first president of the American Public Health
Association. In a later discussion of the early days, Dr. Smith? said, “The Ameri-
can Public Health Association had its origin in that natural desire which thinkers
and workers in the same fields, whether of business or philanthropy, or the ad-
ministration of civil trusts, have for mutual council, advice and cooperation.”

Since the National Quarantine Conventions were necessarily concerned pri-
marily with quarantine matters, the formation of the American Public Health
Association represented a considerable advance in that the scope of interest was
greatly broadened. This was reflected in its earliest meetings wherein were pre-
sented papers on many aspects ol sanitation, on the transmission and prevention
of diseases, longevity, hospital hygiene, and other diverse subjects in addition to
discussions of quarantine. Through the years of its continued existence, the Asso-
ciation has served its members well, providing a common fount of knowledge,
information, and encouragement, and a means ol presenting a united [ront for
the improvement of the health of America.

The National Board of Health. One of the earliest concerns of both the
Quarantine Conventions and the American Public Health Association was with
the need for a national board of health. Smillie?! has described the circumstances
which led to the ultimate formation of such a national board, its controversial
four years’ existence, and its painful, premature death from deliberate financial
starvation. Meetings were held in Washington in 1875 attended by representatives
of many state and city health departments for the purpose of considering plans
for the formation of a Federal health organization. The meeting degenerated into
a jurisdictional dispute on the part of the Army, the Navy, and the Marine Hos-
pital Service, which were the three existing governmental departments already
providing certain services in this field. In 1878 a devastating epidemic of yellow
fever swept over a large part of the country. Since the disease was known to have
entered through the port of New Orleans, laxity on the part of the Louisiana
authorities was blamed and public sentiment was aroused. As a result, not only
the Army and the Marine Hospital Service but also the American Public Health
Association sponsored national health department bills. It was the latter bill
that was finally passed by Congress in 1879. It transferred from the Marine Hos-
pital Service all of its health duties and powers including maritime quarantine.
The act created a board of presidential appointees consisting of seven physicians
and representatives [rom the Army, the Navy, the Marine Hospital Service, and
the Department of Justice. About two and one-half months later another act was
passed which gave the board extensive quarantine powers and which authorized
an appropriation of $500,000 for its work. This second act included an unfortu-
nate clause which limited the powers to four years, necessitating a re-enactment
of the bill in order for the work to continue.

The membership of the first board was notable, including J. L. Cabell, J. S.
Billings, J. 'T. Turner, P. H. Bailhoche, S. M. Bemiss, H. T. Bowditch, R. W.
Mitchell, Stephen Smith, S. F. Phillips, and T. S. Verdi. The four years of life
of the National Board of Health were marked by an ambitious and efficient pro-
54 INTRODUCTION: PUBLIC HEALTH

gram of studies and services marred by the persistent and vociferous opposition
of Dr. Joseph Jones, secretary of the Louisiana Board ol Health. The latter
objected to the presence of “Federal agents and spies” and seized every oppor-
tunity to belittle and misrepresent the activities of representatives of the National
Board. Intent as he was on destroying the new organization, he was saved the
trouble by Dr. John Hamilton, the Surgeon General of the Marine Hospital
Service. Dr. Hamilton, although professionally inept, possessed considerable po-
litical astuteness. Realizing that the National Board of Health would pass out
of existence unless the law of June 2, 1883, was re-enacted and that in such an
event its powers and functions would revert to the Marine Hospital Service, he
worked quietly and effectively to prevent re-enactment. Charging misuse of funds,
extravagance and incompetence, he succeeded in bringing the National Board
of Health to an untimely death.

One of the members of the Board, Stephen Smith, from the first had favored
conferring all national public health duties and powers on the National Board
of Health but incorporating in it the officers, staff, and activities of the Marine
Hospital Service and any other agencies concerned with public health matters.
Smillie20 analyzed the situation in the following terms:

He foresaw that Congress would lose interest in the National Board of Health,
but would continue to support a service agency that had full-time career officers and
was incorporated as an integral part of national government machinery.

In retrospect we realize that Stephen Smith was right. The unwieldy board of
experts, each living in a different community and attempting to carry out administrative
duties, with no cohesion, no real unity of opinion and no central authority, was an im-
possible administartive machine. A centrally guided service, such as actually developed,
had unity and purpose, but unfortunately lacked intelligent leadership. The public
health policies for a great nation for many years were determined solely by the opinions
—sometimes the whims and personal prejudices—of a single individual. It would have
been a much better plan if Dr. Stephen Smith’s half formulated plan of 1883 could have
been carried out, thus salvaging the really important features of the National Board of
Health and incorporating in it a service agency with a full-time personnel, an esprit de
corps, and a strong central administrative machine. The members of the Board of Health
selected by the President of the United States because they were public health experts,
should have been continued as a Board of Health and should have served as a per-
manent policy-forming body, advising and aiding their administrative officer. The
Marine Hospital Service was the most logical existing national agency with which to
vest this national public health function. The Surgeon General should have been made
the executive officer of the Board, and all actual administrative responsibility should
have been centered in him. It was a great opportunity to have organized a close-knit,
effective National Health Service, but there was no single man who had the vision or the
power to solve this simple problem. *

The United States Public Health Service. To consider the history and de-
velopment of the United States Public Health Service, which is the most im-
portant Federal health agency at the present time, it is necessary to retrace our
steps to the year 1798. The United States of America, as a new nation, had just

 

*Smillie, W. G.: The National Board of Health, 1879-1883, Am. J. Pub. Health 33:925-930,
Aug. 1943.
BACKGROUND AND DEVELOPMENT 53

come into existence. Though still largely undeveloped, it was already vigorous
and enterprising. One manifestation of this was its already expanding maritime
trade. Sailing ships for world commerce were coming down the ways at an ever-
increasing rate and the maritime service was becoming one of the nation’s most
important occupations.

The farmer of Virginia and the tradesman of Boston had roots which were
firmly established in their respective communities which they were helping to
support in the form of taxation. The merchant seaman, on the other hand, led a
precarious existence somewhat resembling that of the itinerant or vagabond. In
a great many instances he had neither a permanent abode nor a permanent
route. His ship was the closest approach to a home, and his ship might be in
New York Harbor one week, in Charleston the next, and in Liverpool within
a month. Despite this, he too was an American citizen and deserving of what
security and assistance his nation could find possible to provide its citizens. For
a period, however, things did not work out that way. Like anyone, the sailor
was subject to injury or illness. In fact, because of the hazards of his occupation
he was subject to greater than average risk. Furthermore, he was not overpaid,
and what payment he received at the end of a journey was more often than not
quickly removed from him in the taverns and brothels which thrived in the
vicinity of the wharves. As a result, he usually found it difficult or impossible
to pay for whatever medical or hospital care he needed. Because he paid no local
or state taxes and usually was not a member in good standing of whatever port
city he happened to be in when ill, responsibility for him was usually avoided
by the local authorities.

The young American Congress, becoming conscious of this undesirable state
of affairs, passed a Marine Hospital Service Act in June, 1798, which authorized
the President to appoint physicians in each port to furnish medical and hospital
care for sick and disabled seamen. Twenty cents a month was deducted from the
pay of each man, the money being collected from the paymasters by the custom
officers of the Treasury Department. Since the money was placed in the custody
of the Treasury Department, there came about the somewhat anomalous situation
whereby until 1935 the majority of the Federal public health services were carried
out under the aegis of the Treasury Department. The small sum of twenty cents
per month, subsequently increased to forty cents per month, is of particular in-
terest in that it actually represented a sickness insurance payment and provides
the precedent for the first prepaid comprehensive medical and hospital insurance
plan in the country, under the administrative supervision of what eventually
became a public health agency. In 1884, the tax of forty cents a month was dis-
continued and replaced by a tonnage tax. The tonnage tax is still collected but
now goes into the general Treasury from which appropriations are made for the
support of the marine hospitals.

At first the physicians serving the plan were also engaged in the private prac-
tice of medicine, but before long the demands for service became so great that
the full-time employment of physicians was indicated. Originally sailors needing
hospital care were placed in whatever public or private hospitals existed at the
ports. However, as in the case of the physicians, the demand for hospital services
56 INTRODUCTION: PUBLIC HEALTH

 

soon became so great that within two years (1800) the first marine hospital was
constructed at Norfolk, Virginia. This was followed by similar hospitals through-
out the country, at first at certain seaports and later at a number of places along
inland waterways. At the present time (November, 1959) there are sixteen hospi-
tals officially referred to as Public Health Service Hospitals. Twelve are general
hospitals at Staten Island, Baltimore, New Orleans, Seattle, San Francisco, Nor-
folk, Boston, Detroit, Chicago, Savannah, Galveston, and Memphis. The other
four are the Tuberculosis Hospital at Manhattan Beach, New York; the National
Leprosarium at Carville, Louisiana; and the two hospitals for drug addicts and
certain other mental conditions at Lexington, Kentucky, and Fort Worth, Texas.
The total capacity is approximately 6500 beds. In addition, outpatient facilities
are operated in twenty-six cities. The Service also maintains contract arrange-
ments in about one hundred cities where the use ol non-Service facilities is eco-
nomically more feasible. In addition, fifty-five hospitals are operated exclusively
for American Indians and Eskimos.

Through time, eligibility for admittance to Public Health Service Hospitals
has been broadened and now United States merchant seamen constitute less than
50 per cent of all patients. Eligibility now includes:

I. Seamen from all American documented vessels and [rom vessels of the
United States Government (other than those of the Panama Canal) if of
more than 5 tons’ burden, and seamen and cadets in training on State
school ships.

2. Ofhcers and enlisted men of the United States Coast Guard, active and re-
tired.

3. Keepers and asisstant keepers, United States Lighthouse Service, active
and retired.

4. Injured Federal employees receiving care under supervision of the Bu-

reau ol Employee's Compensation.

Persons afflicted with leprosy, those subject to drug addiction, and those

with certain other specific mental conditions.

6. Personnel of the United States Coast and Geodedic Survey.

7. Officers of the Public Health Service and their dependents.

or

Foreign seamen, beneficiaries of the United States Veterans Administration,
Army, Navy, and dependent members of the families of commissioned and en-
listed men of the Coast Guard are admitted and treated as pay patients. It is
interesting that a medical director or supervising surgeon for the service was not
appointed until 1870. His compensation at the time amounted to a salary of
$2000 plus travel expenses. This position was later to become the surgeon general-
ship.

The growing concern of the state and Federal governments with the need
for preventing the introduction of epidemic diseases led to the passage in
1878 of the first port quarantine act. Entry into the country was limited to its
ports and as a consequence it was readily realized that the ports were the nation’s
first line of defense against epidemic diseases. Since the incidence of these diseases
was invariably greater at ports, the physicians of the Marine Hospital Service
BACKGROUND AND DEVELOPMENT 57

 

had more opportunity to see and become acquainted with them. In addition,
since epidemics usually began at the ports and frequently got out of hand, the
states had developed the custom of asking or authorizing the federally employed
Marine Hospital Service physicians to aid in the control of local situations. It
was logical, therefore, that the responsibility for carrying out the new port quar-
antine activities should have been placed in the Marine Hospital Service. Quar-
antine stations presently operate in twenty-three ports.

The law of 1878 embodied another most important new departure, since it
gave authority for investigating the origin and causes of epidemic diseases, espe-
cially yellow fever and cholera, and the best methods of preventing their intro-
duction and spread. With but little delay, attempts were begun to prevent the
entry of communicable disease by control measures carried out at the ports of
origin of those who might potentially be carriers of disease. Marine Hospital
Service physicians were attached to the offices of the consular service in major
foreign ports and a system of reporting communicable disease through the con-
sular service was put into effect. In 1890 domestic quarantine was added, pro-
viding for interstate control of communicable disease. This was an immediate
outgrowth of a particularly devastating epidemic of yellow fever which began
at New Orleans and spread throughout the Mississippi Valley. Between the time
of the Louisiana Purchase in 1803 and the beginning of the twentieth century,
New Orleans experienced no fewer than thirty-seven severe epidemics of yellow
fever, to say nothing of constantly recurring outbreaks of cholera, plague, and
smallpox.

In 1890 Congress gave the Marine Hospital Service authority to carry out
medical inspections of all immigrants. This was intended first to bar lunatics
and others unable to care for themselves, but in the following year “persons
suffering from loathsome and contagious diseases” were added. In that year,
Congress also saw fit to provide quasi-military status for the personnel of the
Marine Hospital Service, so the men were given commissions and uniforms.
The year 1901 saw the establishment of the Hygienic Laboratory. Fortunately,
from the start it was developed with such skill, imagination, and foresight that
it soon became one of the world’s leading centers of public health and medical
research. Originally organized in three divisions of chemistry, zoology, and phar-
macology, its functions were expanded in 1912 by an act authorizing the labora-
tory to “study and investigate the diseases of man and conditions influencing the
origin and spread thereof including sanitation and sewage, and the pollution
directly or indirectly of navigable streams and lakes of the United States and
may from time to time issue information in the form of publications for the use
of the public.” Under consistently able direction, the Hygienic Laboratory, which
was later to become the National Institutes of Health, attracted and developed
a steady stream of outstanding investigators including Carter, Sternberg, Rosenau,
Goldberger, Frost, Leake, Armstrong, Stiles, Lumsden, Francis, Spencer, Maxcy,
and Dyer, to name but a few. The contributions of these men and their co-
workers caused Dr. William H. Welch to state publicly that there was no research
institute in the world which was making such distinguished contributions to
basic research in public health.
58 INTRODUCTION: PUBLIC HEALTH

 

In 1902, recognizing that the Marine Hospital Service had come of age,
Congress renamed it the Public Health and Marine Hospital Service and gave
it a definite form of organization under the direction of a surgeon general. The
reorganization act was ol further significance in that for the first time the Surgeon
General was authorized and directed to call an annual conference of all state
and territorial health officers. In 1912 the Service experienced another change
in title, this time to the United States Public Health Service.

From this point on, the Public Health Service grew rapidly under the im-
petus of an increasingly complex society, two great wars, and an economic depres-
sion. In 1917 the National Leprosarium at Carville, Louisiana, was established.
In the same year, the Service became responsible for the physical and mental
examination of all arriving aliens. The year 1917 is noteworthy also for the
Congressional appropriation of $25,000 for the Public Health Service to spend
in cooperating with the states on studies and demonstrations in rural health work.
This modest appropriation represented the beginning of a new administrative
approach in Federal-state public health relationships. In 1918, because of prob-
lems brought to public awareness by our entry into the First World War, a
Division of Venereal Discases was created with power to cooperate with state
departments of health for the control and prevention of these diseases. In 1929
a Narcotics Division, later renamed the Division of Mental Hygiene, was created
with hospital facilities at Lexington, Kentucky, and Fort Worth, Texas, for the
confinement and treatment of narcotic addicts.

Developments of far-reaching consequence occurred in 1935 with the passage
of the Federal Social Security Act. Title VI of the act which relates to the Public
Health Service was written “for the purpose of assisting states, counties, health
districts, and other political subdivisions of the states in establishing and main-
taining adequate public health service, including the training of personnel for
state and local health work. . ..” Associated with the act was an appropriation
which made possible grants-in-aid to the states and territories according to
budgets submitted to the Surgeon General and approved by him. This brought
with it a most difficult administrative problem for the Service, which has con-
stantly attempted to determine an equitable basis on which the funds may be
distributed. While subject to frequent adaptation, an attempt has been made to
allocate these funds on the basis of four factors: (1) population, (2) public health
problems, (3) economic need, and (4) training of public health personnel. The
method of allocation has carried with it an educational value for state legislators
since considerable proportions of the grants-in-aid must be matched by existing
state and local appropriations. Results were rapidly forthcoming. More than a
year after the funds first were made available, not only was there a marked in-
crease in the number of new local health departments but, in addition, nineteen
states which did not already have such service set up central facilities for the
promotion and supervision of local health administration; thirty-three state
health departments strengthened their public health engineering forces; eleven
added new units for the investigation and promotion of industrial hygiene; pre-
ventable disease control groups were materially strengthened in twenty-four
states; in twenty-seven states the laboratory facilities were augmented; nineteen
BACKGROUND AND DEVELOPMENT 59

 

 

states made needed improvements in the personnel and equipment for vital
statistics; public health nursing was strengthened either directly or indirectly in
practically all the states; eleven states provided special measures for syphilis con-
trol, and thirteen states provided measures for the control of tuberculosis.?!

The program of the Service was further broadened by the passage of the
National Cancer Act in 1937 which provided for the establishment of a National
Cancer Institute for research relating to the cause, diagnosis, and treatment of
cancer, for assistance to public and private agencies, and [or the promotion of the
most effective methods of prevention and treatment of cancer. In 1938, a second
Federal Venereal Disease Control Act was passed, designed to promote the in-
vestigation and control of the venereal diseases and to provide funds for assistance
to state and local health agencies in establishing and maintaining adequate
measures to that end.

In 1939 as part of President Roosevelt's program for the reorganization and
consolidation of Federal services, a Federal Security Agency was created for the
purpose of bringing together a large part of the health, welfare, and educational
services of the Federal government. After one hundred forty-one years, only nine
years less than the life of the nation itself, the Public Health Service left the
now anachronistic administrative jurisdiction of the Treasury Department. At
that time, the Service had the following eight divisions, each under an assistant
surgeon general:

I. Division of Scientific Research (including the National Institute of Health and the
National Cancer Institute)
II. Division of Domestic Quarantine (including State Relations)
ITI. Division of Foreign and Insular Quarantine
IV. Division of Sanitary Reports and Statistics
V. Division of Marine Hospitals and Relief
VI. Division of Mental Hygiene
VII. Division of Venereal Disease Control
VIII. Division of Personnel and Accounts

Since that time, the Service has undergone additional reorganizations, first
as a result of the Public Health Service Act of 1944, and again more recently in
1954 in order to achieve greater organizational efficiency. The present structure
is shown in Figure 22, p. 360. During the interval many further developments of
consequence have occurred. In 1946, the Congress passed the Hospital Survey and
Construction (Hill-Burton) Act, which placed upon the Public Health Service
administrative responsibility for a nationwide program of hospital and health
center construction. Each year since 1947, the Congress has appropriated from
75 to 150 million dollars for this purpose; the Federal contributions are to be
matched by from one third to two thirds of state and local funds. In 1954, the
Congress enlarged the program to permit Federal assistance in the construction
of other types of health facilities, as well as hospitals and health centers. Now
eligible are general hospitals, mental hospitals, tuberculosis hospitals, chronic
disease hospitals, public health centers, diagnostic and treatment centers, rehabil-
itation [acilities, nursing homes, state health laboratories, and nurse training
facilities.
00 INTRODUCTION: PUBLIC HEALTH

 

In 1946, the National Mental Health Act was also passed. This measure
authorized 714 million dollars for the erection and equipment of hospital and
laboratory facilities to be operated by the Public Health Service as a stimulating
center for research and training in the field of mental health; 10 million dollars
for grants to states; and an additional million dollars for demonstrations and
personnel to assist the states.

In 1948, a National Heart Institute was authorized by the Congress and three
other institutes—the Microbiological Institute, the Experimental Biology and
Medicine Institute (these two later joined to form the National Institute of
Allergy and Infectious Diseases), and the National Institute of Dental Research—
were established by regrouping existing units, and the National Institute of
Health became the National Institutes of Health. In 1949, the activities of the
Mental Hygiene Division were transferred {from the Bureau of Medical Services
to the National Institutes of Health to form the National Institute of Mental
Health. In 1950, the National Institute of Neurological Diseases and Blindness,
and the National Institute of Arthritis and Metabolic Diseases came into being,
with the latter taking over the activities of the Experimental Biology and Medi-
cine Institute which was then abolished.

In order to accelerate research, its confirmation and its final acceptance, the
Public Health Service in 1952 completed and opened the National Clinical Center
on the grounds of the National Institutes of Health in Bethesda, Maryland. This
is a research hospital of 500 beds, with twice as much space for laboratories as for
patient care. Each Institute of the National Institutes of Health has space for
patients and laboratories in close proximity. Patients are admitted only when
they meet the requirements of a particular study being conducted by one or more
Institutes. A patient chosen by a particular Institute, for example, may be one
of a group of patients with the same type of condition at the same stage and
site. Often factors such as the patient's sex, age, and weight must also be taken
into consideration. Patients may be accepted from any part of the country.

The planning and conduct of research in the Clinical Center is the respon-
sibility of each Institute. When a problem is selected, the methods of approach
are determined by a research team, which may include scientists from more than
one Institute and from other research organizations.

Special provisions are made so that outstanding laboratory scientists and
research physicians from other institutions may work in the Clinical Center, for
periods ranging from a few months to a year or more, on problems of their own
choosing. As a result, investigations involve numerous scientific fields and widely
varying viewpoints, bringing laboratory and clinical workers into close daily
association in a search for answers both to basic scientific and to practical
problems.

The staff of the Clinical Center immediately responsible for the care of a
patient maintains intimate working relationships with the physicians and insti-
tutions who send patients to the Center. This professional liasion is particularly
important for effecting the extended follow-up frequently needed on patients
after they leave the Center—follow-up which in some cases may be needed for
five to ten years or even longer. In some instances, this liasion is so close that for
BACKGROUND AND DEVELOPMENT 01

all practical purposes the referring physician is a member of the research team,
and the Clinical Center becomes a major addition to the resources used by the
physician for the continuing benefit of his patients.

Among the important postwar developments in the Public Health Service
were the establishment of the Taft Sanitary Engineering Center in Cincinnati
and the Communicable Disease Center in Atlanta, as national headquarters for
sanitary and epidemiological intelligence, planning, and research. In 1956, The
National Library of Medicine was transferred to the service.

The cumulative effect of the foregoing developments has been a remarkable
growth in the size and usefulness of the Public Health Service. This growth may
be illustrated in one way by means of expenditures. In 1900 the budget of the
Marine Hospital Service was $1,371,000; now the total funds available to the
Public Health Service is about 300 million dollars. This has been accompanied
by a corresponding increase in the number of employees, who now total about
2,600 regular corps commissioned officers and about 5,000 reserve officers in the
various professional categories. In addition there are about 13,000 full-time and
about 5,000 part-time civilian employees. About 4,500 of these individuals serve
without compensation as collaborating epidemiologists.

Through the years, great responsibilities have been placed upon the Service.
Fortunately, it is possible to state that the Service has met its opportunities and
responsibilities well, as is readily evident from its admirable record.22

The Children’s Bureau. Standing next in importance to the Public Health
Service in Federal health activities is the Children’s Bureau. The conception,
establishment, and development of this specialized agency are worthy of con-
siderable study by students of public administration. While appearing on the
surface to be concerned with matters of a noncontroversial nature, the Bureau
from its inception has found itself in the position of principal in many disputes,
and the target of not a few administrative and ideologic struggles.

The idea of a separate Children’s Bureau was first suggested to President
Theodore Roosevelt in New York City.? As pointed out later by Julia C. Lath-
rop,?* who served as the first chief of the Bureau from 1912 to 1921, it was no
conincidence that “this bureau was first urged by women who have lived long in
settlements and who by that experience have learned to know as well as any per-
son in this country certain aspects of dumb misery which they desired through
some governmental agency to make articulate and intelligible.”

With little delay the support of numerous protagonists was obtained, among
them the National Consumers League, the National Child Labor Committee,
many national women’s organizations, and church groups. Arguing for a center
of research and information concerning the welfare of mothers and children, they
maintained an active lobby and pressure group in Washington until their goal
was ultimately obtained. One of their most effective arguments was that the
Federal government had already set a precedent by establishing centers of research
and information in other fields relating to national resources and that it might
well become similarly concerned with its most important resource, the mothers
and children of the nation. Between 1906 and 1912, many bills concerned with
the establishment of a Children’s Bureau were introduced and extensive hearings
02 INTRODUCTION: PUBLIC HEALTH

held on each. Both President Theodore Roosevelt and later President Taft gave
support to the movement, which incurred but little opposition. Eventually Con-
gress was spurred to final action and passed a measure sponsored by Senator
Borah on April 9, 1912.

One of the reasons for delay had been the placement of the proposed Bureau
in the Federal governmental structure. The three possibilities suggested were
the Bureau of Labor and the Bureau of the Census, both in the Department of
Commerce and Labor, and the Bureau of Education in the Department of the
Interior. It may be noted that the United States Public Health Service, then in
the Treasury Department, was not considered. This may have been due to the
submergence of the health aspects by the broader social service aspects of the
proposed Bureau. The failure on the part of the Public Health Service to con-
cern itself with the problem at the time was to lay the groundwork for subsequent
controversies over administrative jurisdiction and organization.

The Act of 1912 which established the Children’s Bureau? placed it as an
agency in the Department of Commerce and Labor. When this Department was
divided the following year, the Bureau was retained by the Department of Labor.
The act directed “that said Bureau shall investigate and report . . . upon all
matters pertaining to the welfare of children and child life, among all classes
of people, and shall especially investigate the questions of infant mortality, the
birth rate, orphanages, juvenile courts, desertions, dangerous occupations, acci-
dents, and diseases of children, employment, legislation affecting children in the
several states and territories.” While originally given authority merely to investi-
gate and report, the Bureau trained a highly technical staff of experts who rap-
idly gained in experience. The Bureau thus became the natural agency to be
entrusted with new programs dealing with problems of maternal and child wel-
fare. During the early years of its existence, the Bureau, in accordance with
Congressional direction, followed a path of extensive and fruitful scientific re-
search and dissemination of information. Many studies were made of the effect
ol income, housing, employment, and other factors on the infant and maternal
mortality rates. These studies led to the White House Conferences on child
health, the first of which was held in 1919. Evidence gathered in some of the
investigations was used by the National Child Labor Committee in obtaining
the passage of the Federal Child-Labor Law in 1915. This law, with the Children’s
Bureau designated as the administering agency, was effective from 1917 to 1918
when it was declared unconstitutional by the Supreme Court.

Study of maternal and infant care problems in rural areas led to the intro-
duction of bills intended to encourage the establishment of maternal and child
welfare programs by means of grants-in-aid to the states. The Children’s Bureau,
designated in the bills as the administering and supervising agency, quickly
found itself the subject of attacks from a number of quarters. It was argued that
the adoption of the Sheppard-Towner Bill would provide an entering wedge
for socialized medicine, that it would centralize power in the hands of Federal
bureaucrats, and that personal, family, and states’ rights would be violated. The
American Medical Association, the Anti-Suffragists, the Sentinels of the Republic,
and a number of other organizations arrayed themselves in opposition.
BACKGROUND AND DEVELOPMENT 03

 

During the hearings, a controversy that had begun to smolder between the
Public Health Service and the Children’s Bureau broke through. Some of the
opponents of the bill were willing to compromise by favoring administration
by the Public Health Service. The decision depended on whether the chief con-
cern of the bill was with health or with general child welfare. The Congress,
deciding upon the broader viewpoint, retained the Children’s Bureau as the
administering agency when final approval was given in 1921. One authority26 has
pointed out that unquestionably the Bureau was able to maintain its position
“by right of discovery and occupation and that the Public Health Service had
been derelict in not promoting this type of work with sufficient vigor to maintain
its belated claim to jurisdiction.” In their analysis of the Emergency Maternal
and Infant Care Program, Sinai and Anderson®? in referring to this conclusion
observe that it merits reading and rereading by public health officers today. They
point out that when the suggestion of a governmental health plan arises, one
of the first concerns is with the agency of administration and that control by
right of occupation has occurred more often than not in government.

The Sheppard-Towner Act in a very real sense established a pattern for ma-
ternal and child health programs throughout the country. It provided for Federal
assistance to states in the form of grants-in-aid for use in attacking problems of
maternal and infant welfare and mortality. The states were given authority to
initiate and to administer their own plans subject to approval by a Federal Board
of Maternity and Infant Hygiene consisting of the Chief of the Children’s Bu-
reau, the Surgeon General of the Public Health Service, and the Commissioner
of Education. Prior to the passage of the act, thirty-two states had established
divisions or bureaus of child hygiene. During the following two years, an addi-
tional fifteen states developed programs of this nature. While it is difficult to
conclusively prove a causative relationship, the Children’s Bureau is generally
given major credit for the increased interest and action.

The original act provided for a five-year program. In 1926 a bill was intro-
duced for the extension of the act to seven years. This provided opponents with
another opportunity for attack. The two-year extension, although granted, sig-
naled the end of the program, further efforts to continue it being fruitless. The
importance of the Federal aid was well illustrated by the fact that following ex-
piration of the program thirty-five states decreased appropriations, nine elimi-
nated appropriations, and only five states reported increases for the maternal and
child health program.

With the adoption in 1935 of the Social Security Act, the Children’s Bureau
not only regained its lost functions but added to them. Under Title V of the
Social Security Act, the Children’s Bureau was given responsibility for the ad-
ministration of programs dealing with maternal and child health, crippled chil-
dren, and child welfare services. To implement these ends, the Bureau was allotted
an annual budget of $8,170,000 for grants-in-aid exclusive of administrative costs.
In 1939, this sum was increased to 11 million dollars and in 1946 to 22 million
dollars. Within ten months after the grants-in-aid became available, all of the
forty-eight states, the District of Columbia, Alaska, and Hawaii submitted re-
64 INTRODUCTION: PUBLIC HEALTH

 

quests and plans for approval. In this way, state maternal and child health pro-
grams received a much needed transfusion.

By now, there is ample evidence of the success of the pioneering and stimu-
lating efforts of the Children’s Bureau. Thus, whereas in 1940, Federal contribu-
tions accounted for 48 per cent of the total spent for maternal and child health
activities, in 1954 it was only 26 per cent. Furthermore, whereas in 1940 state
and local funds for this purpose were 37 per cent in excess of the amount needed
for matching Federal funds, in 1954, 83 per cent of the state and local funds
was over and above what was needed for matching.28

With entry of the United States into the Second World War and the subse-
quent draft of a large proportion of the male population, many wives, expectant
mothers, and infants found themselves in somewhat precarious economic positions
which were reflected in their inability to pay for private obstetric and medical
care. Congress, becoming aware of the problem in 1943, decided to take action.
It considered the Children’s Bureau to be the logical Federal agency for the ad-
ministration and supervision of the program of aid which it decided upon.
Once again the factor of prior interest and occupation decided the issue of ad-
ministrative jurisdiction. The Children’s Bureau had attempted, to the best
of its ability and using some of its grants-in-aid funds, to do what it could to
alleviate the situation. Congress decided to take action by means of supplement-
ing the grants-in-aid funds of the Bureau. As a result, a series of appropriation
acts were passed involving a total of more than 130 million dollars. The use of
these sums made possible the provision of much-needed obstetric care to about
1,200,000 expectant mothers and of pediatric care for about 200,000 infants.
An incidental but significant result was that the staffs of the Children’s Bureau
and of the State Health Departments obtained an invaluable experience in the
administration of a medical care program. For many public health administrators
to have had this experience cannot help but be advantageous.

At the present time, the Children’s Bureau is continuing and expanding its
leadership in many fields, including audiology, prematurity, rheumatic fever,
epilepsy, cerebral palsy, mental retardation, juvenile delinquency, nutrition of
growth and development, problems of children of migratory workers, and chil-
dren’s dentistry.

The Department of Health, Education, and Welfare. In 1946 the Federal
Security Agency underwent further accretion and the various Federal health serv-
ices were further consolidated by the transfer of the Children’s Bureau from the
Department of Labor, and the Food and Drug Administration from the Depart-
ment of Agriculture. At about the same time the National Office of Vital Statistics
was transferred from the Bureau of the Census of the Department of Commerce
to the Public Health Service. In this way the activities of the agencies concerned
with various aspects of health and sanitation were brought into closer working
relationship. Then in 1953, the first move taken by President Eisenhower in
reorganizing the Executive Branch of the Government was to propose that the
Federal Security Agency be granted Cabinet status. The proposal became fact
on April 11, 1953 when the Congress established the Department of Health, Edu-
cation and Welfare. On the same day, the first Secretary of the newly-created
BACKGROUND AND DEVELOPMENT 05
Executive Department of Health, Education and Welfare was sworn in office.
The organization of the Department is shown in Figure 21, p. 353.

The Voluntary Health Agencies. While the official, governmental or public
health agencies were still in the process of development, a complementary and
supplementary force appeared in the form of the voluntary or nonofficial health
agencies. Beginning with the establishment of a local antituberculosis society in
1892, the voluntary health movement soon developed considerable force and
magnitude. Spurred by public interest, desire for private philanthropy, and
sometimes by impatience or dissatisfaction with governmental programs, over
20,000 such agencies were established during the ensuing hall century. They
draw voluntary support from literally millions ol persons and serve millions of
others.

Not infrequently the development of these agencies has been intimately
bound to certain strong and appealing personalities such as Beers, Trudeau,
Wald, and Franklin Roosevelt. One interesting aspect ol their development is
that while some, such as the Tuberculosis Associations, began locally and spread
upward to state and national societies, others such as the National Foundation
for Infantile Paralysis began on the national level and spread downward. Still
others, notably the Mental Hygiene Associations, began on the state level and
spread both upward and downward.

One phase of the voluntary health movement, visiting nursing, deserves par-
ticular mention. Dr. William Welch once singled out public health nursing as per-
haps America’s greatest contribution to the public health movement. It had its
origin in 1877 in the Women’s Branch of the New York City Mission and was
organized for the purpose of teaching hygiene in the homes ol the underprivi-
leged. In 1902 Lillian Wald organized the first school nursing program in New
York City, setting up a pattern which was rapidly followed throughout the
nation. Largely from these modest beginnings developed the adoption of public
health nursing as a most important part of any public health program.

County Health Departments. In the year 1910-1911 there occurred in Yak-
ima County, Washington, one ol a series of severe typhoid fever epidemics. Be-
cause it was uncontrolled by local authorities, Dr. Lumsden of the United States
Public Health Service was loaned to bring it under control. In his own colorful
manner, Dr. Lumsden not only solved the particular epidemiological problem but
went on to suggest ways of preventing its recurrence. One ol his strongest recom-
mendations dealt with the desirability ol establishing a full-time resident staff to
deal with all public health matters. Meanwhile, the Rockefeller Sanitary Com-
mission, which had been working in the southeastern United States as well as in
Central America and South America, came to the conclusion that no single dis-
ease, sanitary problem, or public health problem could be successfully attacked
without concurrent efforts aimed at all phases of public health. As a result, they,
too, strongly recommended the establishment of local full-time resident public
health staffs. There resulted the interesting situation whereby at almost the same
moment, at two different places for two different although related reasons, the
first full-time county health departments were established: Guilford County,
00 INTRODUCTION: PUBLIC HEALTH

North Carolina, June, 1911, and Yakima County, Washington, July, 1911.* The
fundamental soundness ol the approach is given testimony by the continual
adoption of the principle so that at the present time about three fourths of the
population have local health services. The pursuit of the principle to its ultimate,
complete coverage of the nation now represents one of the chief aims of all who
are interested in public health, sociology, and medicine.

Development of Professional Training. The appointment ol health offi
cers for many towns and districts in mid-nineteenth century England led to the
establishment of a course of lectures on public health at St. Thomas’ Hospital.
This was the first training ol its kind in England and led to the development
of a number of excellent curricula and schools devoted specifically to the subject.
Despite the many parallel interests and activities, no facilities existed in the
United States for specialized training or education in public health until 1910.
Since sanitary science and engineering were perhaps of predominate interest at
the time, it is not illogical that the first teaching ol public health was carried out
particularly in relation with engineering. The first specific public health degree
was awarded in 1910 at the University of Michigan. Beginning in 1912, a pro-
gram of study was organized at the Massachusetts Institute ol Technology by
William T. Sedgwick, whose strong personality sent forth a large series of out-
standing disciples in the new profession. Alter a few years, realizing that the en-
vironmental phases represented only a part of the total public health picture,
there was formed a joint Massachusetts Institute of Technology-Harvard School
of Public Health, which later divided when Harvard established its own separate
School of Public Health. Meanwhile, the first school ol public health (now de-
funct) was organized at the University ol Pennsylvania.

In considering these early attempts to establish public health training on a
high professional level, we again encounter the name ol Rosenau, who served as
co-director of the joint M.L.'T.-Harvard school, whence he lelt to assume chairman-
ship of the division ol preventive medicine in the Harvard School of Medicine.
It was about this time (1913) that Rosenau brought out the first edition of his
world famous volume, Preventive Medicine and Hygiene. One public health
authority, Wilson G. Smillie, has commented that there can be little doubt but
that this one book has done as much to advance public health as any other single
factor. It is ol interest in passing that Dr. Rosenau in his perennial youthfulness
of mind, on reaching the age ol retirement at Harvard in 1936, went on to es-
tablish and direct another school ol public health at the University of North
Carolina before his death in 1946.

In connection with professional education and training in public health,
recent years have seen many worth-while developments. In the process, the Com-
mittee on Professional Education ol the American Public Health Association has
played a most significant role in stimulation of thought and discussion, crystali-
zation ol ideas, and in the development and implementation of programs for the
improvement of the quality of public health personnel. This is exemplified in its

*Some difference of opinion exists with regard to priority, many contending that Jefferson
County, Kentucky, was first in the field in 1908.
BACKGROUND AND DEVELOPMENT 07

 

current activities, which include the accreditation of schools of public health, the
development of statements on educational qualifications of personnel in the
various public health disciplines, the development of field-training methods and
standards, the conduct ol a professional examination service, the development of
recruitment programs, and the study of public health salaries.

Returning for the moment to academic training, as more and more demand
developed for public health services, many schools and universities began to
offer a wide variety of degrees in public health, often on a questionable basis. In
1911 the leading schools formed the Association of Schools of Public Health.
This stimulated a study by the Committee on Professional Education which led to
the development and application by the Committee in 1916 of a system of accredi-
tation for the granting of recognized degrees in public health. At the present time
(1959) there are thirteen schools so accredited—University of California, Columbia
University, Harvard University, Johns Hopkins University, University of Michi-
gan, University ol Minnesota, Montreal University, University of North Carolina,
University of Pittsburgh, University of Puerto Rico, University of Toronto, Tu-
lane University, and Yale University. The Association maintains contact with
other centers of public health education elsewhere in the world, notably those
in Mexico, Chili, Brazil, and several other Latin American countries, Britain,
France, and the American University at Beiruit in Lebanon. In recognition of
the fact that the accredited schools in the United States serve regional, national
and, indeed, international needs, a number ol bills calling for the provision of
Federal subsidization have been introduced into the Congress during the past
few years. The first definitive result occurred in 1958 when the sum of one mil-
lion dollars was appropriated lor strengthening the accredited schools.

In early 1949, recognizing that the full-time practice of preventive medicine
and public health had long since become a specialty in the medical profession,
the American Board ol Preventive Medicine and Public Health was organized
under the joint sponsorship of the American Medical Association, the American
Public Health Association, the Association of Schools of Public Health, the
Canadian Public Health Association, and the Southern Medical Association.
Rigid standards and requirements with regard to training and experience were
developed, and an examination system was established, upon the satisfactory
completion of which candidates become certified as specialists in this field of
medical practice. Soon alter, in 1950, steps were taken for the development of ap-
proved field residency programs in acceptable public health organizations. Super-
vision and accreditation of these are under the joint aegis ol the American Board
of Preventive Medicine and Public Health and the Council on Medical Education
and Hospitals of the American Medical Association.

Since these last developments apply only to physicians, several of the other
professional disciplines involved in public health work are now in the process of
developing similar procedures for the accreditation of field training in their re-
spective specialties.

As a result of these many activities, the past decade has seen extensive im-
provements in all aspects of training, education, experience, and status of those
08 INTRODUCTION: PUBLIC HEALTH

 

who are devoting the energies of their professional lives to the improvement of
the health of the public.

REFERENCES

I. Rosen, George: A History of Public Health, New York, 1958, MD Publications Inc.

2. Top, F. H.: "The History of American Epidemiology, St. Louis, 1952, The C. V. Mosby Co.

3. Osler, William: "I'he Functions of a State Faculty, Maryland M. J. 37:73, May 1897.

1. Hecker, 1. F.: The Epidemics of the Middle Ages, Philadelphia, 1837, Haswell, Barrington

and Haswell.

5. Winslow, C-E. A: The Evolution and Significance of the Modern Public Health Campaign,
New Haven, 1923, Yale University Press.

6. George, M. Dorothy: London Life in the XVIIIth Century, New York, 1925, Alfred A.

Knopf.
Richardson, B. W.: The Health of Nations, A Review of the Works of Edwin Chadwick,
London, 1887 Longmans, Green & Co., vol. II.

8. Bowditch, H. I.: Address on Hygiene and Preventive Medicine, Transactions of the Inter-
national Medical Congress, Philadelphia, 1876.

&. Prescott, W. H.: History of the Conquest of Mexico, New York, 1936, Random House, Inc.

10. Woodward, S. B.: The Story of Smallpox in Massachusetts, New England J. Med. 206:1181,
June 9, 1932.

11. Chadwick, H. D.: The Diseases of the Inhabitants of the Commonwealth, New England J.
Med. 216:8, June 10, 1937.

12. Editorial: Has Baltimore the Oldest Health Department? Am. J. Pub. Health 35:49, Jan.
1945.

13. Newsholme, Sir Arthur: The Ministry of Health, London, 1925, G. P. Putnam’s Sons, Ltd.

11. Kramer, H. D.: ‘The Beginnings of the Public Health Movement in the United States, Bull.
Hist. Med. 21:369, 1947.

15. Holmes, O. W.: Writings, IX, Medical Essays, Boston, 1891, Houghton, Mifflin & Co.

16. Shattuck, Lemuel, and others: Report of the Sanitary Commission of Massachusetts: 1850
(Dutton and Wentworth, State Printers, Boson, 1850), Cambridge, 1948, Harvard Uni-
versity Press.

17. Patterson, R. S., and Baker, M. C.: Seventy-Five Years of Public Health in Massachuetts,
Am. J. Pub. Health 34:1271, Dec. 1944.

18. Cavins, Harold M.: The National Quarantine and Sanitary Conventions of 1857 to 1860

~1

and the Beginnings of the American Public Health Association, Bull. Hist. Med. 13:404,
April 1943.
19. Smith, Stephen: Historical Sketch of the American Public Health Association, Pub. Health
5:7, 1889.
20. Smillie, W. G.: The National Board of Health, 1879-1883, Am. J. Pub. Health 33:925, Aug.
1943.
21. Annual Report of the Surgeon General of the Public Health Service, 1936.
22. Public Health Service: General Organization, Functions, Procedures and Forms, Washington,
June 10, 1958, U.S. Government Printing Office.
23. The Children’s Bureau, Yesterday, Today and Tomorrow, Washington, 1937, U.S. Govern-
ment Printing Office.
24. Lathrop, Julia, C.: Children’s Bureau, Am. J. Sociology 18:318, Nov. 1912.
25. 37 Stat., 79, 737, 1912.
26. Key, V. O.: The Administration of Federal Grants to States, Chicago, 1937, Public Admin-
istration Service.
Sinai, Nathan, and Anderson, Odin W.: EM.I.C., A Study of Administrative Experience,
1948, University of Michigan.
28. Eliot, Martha: Child Health Problems: Federal-State Funds and Current Problems, Pub.
Health Rep. 69:66, Jan. 1954.

13)
~1
chapter 3

World health problems

 

Inadequacy of Data. The ultimate strength ol a nation is to be found in
the quantity and quality of its people. Everything else, including agricultural,
mineral, or industrial potentials, is ol value only to the extent and in the man-
ner in which they may be related to people. The quantitative measure ol a
people is, of course, the population, especially the numbers who are available to
produce goods or children. The qualitative measure ol a people is largely de-
termined by its degree of illness or health and the rates by which it dies or sur-
vives. Four factors are involved in the growth or decline of a nation’s popula-
tion—the numbers of births, deaths, immigrants, and emigrants. At the moment
we are not concerned with the last two. The first two, numbers ol births and
deaths, are of major social, economic, political, public health, and medical im-
portance to every nation. Beyond this, their relationship to similar factors in
other countries, especially those near by, is Irequently of utmost importance. It
therefore would appear fundamental to any consideration ol international prob-
lems or relationships that we have readily available an adequate body ol accurate
statistical data relating to the number of persons in each nation as well as the
rates and manner in which they are born, live, and die. Such, unfortunately, is
not the case. The student of international health problems is confronted at the
outset by gross inadequacies in this respect and is forced to work, to a consider-
able degree, on the basis of impressions, estimates, and generalizations.

It is not our purpose at this point to attempt to evaluate the completeness,
accuracy, or comprehensiveness of various national or international vital statistics.
However, it may be worth pointing out that, generally speaking, the more com-
plex industrialized and highly developed countries have the most exact and ade-
quate vital data available, whereas the lesser developed and younger nations, and
unfortunately many ol those with the most outstanding health problems, tend
to have the least satisfactory information about their people. One might generalize
and say that population enumeration and birth and death registration are rela-
tively good in the countries of Northern and Western Europe, in parts ol Central
and Southern Europe, in the British Dominions, in North America, and in
Japan. Conversely, they are less accurate, to varying degrees ol course, in most

09
70 INTRODUCTION: PUBLIC HEALTH
countries of Central and South America, in parts of Eastern and Southern
Europe, and in practically all of Alrica, the Middle East, and Asia.

Some General Observations. Despite the limitations ol inaccurate and in-
complete vital data, there does exist sufficient knowledge and information to in-
dicate considerable variation among countries with regard to the [ertility, health,
and longevity ol their populations. In evaluating these variations, it is important
to realize that many biological, environmental, and social lactors are involved.
Thus climate, the nature of the soil, food consumption and habits, physical in-
heritance, and habits of work or exercise may affect the fertility, health, and
mortality experiences of populations. Beyond these there are, of course, the in-
fluences ol public health facilities, medical and nursing services, housing stand-
ards, and occupational conditions. It is worth noting that even with regard to
these [actors there exist large gaps in our knowledge and understanding.

The key factor in determining the size ol a population is the extent to which
it can reproduce and maintain or increase itsell. Various methods have been
devised in order to measure this, the most common of which is the birth rate.
In general, there appears to exist an inverse relationship between the birth rate
and the degree ol development ol complexity ol a nation. Thus, the greater the
degree of industrial and scientific progress, urbanization, and elevation of the
standard of living, the more the birth rate tends to be depressed. There are, of
course, a number ol exceptions to this generalization. Nevertheless, birth rates
have declined rather consistently in the countries ol Europe, in the British Do-
minions, and in North America. By contrast birth rates have tended to fall less
or to have increased in the countries ol Asia, Africa, and Central and South
America.

The birth rate in itsell is neither a true measure ol human fertility nor indi-
cative ol the extent to which the number of births is sufficient to maintain or to
increase the population ol a nation. Because ol this, additional indices such as
the rate of natural increase and [fertility rates have been devised. The rate of
natural increase is simply the annual excess of births over deaths per thousand
population. In general this rate is highest [or the countries ol Alrica, the Middle
East, Asia, Southeastern Europe and in parts of Central and South America, and
is lowest in Northern and Western Europe and in North America. Even this rate
ol the numerical excess ol births over deaths, however, is not a conclusive indica-
tion of the ability ol a country’s population to reproduce itself. A particular
country at a given time may have a very large excess of births over deaths, yet
its birth rate, especially when determined in relation to the number of persons
of childbearing age, may not be high enough to eventually maintain the present
population. This can occur when a country has a temporarily high proportion
ol young adults due to immigration, or as a result of a mass delayed genetic
action, such as occurs during a period ol warlare followed by the return home
of large numbers ol young men. As a result of such circumstances, the birth rate
temporarily may be much higher than the death rate, but the gross numbers ol
births may not be large enough to maintain permanently such a favorable age
distribution. There results eventually a population with a relatively high pro-
WORLD HEALTH PROBLEMS 71
portion of older persons and a concomitant fall of the birth rate, even below
the level of the death rate.

In view of the foregoing, one might conclude that if the variations presently
observed continue, the trends of population growth in various countries will
differ in the future as compared to the past and present. North America, the
British Dominions, and many of the nations ol Europe will probably experience
stabilized or even decreasing populations unless their net reproductive rates in-
crease, their mortality rates decrease even more than they have, or major im-
migrations occur. The countries of Asia, Alrica, the Middle East, and Central
and South America on the other hand will have increasing populations if their
present fertility rates continue. In addition, barring the influence of other factors,
these increases will tend to be greatly magnified il mortality rates are subjected
to any considerable extent to even present-day scientific knowledge. It must be
remembered, however, that there are many [actors which might change or even
reverse these trends. Among the most important of these, it is believed, is the ap-
parently inevitable result of a lower birth rate in the face ol a continuous and
sustained elevation of the standard of living.

The crude death rate is one of the most common and convenient indices of
the health of a community or nation. In viewing the world scene, and despite
inadequate information, it is readily observed that in general the highest death
rates occur in the countries of Alrica, the Middle East, Asia, and parts of Central
and South America, as well as in a few Southern and Eastern European nations.
Significantly lower death rates are experienced by the countries of Western
Europe, the British Dominions, North America, and in a few countries of South
America. It is immediately apparent that the difference observed in the case of
birth rates between more highly developed industrialized countries and less de-
veloped and primarily agricultural countries exists also in the case of death rates,
but in a reciprocal sense. Progress in combatting preventable disease and reduc-
ing mortality has been closely related to the widespread application of advances
in medical, physical, and chemical sciences. This has occurred to the greatest
extent in the Western European countries and in North America, the most highly
industrialized and urbanized areas in the world. One may generalize, therefore,
by saying that death rates are lower in the more highly developed countries and
higher in the more underdeveloped countries. Similarly, one might say that death
rates tend to be lower in the more urbanized and industrial countries and higher
in the more rural and predominantly agricultural countries.

While this relationship appears to apply to many specific death rates, it is
by no means universally true. Certainly the relationship applies to the infant
death rate and the maternal mortality rate, as it also applies to the specific rates
ol death from almost all of the communicable diseases which can be controlled
by public health, sanitation, and immunization methods. One outstanding group
ol exceptions, however, does exist. Death rates lor the degenerative diseases of
middle and later life, such as cancer, hypertension, and the like, are in general
much higher in the economically more privileged and industrially and scientifi-
cally more advanced countries of Western Europe, North America, and Austral-
asia. This apparent difference is undoubtedly due to the higher proportion of
72 INTRODUCTION: PUBLIC HEALTH
persons who reach later lile as a result ol public health measures and to more
accurate cause-of-death reporting in the more advanced countries.

In addition to birth and death rates, but as a function of the latter, average
expectation of life should be considered briefly. The average expectation of life
varies considerably among the different nations of the world, from a low ol
perhaps about 30 to 35 years to a high of about 70 years. As would be expected
Irom the preceding consideration ol death rates, an average person's life ex-
pectancy is much greater in the countries of Western Europe, the British Do-
minions, and North America than it is in most of the rest of the world. The dil-
[erences between countries in this respect are significant at all age levels, but
appear to diminish consistently as one approaches the older ages. The logical
conclusion, upheld by a consideration of age-specific death rates, is that the
greatest risks to life in the underdeveloped and less privileged countries are ex-
perienced most by infants and young children and that once an individual has
passed these hurdles he stands a reasonable chance in most places of attaining
an advanced age.

One final interesting aspect ol the variation in death rates and life expect
ancies relates to the differences that are observed between races. That such dil-
lerences exist in general is not subject to question. It is not known, however,
whether the differences are related to inherent racial characteristics or to the
social and economic environment. In general one is inclined to feel that the
difference is circumstantial rather than inherent. This appears to be borne out
by the fact that the Negro in the new world, although he still has a somewhat
lower life expectancy and higher death rate than his white compatriot, never-
theless finds himsell in a decidedly more advantageous situation than do the
members of his race who are still in Africa. Furthermore, the discrepancy between
the rates lor whites and Negroes in the Western Hemisphere through time has
consistently become less. That the problem is not simple however is indicated
by the situation in Hawaii where the life expectancy ol native Hawaiians is
significantly less than for other races at every specified age except under one year.
In fact, Caucasian-Hawaiians also show a shorter life expectancy than Caucasians,
Japanese, and Chinese who live on the islands. The explanation for this and
similar phenomena remains to be determined.

Extent of World Health Problems. When one attempts to reduce a study
and analysis of world health problems to the lowest common denominators, the
conclusion is inevitable that a sound knowledge and consideration of two im-
portant but related fields is a prerequisite. These are the sciences of biology
and climatology in their broadest senses. Man is a biological being whose be-
havior, cultural development, physical development, habits of feeding, clothing,
and housing, and, it would appear at least to some degree, methods of political
organization are determined largely by biological factors, particularly his reaction
to his environment. By like token, the majority of the preventable illnesses to
which man is subject involve other biological beings: bacteria, viruses, protozoa,
helminths, insects, and the like. Intimately influencing the extent of favorable
development of man on the one hand, and ol these factors which may act to his
detriment on the other, is the climate of the environment in which he and they
WORLD HEALTH PROBLEMS 7J

are cast. A few examples will serve to illustrate these obvious points. Since man
is a satisfactory host [or the plasmodium of malaria and since he shares this un-
fortunate role with the mosquito, it is obvious that, in the absence of scientific
interference, humans affected by malaria are to be found most frequently in
areas where the climate is most conducive to the propagation of the mosquito.
Such conditions, of course, are found especially in the warm, moist, tropical, and
subtropical zones of the world. In contrast, it is to be expected that the serious
pulmonary infections are found most [requently in the less temperate climates
with wider and more frequent variations in temperature. These climatic con-
ditions are conducive to frequent upper respiratory diseases, which so olten are
the precursors of more serious illnesses ol the pulmonary system. Between these
two situations one might point to typhus fever which requires environmental and
climatic conditions which are not so cold as to discourage the propagation of the
louse, yet cold enough to cause the human host to wear considerable clothing,
usually in a continuous and unwashed manner. II climatic conditions are such as
to combine a certain degree of coldness with continued inadequacy of water,
thereby precluding bathing and the washing of clothing, that is better yet for
the rickettsia and the lice which carry them.

In view ol the foregoing, one would rightly expect to find that the greatest
incidence ol preventable disease at the present time is to be found in the warmer
areas of the earth. If the factors of biology and climatology were correlated with
the degree ol economic development and applied scientific knowledge (and in-
deed the latter would appear to be functions of the former) it would be possible
to sketch on a globe a broad zone, with necessarily indefinite borders and with
certain variations, which in general would overlap the equator about 20 to 25
degrees in both directions. This band or zone would include the areas ol the
earth in which are now found the bulk of the preventable infectious diseases and
premature deaths.

To most of those who reside permanently outside ol this zone the extent ol
preventable disease seems incomprehensible. Nevertheless, as Paul Russell has
said, “Nothing on earth is more international than disease.”

Consider first malaria, which is still the leading cause ol death in the world.
In India! “no less than 75 million persons suffer from it every year, and during
epidemic years the incidence may reach up to twice as much or even more. It
has been calculated that approximately hall of the 514 million annual deaths in
India are accounted for by fevers. Nearly one-seventh ol these fever deaths are
directly attributable to malaria. Apart from this high annual mortality, malaria
is also responsible for untold sickness and suffering. Untreated or partially-treated
malaria leads to general debility and anaemia, and reduces the resistance ol the
individual to other diseases. This results in an unduly high rate of morbidity.
Thus, by sapping the vitality of whole groups of population, malaria has been
largely responsible for impeding the development of the country’s agricultural
and other natural resources. The economic loss to the nation is therefore in-
calculable.” * In Liberia, 90 per cent of the children under five have positive blood

 

*Summary Proceedings of the First Meeting of the Central Council of Health held at Hydera-
bad January 29, 30 and 31, 1953, Govt. of India, Ministry of Health, p. 35.
74 INTRODUCTION: PUBLIC HEALTH

smears and 70 per cent of the adults are continuously infected. It is a constant
scourge of a large part of the lowlands of South and Central America, large
parts of Africa, and practically all of South and Southeast Asia. For the world as
a whole, it has been estimated that malaria claims about 300 million cases and
from 4 to 6 million deaths each year.

Bilharzia affects the populations of large parts of Africa, Northeastern South
America, Japan, and Southeastern China. In Egypt about three fourths of the
population are affected. For the Middle East it has been estimated that from 20
to 30 million or 90 per cent of the rural population suffer from this debilitating
disease which in general reduces the productivity of a population by at least
one third.? Wright? estimates its cost to Egypt at about 20 million pounds per
year. Lower Egypt is affected more than Upper Egypt. It is significant that 22
per cent of Army recruits from the former must be rejected for physical defects
compared with only 3 per cent from the latter.

Helminthic or worm infestations represent one of the greatest drains on
human energy and health. Some careful estimates have been made of their ex-
tent, and the resulting figures are staggering. To give a few examples, hookworm,
the aptly termed “assassin worm,” which is one of the worst scourges to suck
the lifeblood and strength of a population affects about 460 million persons
throughout the world, over 200 million in India alone. For the roundworm,
ascaris, an interesting and dramatic picture has been painted by Stoll.* The total
case load approaches 650 million persons. China's load alone has been computed
to be about 335 million cases with an estimated 6 billion adult ascarides. This
number of worms is equivalent to the combined weight of almost half a million
adult men and they consume enough food annually from the bellies of the al-
ready hungry Chinese to feed the entire populations of Guatemala and Costa
Rica together. It has been calculated further that this many worms together pro-
duce about 18,000 tons of microscopic eggs which are broadcast continuously
over the landscape. All together Stoll has estimated that while there are just under
2200 million people on earth, considering multiple infestations, there are just
over 2200 million cases of helminthic infestation among them. The larger share
of them are in the so-called underdeveloped areas of the world. He describes their
significance dramatically by saying, “Helminthiases do not have the journalistic
value of great pandemics like flu or plague . . . but to make up for their lack
of drama, they are unremittingly corrosive.”

In India there are more than 2 million blind, mostly from trachoma, gonor-
rhea, and syphilis. Many millions more are affected by trachoma to a degree less
than total blindness. An idea of the economic burden involved may be obtained
from figures from a much smaller country. Tunisia, with only 314 million inhabi-
tants loses an estimated 25 million work days per year because of trachoma.
Leprosy claims a world total of from 5 to 7 million cases. It is estimated that in
India a million persons and in China 2 to 4 million persons suffer from this
disease. In Alrica there are probably about 114 million cases. Some estimates for
Latin America include Brazil—40,000; Bolivia—12,000 to 15,000; Paraguay—
10,000 to 12,000; Argentina—12,000; Mexico and Colombia—9,000 each; and Peru,
Venezuela, and Cuba about 3,000 each. Yaws is one of the most important eco-
WORLD HEALTH PROBLEMS 75

 

nomic disease handicaps. Throughout the world it is estimated that there are
30 million cases, approximately hall of them in the new Republic of Indonesia.

With regard to tuberculosis, which may rightfully be considered a disease
ol poor economy, there are probably about 50 million cases and about 5 mil-
lion deaths each year throughout the wor'd. Studies have indicated the existence
of about 1,300,000 cases and 35,000 deaths each year from this disease in the
Philippines, and India has an estimated 214 million cases with about 500,000
deaths annually. China, with 50 per cent more people than India, has a tuber-
culosis rate about twice as high as India. Recognizing the fact that in most of the
world there is no, or at best only poor, reporting and satistics, several interesting
attempts have been made to analyze the world prevalence of tuberculosis. In one
such study, the countries of the world were arrayed into the following four
groups:

Group
I Very low prevalence Rates under 49 per 100,000
IT Low prevalence Rates from 50 to 99 per 100,000
IT Medium prevalence Rates from 100 to 149 per 100,000
Iv High prevalence Rates over 150 per 100,000

At the time ol the analysis in 1946, the rates ranged from a low of 34 for
Denmark up to 550 for Greenland. Only four countries, Denmark, Australia,
Netherlands, and the United States were in Group I. Thirty-two countries were in
Group II, twenty-six were in Group III, and thirty-four countries were in Group
IV. Even this does not tell the whole story. The picture becomes more shocking
when populations affected are considered rather than numbers of countries.
When this is done, there appears the following:

Group TB Death Rales Number of Countries 9% of World Population
I Very low 4 8
1I Low 32 14
II Medium 26 8
Iv High 34 70

This, it should be realized, is in the face of considering death rates of from 100
to 149 per 100,000 as medium!

It is impossible even to estimate the number ol cases and deaths attributable
to typhoid and paratyphoid fevers, the diarrheas and dysenteries, and other re-
lated illnesses acquired through the gastrointestinal tract. That their incidence
is tremendous is common knowledge. An indication of this is shown by the
statement ol the Director-General of the World Health Organization who said
that “one-fifth of all deaths throughout the world are due to faulty environ-
mental conditions.” He pointed out that “probably three-fourths of the world’s
populations drink unsafe water, dispose of human excreta recklessly, prepare
milk and food dangerously, are constantly exposed to insect and rodent enemies,
and live in primitive condition of insanitation.” By virtue of the circumstances
which tend to bring about such undesirable environment it is again obvious that
these diseases are most widespread in the predominantly rural agricultural na-
tions of the world.
70 INTRODUCTION: PUBLIC HEALTH

 

Filarial infestations are another widespread cause of physical incapacitation
and economic loss. Wuchereria bancrofti is found in most tropical countries and
particularly in the Republic of Indonesia, northern Australia, parts of South
Asia, Japan, Africa, the West Indies, the northern coast of South America and
the eastern coast of Brazil. In addition, Wuchereria malay: occurs frequently
in the Malay peninsula, in Sumatra, Borneo, New Guinea, India, Indo-China,
Ceylon, and South China. Onchocerciasis is perhaps the best known filarial dis-
ease of the Western Hemisphere, occurring in Mexico and Guatemala. Elsewhere,
it is found on the west coast of Africa from Sierra Leone to the Congo Basin,
then eastward across Africa through the Congo and the Sudan to Uganda, Nyasa-
land, and Kenya. The numbers of persons affected by these types of filariasis are
difficult to determine but are known to be large. Some idea of their magnitude
is indicated by the incidence ol infestation by one other filarial worm, Dracun-
culus medinensis or the guinea worm. Approximately 50 million people act as
host to it.

Another geographically very widespread disease is leishmaniasis. While its
victims are unnumbered it is known to occur in its various forms across South
and Southeast Asia, the Middle East, North and Central Africa, and in a num-
ber of South and Central American countries. A somewhat related disease, tryp-
anosomiasis, is of particular significance since along with malaria it bars from
effective use the tremendous area of central Africa which many consider to con-
tain some of the best agricultural and grazing land in the world, equal to or
surpassing in quality that of Argentina or of the central United States. The total
area involved is about 414 million square miles. This is 50 per cent again as
large as all of the United States of America. The potential importance of the
effective use of this tremendous area to the future world food supply is obvious.

The venereal diseases are truly world wide in occurrence, but again their
true extent is unknown. Guthe and Hume® have pointed out that if the dis-
covered incidence of syphilis in Denmark and Finland in 1946, of 100 to 200 new
cases ol syphilis per one hundred thousand persons per year were applied to the
world’s population of 2 billion people, the result would be from 2 to 4 million
newly acquired cases ol syphilis annually. There is of course good reason to
consider this incidence rate as low for the world as a whole. Beyond this il the
conservative ratio of one case of syphilis to three ol gonorrhea is applied, the
result is an estimated minimum of from 6 to 12 million new cases of gonorrhea
per year. In terms of prevalence, if the probably low rate ol 2 per cent is applied,
an estimated total of 20 million cases ol syphilis results.

Economic, Social, and Political Relationships of World Health Problems.
From what has gone before it is obvious that the major portion of the vast mass
of preventable disease in the world is concentrated in what have been commonly
called underdeveloped areas or countries. At this point it should be recognized
that the term “underdeveloped™ is quite unsatisfactory and that citizens ol coun-
tries so described often object to it. Perhaps such understandable objection based
upon commendable national pride may be somewhat assuaged by pointing out
that the term implies that there is something worth developing—a situation not
without its desirable aspect. It would seem equally obvious that one cannot
WORLD HEALTH PROBLEMS 77

speak, think, or act about the health problems ol these countries or areas within
an isolated substantive framework. Large proportions ol the human beings who
live in these areas, and they constitute a majority of the population of the earth,
eke out a miserable existence under circumstances which are undesirable from
many different standpoints, of which ill health is only one. Their housing is
inadequate, their economy unbalanced, their food supply precarious, their
methods of performing daily tasks primitive, their educational horizons limited,
and their daily work relatively inefficient and unproductive. What is cause and
what is effect? Widespread preventable disease unquestionably serves as a barrier
to progress in any direction, be it economic, social, or political. A population
which is chronically ill understandably has a decreased productivity. Thus, in
planning the program for the provision of safe water supplies in rural Venezuela,
it was found that about 2 million man-days of work were lost annually because
of typhoid, paratyphoid, the dysenteries, and enteritis. This was estimated to rep-
resent a total productive loss of Bolivars 2,321,000. It was further estimated that
the cost of medical treatment and care of cases of these preventable diseases
amounted to Bolivars 1,643,000 per year, approximately 514 million dollars.
The loss of manpower in Southern Rhodesia due to malaria has been reported to
be [rom 5 to 10 per cent of the total labor force with the greatest incidence of the
disease at the peak period of agricultural production. Similarly, in Haiti a pro-
gram for the mass treatment of yaws returned 100,000 incapacitated persons to
work and increased the national production to 5 million dollars a year.

It has been estimated by Paul Russell” that any nation which imports the
products of a highly malarious country pays the equivalent of a 5 per cent malaria
tax. For what the United States imports from such areas each year this would
amount to additional hidden cost of about 175 million dollars per year. Wide-
spread disease also serves as an effective barrier to the development of agricultural
lands and of natural resources. The effective settlement of such areas as Sumatra,
Borneo, Central Africa, large areas of South America, and until recently the
Terai of India, Pakistan, and Nepal, and large parts ol Sardinia, to mention but
a few examples, has been prevented by disease, primarily malaria and other
insect-borne diseases. The accomplishments in the last two locations give some
indication of the potential elsewhere. The control of malaria in Sardinia during
the past decade has paved the way for the resettlement of about a million Italians
from the overcrowded mainland. Similar measures in the Terai have made it
possible to begin the opening of this great fertile area so badly needed to feed
the people of India. From 1949 to 1954, 35,000 acres were cleared and put into
production and eleven new industrial undertakings, such as flour and rice mills
and food preservation plants have been initiated. By 1951 the population was
almost 300,000 and this is just the beginning.

For the individual, educational and intellectual development is difficult,
if at all possible, when the body is chronically drained of its energy by illness
and parasites. This was illustrated in the Philippines where it was found that
malaria control reduced school absenteeism [rom about 50 per cent daily to 3
per cent. At the same time, industrial absenteeism was reduced from 35 per cent
to under 4 per cent. Uncontrolledvdisease in the environment and the continuance
78 INTRODUCTION: PUBLIC HEALTH

Table 2. Comparison of Economic, Health, and Educational Conditions in the
More Developed and Less Developed Regions of the Free World

 

 

More Less
Condition Developed Developed
Regions Regions
Population, 1950—millions 534.0 1,061.0
National income, 1949—$ per capita 690.0 70.0
Nonhuman energy, 1950—metric tons of coal per capita or equivalent 3.8 0.2
Per cent males in nonagricultural employment 73.0 33.0
Births per 1,000 population, 1950 21.7 43.5
Deaths per 1,000 population, 1950 10.5 25.9
Infant mortality per 1,000 births, 1950 45.0 183.0
Expectation of life (years) 63.0 34.0
Crop yields (bushels per acre):
1949-51—Wheat 26.0 13.0
1949-50-1951-52— Rice 69.0 30.0
Calories per person per day 2,800 2,000
Animal protein per day-—ounces 1.4 0.4
Persons per physician (1945-50) 1,000 14,000
Daily newspapers—per 100 persons, 1948-51 31 2
Radio sets—per 100 persons, 1948-51 | 28 1
Illiterates per 100 persons:
Males 5 64
Females 7 83
Elementary school teachers per 1,000 3.6 1.3
Motor vehicles—per 100 persons, 1950 12 0.4
External trade—$ per capita, 1949 140 32
Consumption of textiles—pounds per capita, 1948 21 5

 

 

 

of conditions which breed unproductivity and illiteracy also effectively discourage
investment from within or without as well as industrial development. Finally, a
low economy and standard of living attributable directly or indirectly to wide-
spread ill health is a constant encouragement to political instability. Under such
circumstances people have many reasons for discontent and have very little to
lose in resorting to violence.

We are dealing here, of course, with a vicious circle. Disease breeds poverty,
and poverty in turn breeds more disease. A similar relationship exists between
disease and illiteracy, political instability, and many other factors. It is difficult
or impossible to state which factor is primary, which is cause, and which is effect.
Once the cycle is established, however, it is clear that each factor contributes to
the continuance of all other undesirable factors. This has been referred to as
cumulative causation. The relationships are illustrated here in Table 2 which
presents data for countries of the free world, distributed by regions—more de-
veloped regions, and less developed regions. For the sake of depicting broad
geographic areas of relative development and for the sake of convenient general
WORLD HEALTH PROBLEMS 79

 

 

statistical handling, certain individual countries which are obvious exceptions
to the region in which they are located are nevertheless included in that region.
The more developed regions included North America, Western Europe, Southern
Europe, Australasia, and Japan. The less developed regions included Latin
America, Southeastern Europe, the Near East, Africa, South and Southeast Asia.
It will be observed first of all that twice as many people live in the less developed
regions than in those that are more developed. Beyond this, it will be noted
that in the case of every index (and they measure health, agricultural develop-
ment, industrial development, education, trade, and food consumption), the
less developed regions are significantly disadvantaged as compared with the more
developed regions.

The solution of the problem is not easy. Certainly it cannot be accomplished
by an attack upon health problems alone. In fact, such an approach would carry
with it certain very real dangers, if indeed it were to really succeed at all. Ad-
vancement must be made in many fields simultaneously. In this regard, the state-
ment of Gunnar Myrdal® at the Fifth World Health Assembly is worthy of note in
summarizing the complexity of the situation and in outlining a guide for effec-
tive, lasting action:

The task of social engineering is to proportion and direct the induced changes in
the whole social field so as to maximize the beneficial effects of a given initial financial
sacrifice. One important corollary to the theory of cumulative causation is that a rational
policy should never work by inducing change in only one factor; least of all should such
a change of only one factor be attempted suddenly and with great force. This would
in most cases prove to be a wasteful expenditure of efforts which could reach much
further by being spread strategically over the various factors in the social system and
over a period of time. What we are facing is a whole set of interrelated adverse living
conditions for a population. An effort to reach permanent improvement of health
standards aimed to have a maximum beneficial effect on the well-being of the people
will, in other words, have to be integrated in a broad economic and social reform
policy. Such a policy will have to be founded upon studies of how in the concrete situa-
tion of a particular country the different factors in the plane of living are interrelated

and how we can move them all upwards in such a fashion that the changes will support
each other to the highest possible degree.*

REFERENCES

I. Summary Proceedings of the First Meeting of the Central Council of Health, Hyderabad,
Jan. 29-31, 1953, Government of India, Ministry of Health.

2 . United Nations Document E/1327/Add. 1.

3. Wright, W. H.: Medical Parasitology in a Changing World, J. Parasital. 37:2, Feb. 1951.

4. Stoll, N. R.: This Wormy World, J. Parasitol. 33:1, Feb. 1947.

5. Hyde, H. V.: Sanitation in the International Health Field, Am. J. Pub. Health 41:1-6, Jan.

1951.

6. Guthe, T., and Hume, J. C.: International Aspects of the Venereal Disease Problem, New
York, 1948, American Social Hygiene Association, Inc.

7. Russell, P.: A Lively Corpse, Trop. Med. News 5:25, June 1948.

8. Myrdal, Gunnar: Economic Aspects of Health, Chronicle of World Health Organization
6:207, Aug. 1952.

*Myrdal Gunnar: Economic Aspects of Health, Chronicle of World Health Organization
6:207, Aug. 1952.
chapter 4

The economic justification
of public health activities

 

Inevitability of Health Costs. There are two related objections that are occa-
sionally heard with regard to public health activities. One is that the establish-
ment and growth of public health agencies and programs have resulted in in-
creasing costs to the public. The other is that public health workers are at a dis-
advantage in that they cannot point to their successes. This latter statement is
made in contrast to the position of the private physician who with justification
can point to the saving ol many specific lives by his judicious medical and surgical
management. Granted that the public health worker cannot point out particular
individuals who have been spared illness and premature death by public health
programs, this is more than compensated [or by the possibility of measurement
in a larger and ultimately more dramatic sense. It must be realized that the
fruits of our labors are in essence quite different from those of therapeutic medi-
cine and that accordingly the bases ol measurement cannot be expected to be the
same. Public health work is not fundamentally concerned with the repair ol
damage already done. Rather, we deal with the prevention ol damage in the first
place and the promotion of positive health. Furthermore, by virtue ol the
irrefutable fact that, although healthy living is expensive, illness is even more
so, it should be possible to demonstrate that preventive and promotive health
activities offer a sound financial investment to the individual and to the com-
munity.

Most intelligent people appreciate the reduction in human suffering that
has resulted from the public health movement. It must be realized, however,
that the further removed one is by time and space [rom the threat of personal
suffering, the less consideration is apt to be given to it. In other words, in public
health work, our very success tends to mask our value. It is appropriate, there-
fore, that the public and its elected representatives be given cause to appreciate
the wisdom of expenditures for health from an altogether different viewpoint.

As will be pointed out elsewhere, the costs ol all governmental services have
persistently increased. Proportionately speaking, the expenditure for public
health services represents an area of considerable expansion. This has caused
many to point to public health programs as an added economic burden to the

§0
ECONOMIC JUSTIFICATION 81

taxpayer. It is important to point out and to demonstrate that an increased sum
ol money spent wisely for health services represents not an increase but actually
a decrease in the net bill for personal and community welfare. The construction
and maintenance costs of public water purification and sewage disposal plants
are admittedly great. These costs, however, do not represent an addition to our
economic burden because their absence would cost us a similar, if not a greater,
sum [or individual facilities and (or increased medical care and lost earnings
resulting from the illnesses that would not be prevented. A single or repeated
outbreaks of typhoid fever, for example, would cost a community much more
in the long run than the installation of engineering and other measures designed
for their prevention. A sound financial policy for public health services there-
fore must take into consideration not only the humanitarian and social gains but
also the economic advantages to be derived therefrom. The problem then is to
bring before the public consciousness and to organize costs which in any case
are destined to occur, either as hidden individual expenditures or as socially
beneficial public appropriations.

Economic Value of Life. Beyond the inevitability of these expenditures is
the added factor of the economic value of the lives made possible or continued
by public health endeavors. To many, the thought of placing a monetary value
on human life appears to be indecent, immoral, or inhumane. By and large, our
reactions to life and death are based primarily upon emotion and sentiment, and
ordinarily we deliberately avoid any thoughts that have an economic flavor or
that border on the materialistic. Yet, to be realistic, it must be admitted that
life does have a monetary value. The death of a parent brings to society as a
whole, as well as to the particular family involved, an economic as well as a
sentimental loss quite real and irreparable. This may manifest itself in a lowered
standard of living for the family, the necessity of public financial aid, or the loss
of a trained worker. Furthermore, governmental recognition is given to the value
of a life, and one seldom hears voices raised against the concept ol income tax
exemptions.

Many have tried to evaluate man or, in other words, to put a price upon
his economic worth. One of the earliest attempts was that of Sir William Petty
(1623-1687), who originated many ideas later used by the political economist
Adam Smith in his Wealth of Nations and other works. Petty! derived his esti-
mate as follows:

Suppose the People of England be Six Millions in number, that their Expense at
£7 per head be 42 Millions: Suppose also that the Rent of the Lands be 8 Millions, and

the yearly profit of all the Personal Estate be 8 Millions more; it must needs follow

that the Labour of the People must have supplied the remaining 26 Millions the which

multiplied by 20 (the Mass of Mankind being worth 20 years purchase as well as land)
makes 520 Millions as the value of the whole people; which number divided by 6
Millions makes about [80 the value of each Head of Man, Woman and Child and of
adult Persons Twice as much; from whence we may learn to compute the loss we have
sustained by the Plague, by the Slaughter of Men in War and by sending them abroad

into the Service of Foreign Princes. *

 

*Petty, Sir William: Political Arithmetic or a Discourse Concerning the Extent and Value
of Lands, People, Buildings, etc., ed. 3, London, 1699, Robert Clavel, p. 192.
82 INTRODUCTION: PUBLIC HEALTH

Later, Sir William Farr and Irving Fisher made more scientific computations,
using the life table technique, which by their time had been developed. This
approach has been even more completely pursued in recent years by Dublin and
Lotka, whose several publications? of considerable social significance have been
drawn upon freely in the following discussion.

The human body may be considered as similar to a machine. Like other
machines its proper function depends on the movement and interaction of vari-
ous physical and chemical parts, complicated and augmented, however, by a third
and much more complex factor—biological reaction. To resort to a crude analogy,
the body might be likened to an internal combustion engine with limbs in place
ol pistons and the organs of internal secretion acting as the carburetor. Super-
imposed upon these is the supervisory function of the human mind which might
be compared with the governor on an internal combustion engine. In a like man-
ner, the human body may be regarded as an economic unit brought into existence
for measurable, potential, productive purposes.

A machine designed for the production of ball bearings, for example, is of
no intrinsic value in itself, its true value being measurable only in terms of its
capacity to produce ball bearings, thereby justifying its existence. Similarly, ex-
cept in a completely paganistic and hedonistic society, the mere existence of life
is of little, if any, value. As pointed out by the Committee on Health Problems
in Education, it should be realized that life and health in themselves have real
value only as they promote efficiency and happiness, and that, in the final analysis,
it is the quality of life that counts and not the quantity. Of themselves, life and
health are valueless, their true value depending upon the activities engaged in
by virtue of them.*

To return to the example of the machine, it is necessary for it to pass through
several phases or steps before it is even ready to be of productive value. First, it
must be built, which presupposes the existence of a factory in which it may be
constructed. Its construction, therefore, involves from the start a considerable
capital outlay for factory site, labor, and tools. On completion, the machine is
not yet of true value. It must be prepared for use or function. This involves a
series of installation expenditures for its inspection and checking, for transfer
to the site where it is intended to function, and for oiling, tuning up, and other
preparations. Following this, the machine is ready to become productive, and the
extent and efficiency of its usefulness depends on its original quality or lack of
structural defects, the correctness of installation, and the manner in which it is
routinely cared for while in use. It must be carefully and repeatedly lubricated,
fed the proper fuel, inspected, overhauled, repaired, and given proper rest in-
tervals rather than constant grinding use which would lead to metal fatigue.
During this period of use, therefore, a certain amount of expenditure and effort
is constantly required to maintain the machine, and its ultimate value can be
determined only after the value of that expenditure and effort is deducted from
the gross value of its productivity.

With man as with machines, there are always debit as well as credit items
during the period of productivity. It is the hope and goal of the manufacturer
that his machine will continue to function with relative efficiency at least long
_ oo oo ECONOMIC JUSTIFICATION  &3
enough to produce sufficient items for sale to offset all of the debits incurred by
the capital investment and the installation and maintenance costs. In other words,
from the moment the machine is purchased, the curve of the cumulative invest-
ment in it continues to rise, the curve of cumulative productive value lagging for
a considerable period. It is not until these two curves cross that the manufacturer
can breathe easily and begin to reap a net benefit from the use of the machine.
If any untoward circumstances develop before the two curves cross, the manu-
facturer stands to lose a considerable investment.

Many things may go wrong alter purchase. The machine may have been
unsuspectedly defective, it may have been damaged during transportation and
installation, or it may have worn out prematurely due to improper use or care.
These are but a few ol the undesirable potentialities the manufacturer must
constantly guard against. Even after the two curves cross, all is not necessarily
clear sailing because, the longer the machine is used, the greater is the tendency
for parts to wear out and for maintenance and repair costs to increase. Sooner
or later a time is reached when these costs become greater than the value ofl the
items produced and the two curves cross again. Continued use is no longer
profitable. The machine has now passed into the phase of obsolescence or, in the
case of human beings, senility. More idealistically, it may be considered the
period of retirement or senior citizenship.

It is of interest to attempt to analyze the items which contribute to the debit
and credit columns of human life. One such analysis, based upon data and crude
calculations for the year 1955, is presented in the following pages. In so far
as possible, an attempt has been made to calculate or to estimate monetary values
for the many factors considered. It must be stressed, however, that this is done
simply to illustrate a general principle, and the reader should realize that the
values assigned are at best no more than very crude calculations and estimates
which are subject to innumerable influences such as changes in monetary values,
wage levels, cost of living trends, and the extent of unemployment, to mention
only a few. In other words, the figures given are not intended to represent true
dollar values to be quoted as such but are presented simply to illustrate a concept.
The entire picture is summarized in Table 3.

Table 3. Summary of Factors Involved in the Socioeconomic Value of Any
Single Human Being—With Crude Illustrative Figures—United States

Capital Cost*

1. Economic incapacitation of mother $500
2. Risk of death to mother (prorated) 12
3. Risk of injury to mother with immediate or subsequent effect
on her economic value (prorated) ?
4. Immediate costs of childbearing 488
5. Risk of infant death (prorated) 40
6. Risk of infant illness or injury ?
7. Interest on capital investment 30
$1,070

 

*The investment that society has in each infant by the time it is born.

(Continued on next page)
8&4 INTRODUCTION: PUBLIC HEALTH

Table 3. Summary of Factors Involved in the Socioeconomic Value of Any Single
Human Being—With Crude Illustrative Figures—United States—Cont’d

Installation Cost

 

1. Shelter, clothing and food $11,900
2. Value of time mother devotes to child care 15,750
3. Education—family and community contribution 4,500
4. Medical and dental care and health 600
5. Recreation and transportation 3.000
6. Insurance 100
7. Sundries and incidentals 900
8. Risk of death during first eighteen years (prorated) 250
9. Risk of disability during first eighteen years ?
10. Interest on installation costs 23,000
$60,000
Period of Productivity}
Credit
I. Earning potential £60,000
2. Interest on earnings 50,000
3. Noneconomic potential ?
$110,000
Debit
I. Risk of disability during productive period $4,000
2. Medical costs 6,500
3. Risk of premature death 200
4. Risk of becoming substandard 5,500
5. Interest on debit items 15,000
$31,200

The investment that society has in cach individual by the time he reaches 18 years of age.
fThe return that society can expect from its investment, with the risks involved during
this period.

FACTORS ENTERING INTO THE VALUE OF A HUMAN LIFE
Period of Initial Capital Investment

I. Value of Economic Incapacitation of the Expectant Mother —$500

All adult females as well as males have an economic productive potential. For the
majority of women this potential is eflected in either or both of two ways: employment
for wages or occupation as a housewife. Ordinarily the latter is not thought of in an
economic sense since it rarely involves the transfer of an agreed-upon sum of money
for services rendered. None the less, the housewife and mother fulfills a function of real
economic value. In fact, her absence would necessitate the employment of a paid substi-
tute. The average period of incapacitation for childbearing might be estimated roughly
at three months, the actual degree of incapacitation varying throughout the period of
pregnancy and with individuals. In 1955, the age of the average pregnant woman was
24 years and the annual value of her real or potential efforts might be estimated at an
ECONOMIC JUSTIFICATION

average of $2,000. This considers her to be in the most typical economic class for her
sex, which in 1955 reported a maximum potential annual income of approximately
$2,500. Incapacitation for about one fourth of her twenty-fourth year, therefore, repre-
sents about $500 as part of the capital investment in the anticipated child.

2. Prorated Value of the Risk of Maternal Death —Hi12

If the efforts of a housewife and mother have an economic value and if, as will
be developed, she herself represents a considerable investment, her death as a result of
childbearing will constitute a monetary loss to her family and to society. In 1955
there were about 1,950 maternal deaths related to the 4,041,000 births which occurred in
the United States. The average age of the women who died was 29 years. The average
net value of the potential future activity of each of them might be estimated at about
$26,000. Therefore, the monetary loss as a result of maternal deaths was the product of
$26,000 times 1,950 deaths, or about $50,700,000 per year, which, if prorated among all
of the births, amounts to $12 as the value of the risk of maternal death, which should
be added to the cost of each child born alive.

3. Value of the Risk of Injury Short of Death lo the Mother ?

As a result of childbearing, many women suffer disabilities or illnesses which,
although they do not cause death, have a subsequent effect on their well-being, eco-
_ nomic productivity, and length of life. As in the case of maternal deaths, the total
economic effect of this should be prorated among all infants born. Though extremely
difficult if not impossible to estimate or calculate, its effect appears elsewhere in terms
of medical expenditures and shortened lives.

4. Immediate Costs of Childbearing —$488

Here are found a number of readily recognizable items. Included are the costs of
prenatal and postnatal care, hospitalization, delivery, and expenditures for special ma-
ternity clothes, layettes, and the equipment for the care of the newborn infant. There
also should be included an item for housekeeping assistance. While some objection
might be raised to this, it may be pointed out that in some households a housekeeper
is actually employed for a period preceding and following delivery. Furthermore, since
this is not possible for the majority of families, some housekeeping assistance is required
and furnished by a relative, friend, or neighbor. Their time and effort has value, and
calling upon them to assist in the home of the expectant mother ultimately involves
their temporary removal from productive enterprise elsewhere. Estimates of these costs
for the most typical economic class have been adapted from studies by the Metropolitan
Life Insurance Company and the Maternity Center Association, New York City, and are
presented in Table 4. The average figure may be considered to be about $488.

Table 4. Estimates of Average Cost of Births for Women
in the $4500 Family Income Class

House- | Minimum

 

 

85

Type of Total Hospital | Physicians
Service Cost Cost Fee keeper | Layette Incidentals
| — SN
At home 8300 | $... | 870 $150 | $60 $20
Ward 325 95 | So | 150 60 20
Semiprivate 535 150 150 | 150 60 50
Private 735 | 200 225 | 150 60 100
86

INTRODUCTION: PUBLIC HEALTH

 

5. Prorated Value of the Risk of Neonatal Death —$40

Like their mothers, infants may be subject to injury or death as a consequence of
abnormal development or of the birth process. This is analogous to the machine that
might be defective in construction or damaged shortly thereafter. During 1955 in the
United States, there occurred a total of 167,700 known nonproductive deliveries, con-
sisting of 90,000 stillbirths and 77,000 neonatal deaths. Up to this point, there had been
invested in each of them an average of $1000, which, if multiplied by the number of
known nonproductive deliveries, gives $167,700,000 as the annual monetary loss they
represent. If this figure is prorated among the year’s 4,041,000 live births, each infant
bears as his share of the risk of not being born alive or surviving one month a sum of
about $40.

6. Value of the Risk of Injury Short of Death to the Infant ?

As in the case of mothers, infants may suffer nonfatal damage before or during or
shortly after birth. Again, the economic significance of this is difficult or impossible to
determine. However, it shows up subsequently in the form of medical expenditures and
shortened life.

7. Interest on Capital Investment —$30

If a man and woman originally considered the pros and cons of prospective parent-
hood and, deciding against it, invested the total of the sums listed above for a period
corresponding to that of pregnancy, there would accrue at 314 per cent compound in-
terest about $30. While this may sound venal, the fact remains that a considerable num-
ber of people do just this.

The total capital value of a child at birth is therefore about $1,070, which represents
the economic interest which the parents and society have in it by the time it leaves the
human factory.

Period of Human Installation Costs
While the mechanical contrivance upon purchase may be installed and made ready
for productive performance in a relatively short time, a rather lengthy period and a
considerable cash outlay are required in order to bring the newly born human mech-
anism to the point of social and economic productivity. Among the costs involved may
be listed the following, the figures for which are in many instances extremely conserva-
tive in view of current prices.

1. Shelter, Clothing, and Food for First Eighteen Years —$11,900

For 1955, a breakdown of this crude estimate was $4,240 for shelter, $1,690 for
clothing, and $5,970 for food. Since exception may be taken to the inclusion of an item
for shelter, it might be pointed out that from an over-all social standpoint, if the
addition of a new family member did not result in overcrowding, necessitating an en-
largement of living quarters, the family was previously occupying more living space
than was fundamentally required.

2. Value of the Mother’s Time Devoted to the Care of the Child —$15,750

Based on the average value of the potential earnings of a 24-year-old woman at
home or at work as $2,500, the value of her time given to the care of the child is esti-
mated to decrease arithmetically from $1,250 for the first year to $400 for the eighteenth
year. The cumulative total is about $15,750.

3. Education —$4,500

It is estimated that the average expenditure for education of a child is $4,500 of
which the community bears the major share.
ECONOMIC JUSTIFICATION

87

 

4. Medical and Dental Care and Health Protection —$600

This small item of expense if increased substantially would undoubtedly result in
considerably enhanced personal value, productivity, and length of life. It is unfortunate
that it is found to be of the same magnitude as “sundries and incidentals.”

5. Recreation and Transportation —$3,000

6. Insurance —$100

Very few children’s lives are insured. The average is found to be about the figure
shown.

7. Sundries and Incidentals —$900
8. Prorated Value of Risk of Death Before Eighteenth Year —$250

Deaths that occur during the first eighteen years of life are analogous to irreparable
damage of a machine following its purchase and during the process of its installation.
During 1955 in the United States, there were about 42,000 deaths among persons be-
tween the ages of 1 month and 18 years. The average age at death in this group was 9
years. The monetary loss attributable to these deaths might be approximated roughly
from the cost items listed above as 9/18 ($1,070 + $36,260) of the costs of birth and of
the installation period, times an annual loss of 42,000 persons, times 18 separate years
during any one of which the death might occur. The product of these figures is about
14 billion dollars, which, if prorated throughout the 55,021,000 persons in the age group
under 18 years, gives about $250 as each individual's share of the risk of preproductive
death.

9. Nonfatal Disabilities During First Eighteen Years —?
As before it is impossible to determine or estimate the value of this effect, but it
shows up subsequently in costs of medical care and premature death.

10. Interest on Installation Costs —$23,000
Again, if a decision had been made against conceiving the child in the first place
and if all of the installation expenses had been invested instead, at the end of eighteen
years there would have accrued at 314 per cent compound interest an additional sum
of about $23,000.
Total installation value, therefore, amounts lo about $60,000 for each child who
successfully reaches the age of 18 years.

Period of Human Productivity

Up to this point the new human mechanism not only has been constructed but has
passed through all of the phases that constitute an installation or get-ready period.
Instead of being bolted to a floor, oiled, checked, and tuned as in the case of a machine,
the human being has been fed, clothed, educated, and otherwise prepared until he
is ready to assume his place as a productive adult member of society. He is now in a
position to begin to repay the considerable investment that his parents and society
have made in him. From this point on the picture becomes complicated by the neces-
sity of considering both credit and debit items. In order to make possible an ulti-
mate balancing of the books, the individual's cumulative gross earnings must accomplish
three things: full repayment of all that has been invested in him, provision of cur-
rent maintenance costs both personal and community, and provision for future retire-
ment in the postproductive period of life. Added to this is the hope of providing if
possible some net surplus to pass on to the succeeding generation. It is upon this sur-
plus that depends all familial and social progress in contrast to stagnation.
88

INTRODUCTION: PUBLIC HEALTH

Credit Items. Three items appear on the credit side of the human ledger. They may
be considered as follow:

I. Net Earning Potential +$60,000

In 1955 the most typical wage class into which working adult males fell was that
which could look forward to a maximum annual earned income of $5,000. This maxi-
mum is approached gradually, beginning with a much lower income at the age of about
18 years when individuals began productive work. The maximum is reached as the
individual approaches his fortieth birthday, following which the annual net income
beings to decline slowly to the time of death or retirement when a marked or complete
drop results. On the basis of his life expectancy, the average 18-year-old male in the
$5,000 maximum annual income class can look forward to gross future earnings totaling
about $100,000. His total future cost of living based on 1955 figures would amount to
about $40,000, leaving $60,000 as the net value of the future earnings of persons reach-
ing 18 years of age. Taxes must, of course, be deducted from this.

2. Interest on Earnings + $50,000

Since interest has been considered in relation to the sums invested in the individual,
to be consistent it should be applied also to his net future earnings. While the indi-
vidual wage carner does not necessarily himself receive the interest, society as a whole
may be considered to benefit since the mere fact that money is spent means that it has
been put to use for gain. Therefore, the $60,000 net future earnings will produce for
the working individual or for other members of society to whom it may be transferred
through purchases, a certain amount of interest. If the interest is compound and the
basis of it is scaled from ages 18 to 70 years, it will accumulate to the approximate
amount of $50,000.

3. Noneconomic Productive Polential +2

The human mechanism differs from the mechanical contrivance in that it has
abilities or potentials to produce value in forms other than material. "Thus a human
being has a reproductive potential which in the light of the foregoing is obviously worth
something. One is reminded of the fact that the totalitarian dictators of recent European
history actually placed a value upon the reproductive potential of women and paid the
individual cash awards for producing children. Despite this, any attempt to evaluate
correctly the reproductive potential of human beings in a monetary sense is pointless.
Human beings also have social and intellectual potentials of incalculable value. Who
would dare appraise a da Vinci, a Beethoven, a Shakespeare? Yet the world is infinitely
richer because of their existence.

Debit Items. Attainment of the age of productive capacity does not necessarily imply
that the individual will actually be able to or will even choose to contribute his share
to society's material advancement. A number of things may act as deterrents, among
which are the forces of disability and premature death and the possibility that the in-
dividual, although by now an adult, may be physically or mentally substandard or anti-

social.

1. Value of Risk of Diasibility After Eighteenth Birthday —$4,000

 

Various surveys have indicated that in the United States about 214 per cent of
working time is lost due to absenteeism or inefficiency attributable to illness or injury.
Incidentally, a considerable amount of this is preventable. Since the national income
in 1955 was about $324,000,000,000, the average economic loss due to disability per po-
tential wage earner, of whom there were about 102,400,000, may be computed as
$324,000,000,000 xX .025
102,400,000
pectancy of fifty years, this would amount to a total of $80 x 50 years = $4,000, which

= $80 per worker per year. With an average working life ex-
ECONOMIC JUSTIFICATION

89

 

represents each wage earner’s prorated share of the nation’s economic loss due to dis-

ability that must be deducted from his average net productive potential.

2. Medical Costs

—5$6,500

The cost of disability in a worker does not merely involve loss of productive power.
Since the individual's actual carry-home pay is usually affected, there results a loss of
family income often necessitating cutting into the future income of the family or into
the wealth of society at large. The extent to which this occurs during the average wage
carner’s life has been estimated by various groups which have studied the problem as
about $3,500. In addition, disabilities require expenditures for medical and nursing care
and sometimes for hospitalization, drugs, and appliances. The results of studies of these
miscellaneous costs places them at an average of about $3,000 during an individual's
lifetime. It is significant that one of the chief reasons for borrowing is inability to meet
the costs of illness. If the illness happens to be of a communicable nature, there is the
added risk of spread of the disease, upon which some value might be placed. The amount
is difficult to estimate but its effect shows up elsewhere in the form of society's total
medical bill and as premature retirement and death. Another factor, the value of which
cannot be calculated but which shows up later, is the risk of lowering the level of
health of an entire family when disability of the breadwinner lowers the standard of

living.

3. Value of Risk of Premature Death of Wage Earner

—$200

The possibility of premature death of wage earners has been referred to. When
this occurs, the worker in most instances has not been allowed to live long enough to
neutralize the investment which has been made in him. By prorating the lost potential
future earnings of those who prematurely die, each worker’s share of this risk of not
fulfilling his life expectancy may be very crudely estimated as follows at about $200

(Table 5).

Table 5. Potential Future Earnings of Prematurely Dead,

United States

| Individual

Age Group | Median Age | Deaths | Net Future |
| 1955 Earnings
_— _— | I — JE — i
19-24 21 | 13.350 $61.000 |
25-44 35 106,360 | 60,000
45-64 55 392,800 27,500
65+ | 72 819,000 750
|
Population over 18 years of age in United States, 1955 — 102,400,000.
$18,612,200,000
—————— = about $200
102,400,000

4. The Risk of Becoming Substandard or Antisocial

Total Lost Future
Larnings

$ 814,350,000
6,381,600,000
10,802,000,000
614,250,000

$18,612,200,000

—$5,500

A large number of individuals are brought to maturity only to be found defective in
one way or another. Many of them require the full-time attention of an additional

large group of potential producers in the form of police, mental hospital attendants,

and the like.
90 INTRODUCTION: PUBLIC HEALTH
It is difficult or impossible to determine the total number of such individuals.
Estimates vary considerably. For the United States in 1955 some of the estimates were
as follows: blind, 330,000; mentally ill or defective, receiving some type of intramural
or extramural institutional care, 840,000; attendants of mental institutions, 100,000;
physically handicapped, 2,230,000; chronic nonproductive alcoholics, 750,000; narcotic
addicts, 60,000; criminals, 400,000 detained and 600,000 at large; police wardens, etc.
750,000; paupers, 80,000; and prostitutes, 250,000. Some of these figures undoubtedly
are overstatements and some of them are duplicative. Nevertheless, they have a double
significance for the average wage earner. First, he himself shares the risk of becoming
substandard. Avoiding that, he finds he must assist in the support of these defectives.
The cost is enormous. The annual bill for the care of the mentally ill alone has been
estimated at well over a billion dollars, and criminals and those who apprehend and
guard them must cost about the same. The partially or totally blind, deaf mutes, the
physically handicapped, and some others contribute varying amounts to their own
support, and more adequate programs for their training and rehabilitation would in-
crease the degree to which they might be self-sufficient. The cost of support of the
handicapped, the substandard, and the antisocial may be put very conservatively at
4 billion dollars annually. Prorated among the wage carners over I8 years of age this
amounts to about $1,000 per wage carner.

In addition, society suffers a loss due to their lack of production. Estimates of this
loss prorated among the wage earners over 18 years of age amounts to about $4,500
per wage carner. In toto, the prorated share of the cost of the risk of becoming sub-
standard or antisocial might be considered about $5,500.

5. Interest on Debil Items —$15,000

The total of each individual's share of all the debits that occur during the pro-
ductive period of life amounts to about $16,000. If this sum instead of being lost were
invested, there would accrue at 314 per cent compound interest about $15,000 at the
end of their productive lives, bringing the total loss to about $31,000.

Summary

If from the total net productive credit of $110,000 in the rough example presented
previously, the $1,070 in capital cost, the $60,000 in installation costs, and the $31,200
in debits during the productive period are substracted, there remains a net balance
of about $18,000 per person for the individual's and society's provision for the period
of obsolescence, retirement, or senility.

Savings Effected by Public Health Measures. The economic soundness of
expenditures lor public health is perhaps more easily demonstrated by still a
different approach. This considers only expenditures saved on hospital bills,
medical care, laboratory work, and similar facilities. One example that has been
well worked out deals with the control of diphtheria in New York City where
an attempt was made to prove, among other things, that it is cheaper to prevent
than to have to treat illness. In 1920 there occurred in New York City about
14,000 reported cases of diphtheria. Three thousand of these were hospitalized
at an average ol $112 ol the taxpayers’ money per case, representing a total ex-
penditure for hospitalization of $336,000. The remaining 11,000 patients were
cared for at home at a cost to the city for various medical services of an average
ol $35 per case, or a total of $385,000. Each of the cases was visited by public
health nurses; hospitalized cases received an average of two visits, and home
cases an average of six visits. At fifty cents a visit the public health nursing costs
amounted to $36,000. The laboratory work on the basis of ten nose and throat
ECONOMIC JUSTIFICATION 91

cultures examined for each reported case at five cents per examination cost
$70,000. Of the patients, 1,045 died from the infection. At an average of $200
each, their funerals cost over $200,000. The total cost up to this point, therefore,
was $1,027,000. In other words, the City of New York in 1920 spent over a million
dollars for the support of the diphtheria organism.

From 1929 through 1931, the Health Department, aided partly by private
funds, carried on an intensive, well-organized campaign to secure the immuniza-
tion of infants and children against diphtheria. The cost of this campaign dur-
ing those three years was $375,000. At the end of the three years, the program was
continued at a cost of less than $10,000 per year. Unquestionably many persons
considered these sums an added economic burden. However, let us see what was
purchased with that money. During 1939 instead of over 14,000 cases, there were
only 543 cases, despite known improved reporting. One hall of these were hos-
pitalized at $112 each. The total hospital bill, therefore, was $31,000. The medi-
cal bills for those remaining at home at an average of $35 per case totaled $9,625.
Nurses’ visits to the patients cost $1,100, and the laboratory work was reduced
to only $2,750. Instead of over 1,000 deaths, there were only 22 for whom the
funeral bill was $4,400. Even if we add to this the cost of $375,000 for the three-
year program plus seven times $10,000 to continue it between 1932 and 1939,
the total bill for diphtheria was only $493,875 or one half of the 1920 bill.

Private enterprise has long recognized the soundness of expenditures for
health and safety. Between 1911 and 1925 the Metropolitan Life Insurance Com-
pany spent over 20 million dollars for health education, carly diagnosis, and
nursing service among its policyholders. During those seventeen years the death
rate for policyholders declined more than 30 per cent, which was fully twice
the reduction that occurred in the general population. In monetary terms the
20 million dollars spent resulted in a saving to the company and its policyholders
during that period of 43 million dollars. This is good business. While the length
ol life for the general public increased five years during the period under con-
sideration, policyholders enjoyed an increased life expectancy of nine years.

Even more spectacular savings become evident when the economic value
ol life is considered with regard to such situations. Charles Bolduan,® for ex-
ample, has pointed out that in 1935 lobar pneumonia caused the death of 2,039
males in New York City, 809 of them between the ages of 20 and 50. He computed
that these 809 deaths occurring among working males represented an economic
loss of about 20 million dollars. This fact was used in requesting $500,000 to
provide adequate pneumonia control work. It was estimated that the expenditure
of this amount would result in a saving ol 5 million dollars.

Further examples may be [ound in relation to other diseases. Parran has
pointed out that while the 2 million dollars of state and Federal funds that were
used in 1937 for the prevention and control of syphilis seems a sizable sum, it
was paltry in comparison with the 10 million dollars spent annually for the care
ol the syphilitic blind and the 32 million dollars spent for the care of the syph-
ilitic insane.

Vaughan, while Commissioner of Health of Detroit, submitted a request to
his city council for an extra $200,000 a year for each of five years for early
92 INTRODUCTION: PUBLIC HEALTH

Table 6. Estimated Saving in Lives During 1955 as a Result of Public
Health Measures Taken Against Certain Diseases, United States*

 

 

 

Death Ratest Deaths
SE _— Lives
Causes of Death Saved
1900 | 1955 Theoretical Observed

All causes 1,719.1 | 930.4 | 2,842,001 1,528,717 1,313,944
Infant mortality 99 9% | 26.4 | 404,729 106,903 | 297,826
Maternal mortality 6.1% | 0.5 | 24,688 | 1,901 | 22,787
Typhoid and paratyphoid 31.3 0.0 | 51,729 | 46 51,683
Dysentery 12.0 03 19,832 | 5560 19,276
Diarrhea and enteritis 139.9 4.7 231,378 | 7.754 223,624
Smallpox 0.3 0.0 496 496
Measles 13.3 0.2 | 21,980 345 21,635
Diphtheria 40.3 0.1 66,603 150 06,453
Whooping cough 12.2 0.3 | 20,163 467 19,696

Scarlet fever and strepto- |
coccal sore throat 9.6 0.1 | 15,866 | 235 15,631
Erysipelas 5.4 0.0 | 8,925 | 28 8,897
Tuberculosis 194 4 9.1 271,704 | 14,940 256,764
Syphilis and its sequelae 17.7% 2.3 | 20,253 | 3,834 25,419
Malaria 6.2 0.0 | 10,247 | 18 10,229
| J
| | 1,040,416

 

 

*Population estimate, July 1, 1955 = 165,271,000.
tPer 100,000 population except infant and maternal mortality which are per 1,000 live births.
11915 rates.

tuberculosis case finding and hospitalization. He was able to demonstrate suc-
cessfully that the total extra appropriation of a million dollars for this purpose
would repay itsell several times over by the end of that period. In 1930 only 15
per cent of the new cases of tuberculosis were found while still in the minimal
stage, 30 per cent were moderately advanced, and 55 per cent were lar advanced.
By 1943, as a result of the accelerated program for case finding and hospitaliza-
tion, the figures for minimal and far-advanced cases were literally reversed so
that 53 per cent ol newly diagnosed cases were in the minimal stage and only
17 per cent had progressed to the far-advanced stage. When it is considered that
the average hospital stay for minimal cases in Detroit was nine months in con-
trast to two years or more for the lar-advanced cases, the enormous saving to the
taxpayers in terms ol hospital costs alone becomes evident. In fact at the time
the program began, it was calculated that the added annual expenditure of
$200,000 saved about $1,400,000 each year.

To [further illustrate the magnitude of the savings that have been effected
by public health activities, Table 6 presents data on a number of causes of death,
ECONOMIC JUSTIFICATION 93
the major share of the reduction of which may justly be attributed to organized
public health programs. For each cause there has been computed the number
of deaths that would be expected to have occurred in 1955 it the rates of 1900
had been maintained. It is seen that by the reduction of these causes of death
alone, well over a million lives have been saved each year. Obviously these lives
have some value. Even if the investment made in each of them were to be con-
sidered as merely $1000, the total value saved to the nation would amount to more
than a billion dollars each year.

Potential Savings by Public Health Expenditures. This in a sense is an
accounting ol past successes. Consider in addition the potential savings in lives
and money that could be made at the present time and in the future, if all cur-
rent knowledge were completely used. When this reasoning is applied to the
total current picture of sickness and death in the United States, the results arrived
at are staggering. Slee,’ in connection with a study of public health problems oi
the aging population, has made a most interesting analysis along these lines. He
considered the problem of the thousands of deaths which occur every year in the
United States and which could be prevented if the present body of existing
knowledge were effectively applied. For each cause of death he estimated the
potential percentage of reduction attainable at the present time, stating for each
the major [actors that would contribute to the reduction (Table 7). His figures
have been modified to bring them up to date. Each of the theoretical percentage
reductions was then applied to the number of deaths that were attributed during
1955 to each particular cause ol death (Table 8). The difference between the
resulting figures and the number of deaths that actually occurred indicate a total
potential saving, at the present time, of over 500,000 lives per year. This saving,
il it had been effected, would have reduced the crude death rate of the United
States in 1955 from 9.2 to 6.1 per 1000 population. That this is in no way a
fantastic concept is given ample testimony by the fact that some American
communities and several nations have actually reduced their rates close to that
level. If the lives that could theoretically be saved are distributed appropriately by
age groups, it is seen that benefits are possible at every point in the life span. The
greatest savings, however, would occur in the adolescent and young adult age
groups where a death involves the greatest possible economic loss. If this analysis
were to be pursued [urther by applying estimated monetary values to each of the
500,000 deaths potentially preventable, the magnitude ol the economic loss en-
tailed would indeed appear to be stupendous. Thus, if again each life saved was
considered to represent an investment of ‘merely $1000, the total value the nation
could save would be 500 million dollars.

It often seems to be fashionable in the United States to complain of high
taxes and governmental costs. On the other hand, the average American does tend
to be a rather practical individual. When it is demonstrated to him that funda-
mentally the public health program is a matter of common sense and of true econ-
omy, he will readily subscribe in most instances to the necessary financial support.
To an ever increasing extent, the American public is realizing that attempted
frugality in public health matters is penny wisdom and pound foolishness.
94 INTRODUCTION: PUBLIC HEALTH

 

Table 7. Postulated Percentage Reductions in Deaths, by Cause,
If All Available Knowledge Used

 

 

 

 

Per Cent
Cause of Death Reduction Suggested Action
Typhoid and paratyphoid 100%, Environmental measures
Immunization
Epidemiologic control
Meningococcal infections 1009, Control of epidemics
Adequate and early chemotherapy
Antibiotics
Streptococcal infections 100%, Chemotherapy
Antibiotics
Antitoxin
Whooping cough 1009, Early and thorough immunization
Hyperimmune serum, chemotherapy, and
antibiotics for secondary infections
Diphtheria | 100% Immunization, early and adequate antitoxin
Tuberculosis 1009, Intensive early case finding
Hospitalization and treatment
Adequate diet and housing
Dysenteries 1009, Environmental control
Chemotherapy
Malaria 1009, Environmental control
Chemotherapy
|
Syphilis 1009, Intensive early case finding
Treatment
Epidemiologic control
Measles 1009, Immune globulin
| Chemotherapy
Antibiotics
Poliomyelitis 100%, Immunization
Neoplasms 50% Early cancer detection and treatment centers
Best possible physician and surgeon
| Chemotherapy

 

Radiation therapy

Where chemotherapy and/or antibiotics have been listed as the explanations for the reduc-
tions in deaths, objection on the basis of the developments of drug-resistant organisms will no
doubt be raised. Gains possible today might be much less in a few years. It is felt that research
will be able to remain one or two drugs, at least, ahead of the organisms.

With the one exception (all other causes) no variation of effectiveness of therapy and other
control measures with age of the individual has been postulated. Since any scheme of correction
would probably have been as liable to criticism as no correction, the latter course was followed.
ECONOMIC JUSTIFICATION 95

Table 7. Postulated Percentage Reductions in Deaths, by Cause,

Cause of Death

Neoplasms—Cont’d

Rheumatic fever

Diabetes mellitus

Exophthalmic goiter

Nutritional diseases

Addictions

Intracranial vascular lesions

Diseases of the heart

Pneumonia, broncho

Pneumonia, lobar

Pneumonia, unspecified

Influenza

Gastric ulcer—stomach and
duodenum

 

Per Cent
Reduction

95%

609%

100%,

100%

25%

10%

109%,

759%

90%

75%

859,

50%

If All Available Knowledge Used—Cont’d

 

Suggested Action

Surgery

Circumcision
Elimination of smoking
Best possible physician
Prophylactic antibiotics

Best possible physician
Intensive early case finding
Diet

Insulin

Applied genetics

Best possible physician
Newer drugs

Good surgery
lodization of all salt

Adequate diet
Diagnosis and treatment

Psychiatry
Nutritional therapy
Sociology
Education

Best possible physician
Antihypertensives and diet
Anticoagulants

Avoidance of infections
Antibiotics

Best possible physician
Heart surgery

Chemotherapy
Antibiotics

Chemotherapy
Antibiotics

Chemotherapy
Antibiotics

Immunization
Chemotherapy and antibiotics for complications
Psychiatry

Best possible physician

 
Table 7. Postulated Percentage Reductions in Deaths, by Cause,
If All Available Knowledge Used—Cont’d

 

 

Per Cent
Cause of Death Reduction Suggested Action
Diarrhea, enteritis, etc. 959% Environmental controls
Chemotherapy
Antibiotics
Appendicitis 1009, Surgery
Chemotherapy
Antibiotics
Hernia, intestinal obstruction 959%, Best possible physician and surgeon
Cirrhosis of the liver 259% Newer nutritional knowledge
Biliary calculi 25%, Best possible physician and surgeon
Nephritis 25% Chemotherapy
Antibiotics
Best possible physician
Diseases of the prostate 50% Best possible physician and surgeon
Diseases of pregnancy 87% Complete elimination of deaths from toxemia and
sepsis, and reduction of deaths from hemorrhage
by 50%
Congenital malformations 109% Diet during pregnancy
Avoidance of viral infections during pregnancy
Surgery (as in recent heart and blood vessel oper-
ations)
Premature births 70% Adequate prenatal care and diet
Suicide 509% Psychiatry
Sociology
Homicide 50% Psychiatry
Sociology
Accidents—motor vehicle 509, Education
Psychiatry
Engineering
Traffic planning and control
Safety measures
Accidents—other 509, Education
Psychiatry
Safety measures
Engineering
All other causes 50% Better medical care (except for under 1 year, where

 

 

deaths from congenital debility, birth injury,
and others peculiar to the first year of life were
reduced by 759% —adequate prenatal care and
diet, adequate care during first vear of life)
ECONOMIC JUSTIFICATICN

97

Table 8. Theoretical Savings of Lives, United States, 1955, Had All

Available Knowledge Been Effectively Applied

 

Cause of Death

Typhoid and paratyphoid
Meninococcal infections
Streptococcal infections
Whooping cough
Diphtheria
Tuberculosis—all forms
Dysenteries

Malaria

Syphilis

Measles

Poliomyelitis

Neoplasms

Rheumatic fever
Diabetes mellitus
Exophthalmic goiter
Nutritional diseases
Addictions

Intracranial vascular lesions
Diseases of the heart
Pneumonia, broncho-
Pneumonia, lobar
Pneumonia, unspecified
Influenza

Ulcer— stomach and duodenum
Diarrhea, enteritis, etc.
Appendicitis

Hernia, intestinal obstruction
Cirrhosis of the liver

Biliary calculi, etc.

Nephritis

Diseases of the prostate
Complications of pregnancy
Congenital malformations
Premature birth

Suicide

Homicide

Accidents, motor vehicle
Accidents, other

All other causes

Totals

 

Population (1955 estimate)

Death rate (per 1,000 population)

Percentage reduction of death rate
(actual to theoretical)

 

Total Deaths
1955

46

907
1,268
407

150
14,950
556

18
3,834
345
1,176
245,849
1,131
25,488
1,210
1,248
2,004
174,152
510,737
22,2006
11,182
4,768
2,755
9,941
7,754
2,273
8,154 |

 

12,211
6,739
18,214
6,450
1,901
20,502
21,456
16,755
7,406
37,437
54,663
270,414

1,528,717

 

165,271,000

9.2

 

 

Theoretical
Per Cent
Reduction

100
100
100
100
100
100
100
100
100
100
100
50
95
60
100
100
25
10
10
75
90
75
85
50
95
100
95
25
25
25
50

 

Theoretical
Deaths

122,924
57
10,195

1,503
156,737
459,063

5,551

1,118

1,192

413

4,971

388

408
9,158
5,054

13,660
3,225
247
18,452
6,437
8,378
3,703
18,719
27,332
135,207

1,014,692

165,271,000

6.1

34.8

 

Theoretical
Saving

46

907
1,268
467
150
14,950
556

18
3,834
345
1,176
122,925
1,074
15,293
1,210
1,248
501
17,415
51,074
16,655
10,0064
3,576
2,342
4,970
7,360
2,273
7,746
3,053
1,685
4,554
3,225
1,054
2,050
15,019
8,377
3,703
18,718
27,331
135,207
98

INTRODUCTION: PUBLIC HEALTH

REFERENCES

I.

Petty, Sir William: Political Arithmetic or a Discourse Concerning the Extent and Value of
Lands, People, Buildings, etc., ed. 3, London, 1699, Robert Clavel.

Dublin, L. I., Lotka, A. J., and Spiegelman, M.: The Money Value of a Man, ed. 2, New York,
1946, The Ronald Press Co.

Dublin, L. I., and Lotka, A. J.: Length of Life: A Study of the Life Table, New York, 1936,
The Ronald Press Co.

Report of Joint Committee on Health Problems in Education, Health Education, Washing-
ton, D. C., ed. 2, 1941.

Bolduan, C. F., and Bolduan, N. W.: Public Health and Hygiene: A Student's Manual, ed. 3,
Philadelphia, 1941, W. B. Saunders Co.

5. Slee, V. N.: Public Health and Old People, Unpublished Study, School of Public Health,

University of Michigan, June 1947.
chapter 5

Behavioral science and public health

 

Introduction. It is strange that while the term “public health” has been
used for several generations, the significance of the two words seems to have been
only recently fully appreciated. It should always be realized that we are dealing
here both with a product—health—and a recipient—the public—and that the most
complete knowledge and understanding of the one is pointless without corre-
sponding information about, and consideration of, the other. This is what Lea-
vell' had in mind when he wrote:

Two major types of changes with which public health must deal are going on in
the modern world: “public” changes and “health” changes. Our professional training
helps us most with the health changes. Our knowledge of biology, chemistry, and
physics and their medical sub-specialties helps us find and use the proper immunizing
agents to prevent disease, the right kinds of food to eat, the best sprays to kill mosquitoes,
and so on. We can usually adjust rather readily to rapid changes demanded as a result of
research which provides better tools with which to combat health problems.

The public changes that are so important in public health work are in many respects
more difficult for us to appreciate. Most of us have limited backgrounds in the basic social
sciences—sociology, anthropology, psychology, economics, and political science—that might
help us understand better the people with whom we must work. Yet public changes are
often of even greater importance than health changes.

. we need a great deal more research to be able to translate the findings of
biological investigation into social application. When we meet a health problem, we
must recognize that two kinds of diagnosis and treatment are necessary. We must under-
stand and deal with the health problem. We must also understand and treat the social
or public part of the situation. Our pharmacopeia in both fields must be strong. It is
no longer sufficient to prescribe drugs and neglect the social factors in a given case.*

The Meaning of Health to Society. It is only natural that each of us tends to
view his particular interests and activities as of paramount significance. Because
of this there is some danger that public health workers may consider public health
goals as ends in themselves and the activities required for their achievement
as necessarily of primary interest to society. Few attitudes are more conducive to
disappointment and disillusionment. This is particularly true if, as is sometimes
the case, the goals have been arbitrarily determined and the activities planned

*Leavell, Hugh R.: New Occasions Teach New Duties, Pub. Health Rep. 68:687, July 1953.

99
100 INTRODUCTION: PUBLIC HEALTH

’

and carried out by “experts,” who obviously are prejudiced, without concern for
the needs, ideas, and wishes of the group. That the latter may honestly look upon
the goals and activities quite differently, or that for reasons ofl group pride, co-
hesion, and self-assertion the group is more or less forced into the psychological
position of objecting or resisting, should give no cause [or surprise.

The fact, of course, is that although health is a common need and the effort
to attain it represents a common drive, it is actually ol secondary rather than ol
primary importance. Man, even in the primitive state, is concerned with the
achievement of a total or integrated way of life. Because of its complexity, this is
not easy to define. Some distinctions are possible, however, especially when ap-
proached through contact with and study ol certain social situations such as primi-
tive societies and societies under stress. In such circumstances one cannot avoid the
conclusion that while man and his societies are subject to many needs, urges, or
drives, only a certain few of these are primary or basic. Such are the urges for
food, for shelter, and for sexual expression or propagation. As lor many other
goals, of which health is probably one, most individuals and society are in-
terested in them to the extent that they make possible the achievement of related
goals, especially those which are primary in nature. It may be argued that the
desire for comfort, the absence of pain, or the achievement of physical well-being
are very relative terms. In societies where the majority acquire malaria or
trachoma, these conditions come to be looked upon as part of the normal pattern
of life and are adapted to accordingly. Ill health, in effect, is considered to be the
presence of any condition which is unusual or beyond these. It might perhaps be
said that man will strive for food, shelter, and sexual expression in the absence
ol complete health, but he will not strive for complete health in the absence of the
others.

A few examples may help to place the desire for health in its proper per-
spective. A man and a woman stranded on an island will ordinarily seek to assure
themselves of food, shelter, and sexual satisfaction before giving attention to other
needs. In most instances they will seek to satisfy these three needs or urges in the
order given because of the differing critical intervals involved. Furthermore, they
will do so in the face of potential threats to their health or safety. Thus, if the only
source of food or of materials [or shelter are in or near an insalubrious spot, they
will still seek them out. Later, perhaps, they may seek out a more desirable al-
ternative. Undoubtedly syphilis could be completely eradicated by abstinence
[rom sexual intercourse on the part of all members of society. The chances of this
procedure being followed are obviously nil because when faced with a choice be-
tween the two, the risk of infection will be readily accepted by the majority. The
example is more than theoretical as the suggestion has been made on more than
one occasion to individuals or special groups to no avail.

Another example of health being relegated to a secondary position was found
in relation to the technical assistance activities in malaria control in North Africa.
In that area the date is the basic element in the food supply. Despite the recog-
nized relief from malaria, the activities eventually were somewhat opposed in
several communities because the DDT killed not only the malaria-transmitting
Anophelenes but also the species of fly which normally carry the pollen from the
BEHAVIORAL SCIENCE 101

male to the female date palm. In order to assure both desirable ends, modifications
in control techniques had to be developed.

There are some situations in which health measures, as deterrents to ultimate
death, are actually regarded as somewhat undesirable. The realization of this
comes as a shock to those accustomed to regarding health as a universally desired
goal. Where conditions for life and survival are difficult and especially where
disease and premature death are common, the social attitude toward death may
be quite different from ours. Not uncommonly, particularly in the case of infants
and very young children, a death is not necessarily too sad an event. The young
child, as a child, does not have yet a fully developed personality and is looked
upon as an added family economic burden. Its timely removal may mean more
food and other things for the rest of the [amily and less suffering and misery for
itself in the long run. An impression ol this may be obtained by observing funeral
ceremonies in less developed societies with high death rates. Here the difference
between the funeral of a productive adult and that of a very young child or of an
elderly person may be quite striking. In the former instance, there is inevitably
genuine regret and sadness shown by the mourners. The adult has been around
long enough for people to get to know him as a personality, but beyond this his
death is recognized as an economic loss of a producer for his family and for the
community. In the case of funerals of elderly persons, there is again genuine re-
gret, but not as much as in the former case. True, the elderly individual's per-
sonality is well known and familiar in the local scene. However, he has served
his economic purpose in life, as he has also served his social purpose in producing
offspring and in transmitting through his life the mores of the group. He now has
become an economic or even a social burden who has to be supported, and any-
how he is now entitled to his well-earned release to the benefits and security of
the herealter. In the case ol infants and young children, the difference may be
even more marked. Often there is relatively little true mourning, the physical
appearance of the funeral procession, if anything, tends to be much brighter and,
among some peoples, even rather cheerful. Songs may be sung, bands may play,
and, when the small body is finally disposed of, there may be a rather enthusiastic
fiesta with dining, drinking, dancing, and indulgence in all other pleasures ol
the flesh. Even in our more sophisticated societies, gradations ol these differ-
ences in attitudes may be observed. Suffice to point to the olt-expressed ameliorat-
ing thought that a deceased child was “pure ol heart” hence much more apt to
achieve everlasting happiness.

Finally, recognition may be given to certain societies in which to be ill and
suffering is considered to be more saintly or godlike. Similarly, in these and other
societies in which it is common to undertake religious pilgrimages to holy places,
to become ill and to die in the process ol, or on completion of, the pilgrimage is
the most desirable thing that could happen.

It is not the intention here to belittle or to discourage efforts made toward
the improvement of the public health, for such would be quite out of tune with
the writer's philosophy and actions. The purpose has been to point out that health
is a relative concept, that its definition and value varies [rom one place to an-
other, and even in a given society through time that it is only one lacet of the total
102 INTRODUCTION: PUBLIC HEALTH So
interest and welfare of the individual and of his society and as such is in constant
competition with all other factors of greater or lesser importance to that indi-
vidual and that society. It is necessary that we realize these things for as Koos® has
pointed out, “What we can expect a community to provide, and its members to
accept, in the way of health activities must therefore be viewed in a [ramework
which is peculiar to that community. This in no way prevents the establishing
of uniform goals or standards for health, but it does mean that community efforts
directed toward better health are necessarily custom-built.”

Social Analysis and Community Organization for Health. Each one ol us is
many things. First of all, we may consider ourselves as individuals, each a com-
posite or compromise of various strengths and weaknesses, interests and prejudices,
abilities and failings. But as some philosophers have claimed, perhaps there is no
such thing as a true individual. Each of us is the product and a part of a series of
environments beginning with the womb. Beyond being individuals we are mem-
bers of families, and beyond that members of varying numbers and types ol social
groups with shared and common needs and interests—complexes of interrelated
families, the guild, the village, the clan, eventually agglutinating to form various
types of cultural and national entities.

Human beings everywhere are members ol groups. As such, they may be de-
pendent upon one another within the groups for sustenance, education, inspira-
tion, economic welfare, and entertainment as well as for many other needs. The
individual needs the group but not necessarily only a particular group, or always
the same group, or the same group for all needs. The same conditions also apply
to the group's need for the individual. While the bonds which link the individual
to the group are usually strong if they are to be of value, they are not necessarily
fixed. They may be and in fact often are broken or transferred. It is in line with
this that individuals are seldom found to be members of only one group. Different
groups are needed for different purposes. Although this is not so apparent in
primitive societies, even there individuals have multi-group attachments—to the
family, to a larger kinship group, to a totem group, to a maturation cult or secret
society, as well as to the tribe. In more highly developed societies the plurality of
group membership is more evident. In addition to the family there is the school,
the church, the social club, the athletic club, the business and professional as-
sociations and many, many others.

The question inevitably arises whether all of these many groups are neces-
sary and important or whether for our purposes or those of others it is possible
successfully to approach and influence all individuals through one group. This is
another way of asking if it is possible to focus all of man’s interests toward one
group. Is it possible to have one group which would satisfy all needs? Clearly the
answer is found in reality. Innumerable groups exist because people develop them
to meet their various and varying needs. An individual requires a social com-
plex of many differing groups in order to obtain sufficient significant or fruitful
relationships which will satisty the various facets of his personality and inter-
ests. Repeated attempts have been made and are still being made to relate
the complete allegiance and interest of people to one single supergroup, e.g.,
the state.
BEHAVIORAL SCIENCE 103

 

All previous attempts along these lines have failed, and one might safely
guess that all future attempts will experience the same fate. Life devoted ex-
clusively to one group is necessarily very narrow and self-limiting. “The man who
can live without society,” said Aristotle, “is either a beast or a god. But the man
who can live exclusively for the state, if indeed such a being exists, is either a
tyrant or a slave.”

Granted then that it is the nature of man to belong to various groups, how
does this affect his behavior and his receptivity? It should be recognized at the
onset that man’s behavior as an individual is usually quite different from his be-
havior as a member of a group or of society, and that his social or group be-
havior varies from group to group. Furthermore, when a point of common concern
or mutual interest exists and can be adequately indentified, widely differing
groups may join forces and with regard to this particular interest jointly behave
differently than each behaves alone. This does not mean that any one group
forfeits its identity. As Skinner? points out, “Social behavior arises because one
organism is important to another as part of its environment. A first step, therefore,
is an analysis of the social environment and of any special features it may possess.”
Since our intention here is social analysis for the purpose of community or social
organization for public health improvement, it is important to distinguish and
identify groups which may be of significance toward that end. There are three
general categories of identifiable groups the existence of which the specialist in
community organization should be constantly aware and which are important
“because community organization for health cannot be carried on in an icy apart-
ness from the social worlds in which people live for whom it is designed, and
because community organization cannot ignore the strength of the factors which
create distinctive values regarding health and which place these values high or
low in the whole hierarchy of values that are a part of . . . life.”

The first of these are groups which provide for ethnic identification. These
are represented by religious, racial, or nationality groups each with their own
prescriptions, prohibitions, and ideals, any one of which may be of significance in
matters of health and sickness.

A second category is related to ethos identification, i.e., bonds which identify
individuals as belonging to the same ethical, economic or social group (sometimes
coincident with a neighborhood). There the economic education or moral nature
of the group may determine the extent or manner ol participation in activities
designed for the improvement of the public health.

Finally, there is the family, which usually represents the most powerful
example of social cohesion. To ignore the position of predominant influence of
the family in the development or conduct of a public health program usually
guarantees failure. The pertinence of Koos’ remarks in this regard justifies their
repetition here.

We may well question the logic of industry—or school-centered programs that
ignore the importance of the family as a “conditioner of attitudes,” and which may
send the individual back into his family to face conflicting ideologies about health and
its value. This is not a plea to abandon school- or industry-centered programs; it is to
point out that such programs can work effectively only if they send the individual back
104 INTRODUCTION: PUBLIC HEALTH

 

to his family prepared to adjust differences that may have been engendered; to make
him, in effect, a health organizer in his own small family world. If the individual is not
so prepared . . . the cost in tensions and frustrations can outweight any small good
the program may have accomplished. *

Society and Culture. Since up to this point reference has been made to several
closely related fields, it is important that distinction be made between society,
the subject matter of sociology, and culture, the subject matter of social or cultural
anthropology. The society is any community of individuals drawn together by a
common bond of nearness and interaction, i.c., a group of people who act to-
gether in general for the achievement of certain common goals. A society has both
quantitative and qualitative characteristics. Thus it is possible to count and
measure the size of the individuals who constitute a society. One of the qualitative
characteristics is its culture, or the manner in which the group as a unit tends
to think, feel, react to stimuli, believe, in other words, its basis for behavior. As
Kluckhohnt describes it, “a culture refers to the distinctive ways of life of such a
group of people . . . a culture constitutes a storehouse of the pooled learning of
the group.” Every society has its own distinctive culture, and since there are in-
numerable societies in each community, in each country, and on each continent of
the world, there are therefore innumerable cultures, each differing to a greater or
lesser degree from all of the others. The study of these cultures, their components,
and their relationships with each other is the subject matter of cultural anthro-
pology, the purpose of which is to aid man in understanding himself. As Kluck-
hohn graphically puts it, “Anthropology hold up a great mirror to man, and lets
him look at himself in his infinite variety.”

In the entire course of history, every member of the human race was born
into some sort of culture. Some of them were primitive, simple, and crude, whereas
others were complex and highly developed. Some dwindled and died, while
others flourished and grew. All of them, however, regardless ol their degree of
complexity or simplicity, developed some form of techniques, religious beliefs,
social systems, and art forms. Every child being born into his particular group
culture is certain to be influenced by it more than by anything else in his entire
life. “As a matter of fact,” says White,> “his culture will determine how he will
think, feel and act. It will det€rmine what language he will speak, what clothes if
any he will wear, what gods he will believe in, and how he will marry, select and
prepare his foods, treat the sick, and dispose of the dead. What else could one do
but react to the culture that surrounds him from birth to death?”

This behavioral determining effect of culture on the individual and the im-
portance of understanding it is stressed further by Benedict.

... The life history of the individual is first and foremost an accommodation to
the patterns and standards traditionally handed down in his community. From the
moment of his birth the customs into which he is born shape his experience and be-
haviour. By the time he can talk, he is the little creature of his culture, and by the

time he is grown and able to take part in its activities, its habits are his habits, its

beliefs his beliefs, its impossibilities his impossibilities. Every child that is born into his

*Koos, E. L.: New Concepts in Community Organization for Health, Am. J. Pub. Health
43:467, April 1953.
BEHAVIORAL SCIENCE 105

group will share them with him, and no child born into one on the opposite side of
the globe can ever achieve the thousandth part. There is no social problem it is more
incumbent upon us to understand than this of the role of custom. Until we are intelli-
gent as to its laws and varieties, the main complicating facts of human life must re-
main unintelligible. *

Beyond this, she says:

The study of different cultures has another important bearing upon present-day
thought and behaviour. Modern existence has thrown many civilizations into close con-
tact, and at the moment, the overwhelming response to this situation is nationalism
and racial snobbery. There has never been a time when civilization stood more in need
of individuals who are genuinely culture-conscious, who can see objectively the socially
conditioned behaviour of other peoples, without fear and recrimination.¥
The importance of culture and the contribution which cultural anthropology

may make to action programs in the field of public health has perhaps become
somewhat more evident to those public health workers who have been working in
lands and countries other than their own and in the field of international health.
They have come to realize, with Carothers? that “the visitor to foreign lands is
always most impressed by the general peculiarities ol peoples, whereas in his
homeland . . . he notices only the individual divergencies.” It should be pointed
out that the choice of words in this statement is rife with significance. It is im-
portant to call attention, however, to the olt-overlooked fact that it is not necessary
to visit “foreign” or “exotic” lands to encounter “cultures.” It is fundamental that
the domestic health worker realize that he too has been born into a culture, has
grown up in it, received his training in possibly still another culture, and in the
conduct ol his work must deal with a great many cultures in his own community.
It is well for each of us to realize that as Oliver Wendell Holmes so aptly re-
marked, “The people in every town [eel that the axis of the earth passes through
its main street.” That is why so many tribal and national names, when traced to
their origins, are found to mean “the human beings,” “real or principal people,”
and similar accolades. Thus, as Gittler® discovered, “The Greenland Eskimo be-
lieves that Europeans have been sent to Greenland to learn virtue and good man-
ners {rom him. Their highest form of praise ol an outsider is that he is or soon will
be as good as a Greenlander.” This is also why our language contains such often-
used phrases as “beyond the pale” or “the other side of the tracks.” It is most
certainly unnecessary to go to the ends ol the earth to find other cultures; we can
find them, must understand them, and must live and work with them in our own
communities.

In this connection, sound action in a field like public health presupposes
sound evaluation of circumstances and situations, and it is important to rec-
ognize that our evaluations are determined by our own cultural background.
In discussing the relationship between science and culture, Bernard? says, “We
have come to use the term ‘definition of the situation’ to describe the process
which people go through in perceiving, evaluating, and interpreting what goes on

*Benedict, Ruth: Patterns of Culture, New York, 1934, The New American Library of
World Literature, Inc., p. 2.

Benedict, Ruth: Patterns of Culture, New York, 1934, The New American Library of World
Literature, Inc., pp. 9-10.
106 INTRODUCTION: PUBLIC HEALTH ey

about them. Even within a given culture, among people using the same language,
the student and the teacher, the husband and the wife, the parent and the child,
the employer and the employee, define an identical situation quite differently.
They all see, hear, and perceive different things, and what they see, hear, and
perceive, has different meanings for each.”* “The truth of the matter,” says Bene-
dict, “is that the possible human institutions and motives are legion, on every
plane of cultural simplicity or complexity, and that wisdom consists in a greatly
increased tolerance toward their divergencies. No man can thoroughly participate
in any culture unless he has been brought up and has lived according to its forms,
but he can grant to other cultures the same significance to their participants
which he recognizes in his own.”

What is the purpose of culture? All cultural traits, habits, prejudices, and
the like are based essentially on a mixture of conscious and subconscious urges
for individual and group survival and perpetuation. As Kluckhohn* indicates:
“Any cultural practice must be functional, or it will disappear before long; that
is, it must somehow contribute to the survival of the society or to the adjustment
of the individual.” Every society has developed institutions and methods of be-
havior to safeguard and perpetuate the practices and beliefs which its members
consider the most important and valuable. In every society, social arrangements
or organizations have been developed over long periods of time on the basis of
proved group experience to meet life’s basic needs. Programs such as public health
necessarily involve the introduction into the culture of the society of new practices
and changes in these arrangements. If such programs are to be constructive rather
than disruptive forces, the social structure and the traditional cultural way of life
of the community must be taken into account and utilized.

Not only are the accepted value systems of a culture deeply ingrained, but
disadvantaged people adhere particularly strongly to their attitudes and beliefs.
This is to be expected since people who for a long time have been accustomed to
crowded living conditions, low economic status, discrimination, and to philosophic
systems which serve to make life under these conditions bearable look upon
change or suggested change with misgivings and suspicion. Their greatest fear is
that things might get worse, and to them, on the basis of their experience, change
often implies that very possibility. Advatageous incentives to change and demon-
strations of the value of new ideas, techniques or actions are necessary to over-
come the natural reluctance of people to change their ways and their fear of the
possible risks involved in following new practices. They need to have proved to
them, in one way or another, that the suggestions will make possible real improve-
ments in their standard of living and need to be assisted in their attempts to im-
plement the suggestions made and to integrate them with the rest of their cultural
pattern. A public health program must demonstrate to people that continuing im-
provement in their welfare and their level of living is its main purpose. It is in-
sufficient merely to enunciate general principles or objectives of health as if

*Barnard, Jessie: Can Science Transcend Culture, Scient. Month. 71:270, Oct. 1950.
Benedict, Ruth: Patterns of Culture, New York, 1934, The New American Library of World
Literature, Inc., p. 33.
BEHAVIORAL SCIENCE 107

they were the end and to think of the people involved merely as a means to that
end. Instead, the people must be able to see clearly and unequivocally that the
public health activity or program is one that attacks the problem not just in terms
of increasing “community health” in the abstract, but in terms of all the needs
of people with much the same aspirations the world over for their families and
for their neighbors.

It is true, therefore, as Paull? says:

The cultural system does limit the range of individual behavior and in this sense
customs exert a restraining influence. Culture defines the values men hold, the goals they
seek, the means they use. By thus organizing their outlook, culture is also a guide to
action, a positive force that channels motivation and imparts meaning to existence. We
are too inclined to perceive the negative and overlook the positive when we behold the
customs of others . . . Now a health program strikes at the uncertainties of death and
disease, and it may seem ironical that the dissemination of improved medical practices
should be impeded precisely by those superstitions that owe their vitality to the hazards
of life deriving from inadequacies of medical knowledge. But faith is strong where risks
are great, and people act slowly when it comes to shifting their faith from a familiar sys-
tem of security to an unfamiliar one, however efficacious the new system may prove to be
in the long run. It should not be overlooked that faith gives psychological security,
whether faith is placed in magic, religion or science.*

One aspect of culture which is easily overlooked is the fact that it is more
than a collection of customs; it is a system of customs, each one more or less
related to the others in a meaningful fashion. A culture has structure as well as
content, it is not just like a haphazard pile of bricks. This gives a clue to the
reason [or the tenacity with which societies hold on to their customs. Each one is
like a gear in a transmission system, each one important, necessary for the
total function, and directly or indirectly related to all of the other gears. As it
is impossible to remove a gear from a transmission system and still have the system
function without an adequate substitute, so it is impossible to remove a custom
from a culture without providing for an equally satisfactory or better substitute
custom. To carry the analogy further, the end result of a transmission system is the
product of its component gears, not merely their sum. Similarly, a total culture is
the product of its component parts or customs—not merely the sum—and if any
one basic part is destroyed or reaches zero, the entire culture collapses. President
Eisenhower had this in mind when speaking at Supreme Headquarters Allied
Powers Europe, he said: “The strength that a nation, or a group of nations, can
develop is the product obtained by multiplying its spirtual or moral strength, by
it economic strength, by its military strength . . . . There can be no army unless
there is a productive strength with a productive power to support it. There can
be neither a strong economy nor an army if the people are spiritless, if they
don’t prize what they are defending.”

Benedict® narrates a significant and touching anecdote in this regard. She
tells of her conversations with a chief of the Californian Digger Indians who had
been “civilized” and integrated to a greater or lesser degree with our Western

*Paul, Benjamin D.: Respect for Cultural Differences, Community Development Bull,
University of London Inst. of Educ. 4:42, June 1953.
108 INTRODUCTION: PUBLIC HEALTH

civilization. He told her of life in the olden days, of the ceremonies, the agri-
culture, the tribal economy, and of how each of these and other customs were
so meaningful to the tribe: “In those days,” he said, “his people had eaten ‘the
health of the desert’ and knew nothing of the insides of tin cans and the things
for sale at butchershops.” It was such innovations that had degraded his people
in the latter days. Then he added one day: “In the beginning God gave to every
people a cup, a cup of clay, and from this cup they drank their life. They all
dipped in the water, but their cups were different. Our cup is broken now. It has
passed away.”

In discussing the social disorganization which developed in the little Guate-
malan town of Tiquisate, which was an experiment in agricultural productive
efficiency, Hoyt!! warns:

The potential economic effects of increasing production cannot be abstracted from
the actual psycho-social effects; and it is possible, if we are not careful, that the dis-

organization accompanying the latter may be greater than the constructive services
of the former.*

She continues:

If Tiquisate is an outstanding example of productive efficiency, it is also an out-
standing example of social disorganization, even to the extent that the latter threatens
the former. This is evidenced by a great deal of drunkenness and prostitution—which
the people themselves deplore—by lax family relations, and by strong social antagonisms
. . . . Although new values appeared, they did not take the place of the old; neither did
they furnish a framework within which the psychic aspects of the people’s old life could
find their place and get the necessary response.

I encountered a somewhat similar phenomenon on the lovely island of Bali.
The government of the new nation of which Bali is a part, wanting to take its
rightful place in the modern society of nations, apparently deplored any custom
which might cause other nations to consider it as backward or primitive. It
therefore passed a law requiring the women of Bali to cover their breasts. Ac-
cording to observers who had lived there for some time, there has come about
a noticeable change in the Balinese males’ attitude toward female breasts and
toward women, and it is significant that in the short time since that law was
passed prostitution has appeared on the island for the first time. That a casual re-
lationship actually exists in this case, of course, is not possible to determine. The
circumstances and timing, however, give some cause to wonder.

In summary to this point, therefore, all human beings are members of
societies, each with its own culture consisting of a complex mosaic of interrelated
customs. These customs have developed through the ages as a result of group
experience in its struggle for survival and for a reasonably satisfactory life. Ac-
cordingly, people relinquish customs reluctantly, and it is well that they do, be-
cause each one, or a truly adequate substitute, is fundamental to the continued
existence of the society. The great contribution of cultural anthropology to the
conduct of programs such as public health is constantly to identify and point out
the importance of cultural patterns of the groups or societies which constitute a

*Hoyt, E. E.: Tiquisate: A Call for a Science of Human Affairs, Scient. Month. 72:114, Feb.
1951.
BEHAVIORAL SCIENCE 109

community or a nation. Social evolution inevitably disturbs cultural patterns, but
that is one price of progress. However, cultural patterns need not be disturbed
more deeply or more rapidly than the people are able to tolerate. This principle
should underlie all of our action.

Effect of Cultural Patterns on Health. With some of the considerations up
to this point in mind, it is obvious that many if not all cultural patterns bear some
relationships to the degree of health of a people, and the extent to which they will
accommodate themselves or be receptive to efforts that might be made to im-
prove their state of health. It does not seem necessary to discuss here the positive
or scientifically desirable contributions ol certain cultural patterns to health or
the even more obvious contributions of sound public health measures in general
to cultural development. Let us therefore concern oureslves with some examples
ol cultural patterns which may have a disadvantageous effect on the health of a
people.

There are many reasons [or ill health, only a few ol which will be discussed
at this time. One readily recognized reason is ignorance or lack of knowledge
about the factors involved in the causation ol illness and death. It is recalled that
during a period when the infant mortality rate for the City of Detroit in general
was undergoing a consistent and significant decline, there were several areas of
the city which did not appear to be sharing in the improvement. Analysis ol those
areas and comparison of them with other sections of the city indicated that they
were populated to a major degree by foreign-born individuals of a particular
European nationality. A study of their cultural habits indicated that there was
considerable family attachment to the infant, and that the environmenal circum-
stances were relatively clean. However, further inquiry brought out that the in-
fants traditionally were taken off the breast at a very early age, following which
they were fed essentially adult foods, often directly from the family table. Con-
current analyses of the causes of infant mortality in these areas indicated a high
incidence of death due to severe digestive disturbances and intestinal infections.
It was necessary, over a period ol several years, to bring to bear the efforts of a
reoriented and rather specialized public health nursing program, assisted by ap-
propriate nutritional and pediatric consultation. In addition to this instance,
there are many groups in which it is the custom for the mother to pre-chew solid
{foods for their babies and young children, not realizing the bacteriologic risk in
their attempt to carry out what appears on the surface to be a logical procedure.

Very often economic factors are cultural reasons for ill health. Until recently
in the United States, and even now in a number of other countries, certain meth-
ods of earning a living have resulted in high incidences tuberculosis and other
diseases. This has been particularly true in the case of certain industrial and
manufacturing activities, and in cases where trading, with its increased contacts,
forms the economic basis of a group. Difficult as it may be for some to believe,
there are many societies in which excrement, both human and animal, represents
the single most valuable if not the only valuable commodity. The reason may
be either for use as a fertilizer or as fuel. The extent of use of human feces
for fertilizer and the inherent dangers are rather well known and need not be
dwelt upon.
110 INTRODUCTION: PUBLIC HEALTH

With regard to the use of excrement as fuel, the following example may be
pertinent. Recently an attempt was made to improve health conditions in several
villages in Egypt by installing latrines, constructing wells, and killing flies with
insecticides.'>13 The project was regarded as less than successful, not just because
the fly population repeatedly developed resistance to the insecticides used, but
particularly because of various cultural features of the situation which could not
be changed within the scope of the project. One factor was that the dung of the
gamous or cow was exceedingly valuable as the only form of fuel for heating
and cooking. Accordingly all members of each household were constantly on the
lookout for dung, would collect it, pat it into cakes, and store it within the con-
fines of the household where it would be safe from thieves. There it constituted a
continuous and most effective breeding ground for flies which for centuries have
multiplied at a tremendous rate. An additional factor was that each house serves
as the home of both the family and its livestock. A significant and permanent im-
provement in the health of the people of these villages, of which there are many
thousands, must depend upon effective separation of the family and their live-
stock, especially the gamous. But, aside from extremely difficult problems of find-
ing adequate space and building materials for stables, in a land where every inch
or arable soil is at a premium and trees are extremely rare, it was found that
not inconsiderable social problems would arise from such a contemplated change.
One of these was the safety and security of the animals. In addition, however, it
was brought out by careful interviews that many women in the villages found
the gamous their only source of companionship within the home during the day
while the men and boys worked in the fields, and that they might resist attempts
to end this sociable relationship. It was concluded therefore that an attack on
health conditions in the villages, by methods of sanitary engineering and fly
control, was not enough. The abominable conditions could not be materially im-
proved without an attack on a very broad front, involving economic and social
measures as well as those which have been carried out.

Bogue and Habashy'* also have described the attitude of the Egyptian villager
toward his animals and the effect of it on attempts to improve health conditions
by quoting a villager involved: “The fellah has his own habits and traditions
which have come down with his long heritage. Many of these habits are good but
many contribute to bad health because of lack of experience or ignorance of their
effect. The poorest farmers keep their cattle and other animals in the same house
they live in themselves . . . In attempting to get at the basis of such a peculiar
habit in this modern time, many approaches were made by the social workers.
One old man explained it to a health educator simply that: ‘We like our animals
and want them where we can see them at night . . They are our wealth. They are
our most prized possessions on which we depend for our very food and livelihood.’
Such a realistic answer causes social maneuverers to stop and think before making
a casual suggestion to move them to a shed.” While these examples may seem
somewhat bizarre, recognition should be given to the presence in innumerable
homes in our own societies of all sorts of animal pets, some of which are none too
clean, others transmitters of specific diseases such as psittacosis, and to many of
which humans may become allergic. Despite all of this, they are maintained on
BEHAVIORAL SCIENCE [11

 

a sentimental or a companionship basis similar to the Egyptian village woman and
her gamous.

An example of misguided effort and of the effect of economic limitation
deals with the attempts by some outsiders to change what they felt were unhygienic
traditional menstrual habits of the Chamorro women as observed by David M.
Schneider while making a cultural study of the island of Yap. The attempts to
make them give up their practical, time-proved although strange custom was suc-
cessful, and they were persuaded to use sanitary napkins. However, the latter are
not made locally, the supply is limited, and the native economy provides for little
cash for the purchase of manufactured goods. As a result, each individual pad is
worn throughout the entire menstrual period, during which time the Chamorro
women, following the example of their American sisters, continue to be active in
their society, where previously they were separated from it. This is cited by Paul!
as an example of unforeseen, undesirable consequences of supposedly progressive
social action. I am reminded of a rather impressive phenomenon of this nature
which TI observed in several communities in Java. Apparently some time in the
recent past a very effective selling job on the merits of the brushing of teeth
must have been carried out. Imported toothpaste, however, is well beyond the
economic capacity of many of the people. Nevertheless, it is extremely common
to see individuals with toothbrushes in their pockets stopping to brush their
teeth at the edges of the many canals which run through the streets. Since these
are actually open sewers, used for bathing, laundering—and for brushing the
teeth—one could not help but wonder if the dental hygenic gains might not better
be forfeited in the interests of other sanitary considerations.

Conflict of desirable health practices with other cultural values which are con-
sidered more important form another basis for the development or perpetuation
of health problems. Few things are as important to people as their religious beliefs.
As a result, if it is a custom not to eat a certain type of food such as animal pro-
tein, individuals will tend to avoid them even if an adequate nonanimal substi-
tute is unavailable. Similarly, although it is well known that certain of the great
traditional pilgrimages mean sickness and death for many people, nothing can
deter them from the tremendous cultural drive to participate in the event. Mod-
esty or moral values are factors of considerable import to most people. There have
been periods in history, and there are still societies in the Western world, where
to see the naked body, even one’s own or that of one’s child, is considered im-
modest and immoral. In such instances, personal cleanliness and hygiene tend
understandably to reach a low ebb. The type of clothing customarily worn is
part of the culture of a people and often has been developed in conformance with
the environment. Sometimes, however, they may act as deterrents to health and
spreaders of disease. The barracan, worn by many people in North Africa, is a very
practical garment from the standpoint of protection from the environment. How-
ever, coupled with the dearth of water and soap, the exceedingly common use
of the long loose sleeves to wipe one’s eyes, nose, and mouth and those of one’s
children, most certainly is a factor in the spread of disease, particularly trachoma,
which is so widely prevalent in the area.
112 INTRODUCTION: PUBLIC HEALTH

 

Hyde!® gives an example of a cultural value, this time the wish for fertility,
superseding not only health but even convenience. *

I recall being told in Egypt of a wealthy landowner who had dug good wells, out
of which his fellaheens could obtain clear and pure drinking water. After some three
days’ use of this safe water, the fellaheens returned to drinking the polluted water of
the Nile. On inquiring into their reasons, the landowner was told that the people pre-
ferred the Nile water, that it was obviously better because the Nile made the fields
fertile and would therefore make the people fertile.

One might speculate on the possible value of an explanation of the relation-
ship between the river water and the ground water through subterranean diffusion
as well as evaporation and precipitation. In addition, it might have been possible
to point to families of desirable size who used water from a well rather than from
the river.

Effect of Cultural Patterns on Public Health Activities and Programs. From
the examples that have been given so far it should be evident that public health
programs are [requently hampered by a [ailure to inquire into or to try to under-
stand customs which the members of the group involved hold very important.
The public health worker is rare indeed who could truthfully claim unqualified
success of every program or activity he has undertaken. Every one of us has had
the experience at some time of planning a program with meticulous care, bring-
ing together every possible bit of technical knowledge available, only to be
thwarted or disillusioned by an apathetic or resistant public. Very often the ex-
planation of failure may be found in the field of cultural anthropology.

There are many barriers to public health success. One of the simplest is the
matter of communication. It is a common trap to feel that just because we under-
stand what we are thinking and saying that everyone else interprets it the same.
Whorl!7 analyzes this in the following way: “Western culture has made, through
language, a provisional analysis of reality and, without correctives, holds reso-
lutely to that analysis as final. The only correctives lie in all those other tongues
which by eons of independent evolution have arrived at different but equally
logical, provisional analyses . . . An important field for the working out of new
order systems . . . lies in more penetrating investigation than has yet been made
of languages remote in type [rom our own.”* Even within the confines of our own
communities, language differences may serve as a communication barrier. Par-
ticularly in our larger communities there are sizeable groups whose ability to
speak and understand our traditional tongue is limited. Certainly more than
one patient has received inappropriate treatment in a hospital, clinic, or health
center because he could not understand his examiner and his examiner could
not understand him. Perhaps the tragedy of such situations is that the more edu-
cated of the duet is the least apt to admit to his handicap or failing. Even where
the same language is ostensibly spoken, there may easily be differences in inter-
pretations ol what is said. There are such things as regionalism and provincialism,

*See also Health Education Pilot Project in Three Villages in Egypt by Bogue and
Habashy.'*

Hyde, H. V.: Education and World Health, Progressive Education, March 1949.

tWhorf, B. L.: Languages and Logic, Techn. Rev. 43:250, April 1941.
BEHAVIORAL SCIENCE [13

 

and there are many words and phrases in our language which have quite different
meanings in different sections of the country, not to mention the varying accents
which those who speak them may use.

The writer received an interesting and valuable lesson on communication
as a barrier in connection with a health education program in Bolivia. Very few
ol the rural people can read, so the use ol educational films, along with other
techniques, was indicated. At first, for lack ol others, films on health which had
been produced for use in the United States were shown. As would be expected,
they meant little if anything to those who saw them. The people, their clothes,
houses, foods, behavior, in fact, everything in the pictures was strange and foreign
to the viewers. The medical and hospital environments presented conditions
much too advanced to be of any practical use or applicability to the local situa-
tions. Then several health agencies in the United States had cartoon-type health
education films made. These were better in that the characters shown had a more
or less universal appeal. However, they were first used with the English sound
tracks, followed sometimes, it is true, by verbal explanations in the native lan-
guage. But the crucial moment of maximum impact had passed, and their chief
function had still been that of entertainment. Following this, the films were made
with Spanish sound tracks, since that was the official language ol the country.
Now, they became uselul as health education films in some areas, notably in a
few of the larger cities. However, they still did not apply to the majority of the
people who needed them the most because they were Indians, a great many of
whom spoke little or no Spanish. Therefore we undertook to translate and dub
in the sound tracks in the two chiel native languages ol the Andes. Now the films
really meant something to the people [or whom they were intended, and they
began to respond well. Incidentally, to my knowledge these were the first films
with speech in the Quechua language ol the Incas and the much more ancient
and rarely heard language of the Aymara.

A slightly different type of communication barrier results from the com-
munciator being held in awe, with the other person ill at ease and nervous.
Foster's tells how, in the Cerro Baron Health Center in Valparaiso, Chile, one
of the finest in Latin America, thirteen women were asked as they emerged from
the physician's room to repeat his instructions. The remarks of ten indicated that
they had failed to profit from the visit. This prompted similar investigations in
other countries, and the results were similar. A variety ol reasons were responsible
for the failure to comprehend the physician's instructions. Often a woman pa-
tient would be nervous and uneasy in the presence of a man, particularly since
she usually was in a lower social class than he. She would therefore be unable to
concentrate or to grasp what was being said. The problem was partially resolved
by having the physician write the instructions on the patient's record card, follow-
ing which a more “sympatico” nurse would explain the instructions in greater
detail and more in terms the patient would understand.

Differences in behavioral patterns may negate carefully planned and well-
intentioned public health endeavors. More than one American public health
worker has learned by bitter experience that the manner in which people relieve
themselves may be subject to a good deal of variation. A great many American-
114 INTRODUCTION: PUBLIC HEALTH

type privies have gone unused for failure to realize that some people by tradition
are “sitters” while others are “squatters.” Actually, as Leavell® points out, it is un-
important for its public health purpose whether the privy has a seat or whether
the squatting method is used in defecation. Even where they are adopted and
used, surprising cultural handicaps may appear. I recall seeing privies designed by
Westerners, using local materials, in rural Burma, and used by the people. The
use of handy, inexpensive local materials is always praiseworthy. However, the
fact that paper in this as in many other places is a luxury was overlooked. But of
even more consequence was the failure to learn that by custom pieces of bamboo
were used for the same purpose that paper is in the Western toilet. As a result, be-
fore long the privy superstructure tended to assume a rather moth-eaten appear-
ance, and the privy-hole became clogged with pieces of bamboo. I recall also talk-
ing one day, through an interpreter, with a rural Thai who really made me think.
He said, in effect, “You Americans are strange. Before you came here, if I felt like
relieving myself, T found a quiet spot in the open with gentle breezes and often
a pleasant vista. Then you came along and convinced me that this material that
comes from me is one of the most dangerous things with which people can have
contact. In other words, I should stay away from it as far as possible. Then the
next thing you told me was that I should dig a hole, and not only I, but many
other people should concentrate this dangerous material in that hole. So now I
have even closer contact not only with my own but everyone else’s, and in a dark,
smelly place with no view at that.” Frankly, T wondered, and I still wonder,
which of us was the more logical.

People will seek to attain and maintain health provided that there are no
other conflicting cultural forces. Even in our more sophisticated societies, people
may react in what they know are illogical or ill-advised ways because of deep-
seated folk ways or cultural traits of which they are sometimes not even aware,
much less understand. Here too cultural anthropology may be of great assistance
to the public health worker, either through analysis of the situations at hand or
by explanation of the same or similar problems in purer culture, i.e., in simpler
or primitive societies. Why do some people resist hospitalization, for example?
It may be that their group customarily looks upon a hospital as a place to ge to
die. Beyond that, cultural anthropologists have found that a very common if not
universal cultural trait is a strong feeling of continuity with the land or, in a
nonrural situation, at least with the home. Remote in our history, but in many
places even yet, there is the feeling that when one dies one should die at home,
that the spirit will reside in the place where one dies, and that the spirit’s place
is with the family. To some people, death away from home means that the spirit
must wander homeless and that it is in an unfavorable position from which to
intercede with the gods on behalf of the family which remains behind.

Another common reason for resistance to hospitalization is reaction against
tendencies to break down the cultural feeling of responsibility for a member
of the family in distress. In addition to pride, this may be on the basis that the
individual is continuous with his family unit. Too, another reason may be a
customary shame in admitting that one is sick, or weak, or inadequate. This
latter is closely related to a common cultural reason for resistance to surgery,
BEHAVIORAL SCIENCE 115

i.e., shame or a feeling of incompleteness. This is emphasized particularly if by
custom much importance is placed upon the part removed, notably, a breast, the
uterus, or the testes. Again, one does not have to leave the domestic scene to ob-
serve this. Closely related to the concept of continuity of the individual with the
land is the fear that the excised part, or in the case of obstetrics, the placenta or
the dead fetus, will not be destroyed or will be separated in space from the en-
vironment of the rest of the body or from the family. In more primitive societies,
of course, the thought enters into the picture that the excised part, if not de-
stroyed, may be used against oneself as a fetish.

In relation to obstetrics and gynecology, there are innumerable taboos or
cultural barriers. A hint as to one of the reasons for this is obtained from a study
of Yap culture by Schneider.’ The Yap woman feels that her genitals are the
locus of power over her husband. Her sex organs have enabled her to secure and
keep a husband and to raise a family and constitute her personal “trade secrets”
which must not be revealed to women rivals. Yap women never allow other
women to view their genitals. Therefore attempts to use native female attendants
in the delivery rooms brought about resistance. The substitution of nonin-
digenous female attendants prove somewhat more acceptable. They were women,
to be sure, but they were alien to the native system of power and sex competition.
A husband may see his wifes secrets, but she knows that no self-respecting Yap
husband would tolerate any man, including an American obstetrician, seeing
and manipulating his wife's private parts. The wife herself does not feel that ex-
posure before any man is as undesirable as exposure before another woman, but
she is constrained by the knowledge that she would be violating her husband’s
personal rights if she allowed the former. A solution was found in this situation
by means of a compromise on both sides. It involved the use of non-native female
attendants, and postponement of the mechanics of antisepsis and delivery by the
physician until after the patient had been anesthetised.

This leads logically to a consideration of the difficulties encountered with
regard to nursing in many parts of the world. Among many peoples, the position
of women is not only subservient or submerged, but they should not even be seen
or move as freely in public as the male. To develop much-needed training pro-
grams for nurses under such circumstances is difficult, to say the least. In some
other cultures, a woman who would touch, cleanse, or come in contact with the
discharges or internal parts of other people, is customarily held in very low regard.
In such circumstances, it is again most difficult to elevate nursing to the status
of a useful, esteemed profession, since among other things only the poorest, least
educated, and least dependable women are Iree to engage in the activities neces-
sary. As one other example of a cultural reason for resistance to nursing care,
there might be mentioned the fear which exists in some societies that to be
touched by or given food by a female nurse might, should she be menstruating,
bring impotence, illness, or death.

Spectacular curative measures are more readily accepted than are preventive
measures which in the long run might be more beneficial. This has been found
true in the development of public health programs in this country as well as
elsewhere. In most parts of the world, therefore, it is quite impractical to com-
116 INTRODUCTION: PUBLIC HEALTH
pletely disassociate promotive and preventive measures [rom those which are
curative. Erasmus® points to the difference in reception and support of the
campaigns against yaws carried on by the Institute of Inter-American Affairs in
collaboration with the governments of Colombia and Ecuador in contrast with
measures to prevent intestinal infections. The results of the yaws treatment were
rapid and dramatic, and even the native healers readily admitted that the modern
medicine was much more effective than their own verbal and magical treatments.
In the case of the preventive measures against intestinal infections, however, the
story was quite different. Many looked upon the symptoms in a young child as a
manifestation of the “evil eye,” outside the realm ol scientific medicine. Since
the conditions under which they lived and their [ailure to understand the ration-
ale ol the suggested measures made obvious rapid improvement impossible, the
latter measures were not successfully adopted.
Summarizing his findings, Erasmus concluded:

.. . Needs created by the process of specialization and the desire for increased
production and profit actually seem the easiest for technicians from another culture or
subculture to meet. The solution is often largely technical, fewer cultural barriers to
a common understanding are presented, and the perception and feeling of needs are
more easily shared by the innovators and the people.

However, when change is being attempted in a field not directly related to increased
production in a cash economy, in other words not directly in terms of profits, the
difficulties increase. In the field of public health, for example, the innovator may con-
sider it highly desirable to introduce basic disease prevention measures into an under-
developed area. But the folk still subscribed to an age-old system of beliefs about the
cause, prevention, and treatment of disease, a system so different that the preventive
measures of the innovator were meaningless. Lacking an understanding of the modern
concepts of the etiology of disease and consequently the reasons for modern methods
of prevention, they may feel no need to adopt the prescribed changes. Thus, despite the
fact that they feel a general need for assistance in combatting the ailments common
among them, they may fail to perceive the need for the specific measures proposed
and may actively resist them. *

An important fact which should always be remembered by public health
workers, particularly the medical component thereof, is that they are constantly
in competition with very ancient folklore, superstitions, and well-accepted ideas,
even in the most modern societies. The practice of the healing arts is the oldest
specialized activity known, and one of the very lew, along with the priesthood
with which it is closely allied, which appears to be a universal characteristic of
all cultures. “The world’s oldest profession” is a phrase commonly applied to
a rather different type ol human activity. However, as Murdock?! points out,
“Prostitution, historically, is a relatively recent phenomenon. I have personally
read accounts of many hundreds of primitive societies, and in not a single one
of them is genuine prostitution reported. Many ol them exhibit forms of such
behavior that we would regard as exceedingly lax, but such laxity does not take
the specific form of prostitution except in the so-called ‘higher’ civilizations . . .
Specialized occupations are exceedingly few in the simpler societies, and with a

¥Erasmus, C. J.: An Anthropologist Views Technical Assistance, Scient. Month. 78:148,
March 1954.
iii... BEHAVIORAL SCIENCE [17
single exception, none occurs more than sporadically. This exception is the
medical profession. Specialized practitioners of the healing art are found, to the
best of my knowledge, in every known society, however primitive. The ‘medicine
man,” in one form or another, is universal and hence must be regarded as the
oldest professional specialist.” *

It this be true, it would appear that medical and public health programs
may have an edge over other types ol social programs, provided that they are
designed so that there is a ready possibility for adequate transference from the
old way to the new. The purpose here is to stress the need to recognize the ex-
istence and acceptance of the old ways. If medical and public health measures
have an edge over the other social measures, then also it is true that the medicine
man, the curandero, and the medical superstitions and folkways have an edge
over the new and strange ideas of modern medicine and public health.

In all instances, from primitive societies in the most underdeveloped areas
up to the most sophisticated groups in our most modern Western cities, there
would appear to exist an interesting dichotomous attitude toward illnesses and
what might be done about them. If the reader will bear in mind the continued
extensive use of patent medicines and the enormous amount of self-medication
as well as the extent to which various types of quacks, faith healers, and pseudo
physicians are used by our sophisticated modern societies, it may be of value to
explore the background of these tendencies in less complex circumstances. In
connection with a ten-year evaluation of the cooperative health programs of the
Institute of Inter-American Affairs, Foster's brought out the significance of this
pronounced distinction between folk illnesses and those recognized by medical
science. As he says, people know that certain types ol disease, which do not
respond to treatment methods of curanderos, can be cured or prevented by the
scientific physician. On the other hand, they feel that there are other illnesses
that are best treated by home remedies or with the aid of curanderos, i.e., illnesses
which are not understood by modern physicians and the very existence of which
they deny. These illnesses which may be referred to as “folk” diseases, are par-
ticularly those considered to be of magical or psychic origin. “If an illness is
diagnosed, for example, as ‘evil eye,” obviously it is poor judgment to take the
patient for treatment to a person who denies the very existence of the disease.”
(Table 9.) Now it may be that the illness is actually admitted and recognized
by a modern physician. Even in this case, if individuals of the society involved,
on the basis of past experience and social custom, regard the condition as due to
magical or psychological etiology, they will tend to rule out the potential use-
fulness of the modern physician—and it must be remembered that it is they who
are in the position to make the primary decision as to what they will do about it.

In connection with the Latin American studies, several attempts were made
to measure the extent ol the practical effect of the distinction beween “folk dis-
eases” and “doctors” diseases.” In Ecuador, under Erasmus’ direction, a list of the
most common complaints was given to forty-eight school children of both sexes,

 

*Murdock, G. P.: Anthropology and Its Contribution to Public Health, Am. J. Pub. Health
42:8, April 1952.
118 INTRODUCTION: PUBLIC HEALTH

 

ages 11 and 12 years. On the assumption that the opinions expressed would cor-
respond reasonably well with those which they had heard from their parents
and other adults, the children were asked to indicate which illnesses they would
take to a doctor and which they would treat with home remedies or take to a
curandero. The results are shown in Table 9. They indicate quite clearly that
even some distinctly physical ailments as well as certain psychological conditions
may tend to be cared for other than by an orthodox physician.

Table 9. Percentage of 48 School Children in Quito, Ecuador, Who Would
Consult a Doctor or a Curandero for Specified Illnesses®

 

 

Would Consult
a Curandero or Would Consult
Illness Treat With a Doctor
Home Remedies (Percent)
(Percent)

Frightf 98 2
Airt 93 7
Witchcraft 86 14
Colic 79 21
Evil eyef 75 25
Stomatitis 72 28
Pasmot 06 34
Open infections 66 34
Urinary complaints 64 36
Skin disorders 01 39
Diarrhea and vomiting 58 42
Emaciation 49 51
Smallpox 31 69
Dysentery with blood 25 75
Pneumonia 25 75
Whooping cough 20 80
Liver complaints 16 84
Paralysis | 9 91
Typhoid 7 93
Bronchitis 6 94
Malaria 5 95
Tuberculosis 4 96

 

 

*Adapted from Foster, G. M.: Use of Anthropological Methods and Data in Planning and
Operation, Pub. Health Rep. 68:853, Sept. 1953.
Diseases with magical or psychological etiologies.

Similar surveys were carried out in Chile and in Colombia, and the results
were similar. If conditions were customarily thought to be due to the evil eye,
bad air, fright, shock, or other magical or psychic causes, ol which most people
felt modern physicians were ignorant, they were almost universally treated at
home with folk remedies or by a curandero. This, of course, often prejudiced their
chances of ultimate recovery, since many times the symptoms were those of serious
BEHAVIORAL SCIENCE [119

 

illnesses. On the other hand, certain clear-cut conditions, such as anemia, appen-
dicitis, hernia, meningitis, pneumonia, smallpox, typhoid, and the like, generally
but not invariably, were considered to be within the province of a modern
physician.

It is all too easy for those of us who have been exposed in our culture to
modern scientific thought glibly and arbitrarily to belittle, toss aside or ignore
the practitioners of folk medicine as if they were completely unworthy of con-
sideration. The illogic of so doing is expressed by Elkins:

Aboriginal medicine men are far from being rogues, charlatans or ignoramuses.
They are men of high degrees . . . men who have undergone tests and have taken de-
grees in the secrets of life much beyond that which ordinary men have a chance to
learn. This training involves steps which imply a discipline, mental effort, courage and
perseverance. In addition, they are men of respected, and often of outstanding per-
sonality. Thus, they are of immense social significance, with the health of the group
depending largely on faith in their powers. Furthermore, the various psychic powers
attributed to them must not be readily dismissed as mere “make-believe,” for many of
them have specialized in the workings of the human mind and in the influence of mind
on mind and mind on body. And, what is more, they are deeply convinced of their
powers, so much so, that as long as they observe the customary discipline of their
“order,” their professional status and practice continues to be a source of faith and
healing power to both themselves and their fellows.*

Returning to the Latin American scene, which is much closer to ours in the
United States, Foster's analysis of the relationship between the modern physician
and the curandero is of particular pertinence and may be applied to our domestic
scene with adequate provision made, of course, for differences in degree and type
of social camouflage.

The conflict between folk medicine and scientific medicine is summed up in the
persons of the physician and curandero. Each represents the highest achievement in his
field. The attitudes of the people of Latin America toward each, therefore, are pertinent
to this study. Unfortunately, the physician frequently comes off second best. This is
due in part to the inherent nature of the situation, and in part to native suspicion of
individuals in other social classes, particularly those above them.

The curandero operates under conditions that are relatively more favorable than
those of the physician, from the point of view of impressing the patient with concrete
results and apparent success. He treats folk illnesses, the symptoms of which often are
so ill-defined that he cannot help but succeed in alleviating them. If the vague physio-
logical symptoms identified with the illness persist or reappear after the cure, the
curandero can always say that the case has become complicated and requires another
series of cures or a different cure, or that a new and different illness has attacked the
patient. Also, most curanderos do not claim to cure all illnesses, and in many cases can
even recommend that a patient consult a physician. These factors establish the curan-
deros in the minds of the folk as fair, open-minded individuals willing to admit their
limitations. Finally, the curandero’s diagnostic techniques do not require elaborate and
exhaustive questioning of the patient as to symptoms, case history, and the like. He has
certain magical or automatic devices which he applies to specific situations, and the
answers follow almost like clockwork. Moreover, there are many cases reported by field

*Elkins, A.: Aboriginal Men of High Degree, Sydney, 1944, Australasian Publishing Co.,
Ltd. Quoted in Leavell, Hugh R.: Contributions of the Social Sciences to the Solution of Health
Problems, New England J. Med. 247:885, Dec. 4, 1952.*
120 INTRODUCTION: PUBLIC HEALTH
observers in which a physician failed to cure an individual and a curandero had ap-
parently genuine success.

The physician enjoys few of these advantages. His diagnosis is seldom cut and dried,
he cannot guarantee quick results, and he seldom enjoys the faith and confidence ac-
corded the curandero because he is from a social class instinctively distrusted by the
majority of his patients. Moreover, the physician seldom admits that a curandero can
cure things which he is incapable of treating, and this is interpreted as meaning that he
conceitedly and selfishly believes himself to be the sole repository of medical knowledge
—a point of view which the villager is loath to accept.

oriticisms of physicians and their professional methods are rife among the patients
of the lower class, and such criticisms are usually based on a complete lack of compre-
hension of medicine, its methods, and its limitations. Several patients pointed out that
physicians asked them questions about their symptoms, which showed that the physicians
were not as smart as they thought they were. A good curandero doesn’t have to ask
questions, so why should a man who pretends to know a great deal more have to do so?
Another patient scornfully pointed out that a President of Colombia died “even though
he had 50 physicians at his bedside.” The implication was that if 50 physicians could
not keep a man from dying, a single doctor in a short interview was almost worse than
worthless.

A final handicap of the physician is the general tendency of the people to ex-
haust home remedies and the arts of the curandero before appealing to the physician.
‘The physician, therefore, gets many cases too late to effect a cure and many others
which are simply incurable. Hence, the failures of folk medicine as well as those of his
own profession are heaped upon his shoulders. *

In fairness, it must be admitted that there are many points of value to be
found in folk medicine. In fact, one might consider our modern scientific medi-
cine as a natural extension and elaboration ol folk medicine on a scientific basis,
thereby representing our “scientific folk medicine.” The number ol effective
drugs which have originated in folk medicine is rather impressive: quinine,
rauwolfia, mescaline, chalmoogra, opium, coca, curare, and many laxatives, to
mention but a few. As to physical techniques, one might mention massage, baths,
sweating treatments, surgery, and even inoculation. In the field ol mental health
and psychotherapy, a great deal can be learned from the practitioner of simple
folk medicine.

It is interesting that although knowledge of the causative agents was lacking,
certain illnesses traditionally have been considered as communicable, and it was
believed that those who suffered therefrom should be kept apart from the other
members ol society. Beyond this, it is commonly felt that individuals subject
to certain debilitating illnesses are in a weakened condition, and that visitors
may unintentionally harm the patient as a result of strong “humors” which they
may carry. Therefore, even without regard to the possible communicability of
the patient's illness, isolation is carried out for the patient's own good. It is
worthy of note that our own attitude toward the value of isolation in a great
many instances has shifted to exactly this point ol view. Where concern exists
with regard to the evil effects of aire, strong humors, or similar folk influences,
it may be possible to take advantage of this for, whatever the reasoning, an
essentially hygienic practice is followed, one that with value can be made use of

 

*Foster, G. M.: Use of Anthropological Methods and Data in Planning and Operation, Pub.
Health Rep. 68:853, Sept. 1953.
BEHAVIORAL SCIENCE [121

 

by physicians and nurses in the treatment and prevention of spread of com-
municable diseases. They need not express an opinion on the potential danger
of aire; they can simply say that visitors are undesirable for the patient's sake,
and the family will probably follow the recommendation, even though they are
thinking in terms of contagion and the family in terms of magic.

In most il not all instances, it is probably ill-advised merely to ignore the
patient's ideas about his illness and the relationship of established folkways to
it. Foster®® warns that: “The common tendency on the part of doctors and nurses
to ignore, if not to ridicule, folk concepts of illness, probably reduces their effec-
tiveness . . .” He illustrates this with a number of instances in which modern
physicians and especially nurses wisely listen to patients’ complaints and to their
ideas of magical and metaphysical relationships thereto, then following up by
relating their suggestions [or modern scientific treatment to those familiar, ac-
cepted ideas. This accomplishes several things. It puts the modern physician and
nurse a notch higher in the patient's estimation since not only did they not
poo-poo the patient's valued ideas and the folk traditions, but actually exhibited
some interest and understanding of them. From this starting point there develops
a greater understanding and receptivity by the patient of scientific medicine and
its practitioners. This is one of the most important ways that erroneous folk
practices may eventually be dropped and more effective and suitable scientific
practices substituted for them.

It would sometimes appear that we, as well as others, tend to make a fetish
out of terminology. Alter all, words and titles are of little consequence—the funda-
mental concept and what is done about it is truly important. I had the experi-
ence of working at one time as the health officer of a county in a southeastern
state, the county seat of which was the international headquarters of a rather
radical religious group. It not only refused to recognize the germ causation of
some diseases, but actually refused to admit the every existence of illness of any
kind. If there was something the matter with an individual, he was not sick—
rather, God was displeased with him or with something in his environment, and
when God became happy again the individual would recover. Meanwhile, of
course, he might die [rom a preventable discase. These ideas were deeply ingrained
in the religious beliefs of these people. It was obviously [utile to try to convince
them otherwise. In terms of their religious tenets in which they had absolute faith,
they knew they were right, and, alter all, they were entitled to whatever religious
beliefs they wished. Nevertheless, this posed a very serious problem with regard
to not only their welfare, but also the welfare of everyone with whom they had
contact.

Actually, it worked out reasonably well. IT went out of my way to become a
good [riend of the elderly bishop who was the head of the church. He was ob-
viously a good and sincere man. He believed that he and his people were doing
the right thing. Who was I to say no? One day as we sat chatting I said to him,
in effect, “Look here, Bishop, you and I may disagree on a philosophic basis
about certain things. We do however have one very important common interest—
we are both honestly interested in the well-being of your people and of all people.
Furthermore, we also have a very important point of common agreement, we each
122 INTRODUCTION: PUBLIC HEALTH

recognize that at certain times something undesirable happens to people. Let
us not argue about what causes that something to happen. After all, the cause is
incidental to the effect. If you want to say that it is displeasure on the part of
God, that is all right with me. On the other hand, if it makes me happy to think
that it is a bacterium, it can do no harm for me to think so. But, let us, you and
me, work together in doing something about the result.” After that, I had no more
difficulty. If I wished to impose isolation in a case of communicable disease, it
was on the basis of preventing contact of the general public with influences that
had displeased God. If T wanted to use immunizing agents, it was on the basis
ofl injecting God-inspired material to help keep away unknown displeasing factors
which might harm people. If T wished to prescribe drugs and medicines, it was
on the basis of giving materials to assist in driving out or removing from the body
the things that had displeased the Lord. In fact, we got along so famously that
I finally found mysell consulted on various church matters.

How does all of the foregoing tie together? We may gain a clue if we accept
the idea that our goal as public health workers must be to make good personal
and community health practices an accepted part of the way of life and culture
of people. This cannot occur spontaneously, and it cannot be done merely by
destroying what to us may seem to be erroneous customs. It must be carefully
planned and worked at over a long period of time. We have long since learned
the inadequacy of doing things to or even for people. We realize now that the
best way is to do things with people, and in order to do so we must understand as
thoroughly as possible the cultural factors which make them act the way they
do and tailor our suggestions and programs to the accepted general cultural
pattern of the group. We should constantly relate our efforts to something
familiar, something most people already know, do, and accept. In addition, we
must recognize that our own communities, sophisticated as they may appear to
be on the surface, consist of numerous societies and numerous cultures. We must
recognize that so-called sophistication may merely substitute city ways for folk
ways, and that many of our customs are fundamentally the same as those found
elsewhere, having merely been transferred, transformed, or adapted to a new
environment or set of social conditions.

Effect of Public Health Activities on Cultural Patterns. Discussion up to
this point has centered on the effect which cultural patterns may have on the
public health and on public health activities. A brief consideration of inverse
relationship would seem to be in order. If public health programs are successful
in their attempts to improve the state of physical and mental health of a people,
it should be obvious that there are complex far-reaching effects on many if not
all other phases of the culture of the people. Thus, if workers are made healthier
and more alert mentally, their ingenuity and inventiveness tends to increase. To
the extent that they may produce more and better mechanical aids to their
labors, they then find it not only possible to produce more but they do it more
easily and in less time. This makes possible a shorter working day for the average
person and, concomitantly, more time for leisure. With more time of their own
on their hands, people tend to engage more in the pursuit of some of the less
tangible cultural activities, i.e., recreation, study, reading, and the fine arts, and
BEHAVIORAL SCIENCE 123

 

gradually because of an increased standard of living have more and more money
for such activities.

A measurable effect of public health activities is a decrease in the number
of deaths and an increase in the average life expectancy. Thus in the United
States since the beginning of the twentieth century, infant death rates have been
lowered from about 200 per thousand live births to about 26 at the present time.
This means that instead of every fifth baby dying, only every thirty-fifth baby
now dies. In the same period of time the average life expectancy has been raised
from about 49 years to almost 70 years. The social consequences of such a rapid
effect of public health activities are many and far reaching. There are more
mouths for the family and the nation to feed, greater housing needs, more schools
to be built, more school buses to be made, more recreation facilities, and more
of other civic and social activities needed. On the other hand, it also means that
less money will be needed for the care of preventable illnesses, much less family
worry and sadness, a changed attitude toward illness and death, healthier chil-
dren who in a short time become more alert, better informed, and capable citizens
and workers. One might generalize by saying that in many or all such situations,
rapidly improved health conditions tend to result first in increased social pres-
sures and problems, and a little later in greatly multiplied social benefits.

The provision of more and healthier people, then, sets off a whole chain of
events, all aimed at improvement of our national culture and all resulting
eventually in an improved standard of living for everyone. There are more people
available to work in our offices, businesses, farm lands and factories, and because
they are on the average healthier than their parents and grandparents, they can
produce more, which means an increase in the individual share of the material
things of life. At the same time, attitudes toward marriage and family life are
strongly affected by the results of public health measures. To approach this
negatively, if death rates are high in general and if maternal mortality rates are
high in particular, family structure must be adapted accordingly. The husband
and children must accept the possibility of having several wives and mothers,
and for the woman childbirth is surrounded by real fear and many superstitions.
Because of the frequency of deaths of the mothers, the position of the older sur-
viving female relatives is much more important in the total family picture than
in our present typical American situation. Also, because of high infant and child
mortality, husbands, public opinion and nature conspire to keep the woman
pregnant most of the time. One might say further that the generally pregnant
state of the recognized wife results in the most marked accentuation of the double
standard. The male tends toward more widespread promiscuous relationships
which tend to be accepted more readily by society, and this, of course, invites
a greater prevalence of venereal diseases.

Lowered infant mortality and maternal mortality rates, on the other hand,
tend eventually to bring about a pattern of smaller families but families which,
in some respects at least, have stronger immediate family bonds. In our current
American society, this has had a marked effect on the size of houses and even
their architecture, as well as on the use which is made of the home. A social com-
plication has resulted however by virtue of the concurrent lengthening of life
124 INTRODUCTION: PUBLIC HEALTH

and a growing number of elderly individuals. This fact, related to a change in
social attitude or interpretation of family constituency and responsibility, as well
as to the change which has occurred in the size and layout ol the modern small
home, leaves a sizable proportion of the population, the grandparents and other
elderly persons, with little or no home base. The development ol a social prob-
lem of this unfortunate type results inevitably in a social reaction. Some symp-
toms of this are evident in the increasing literature and social legislation dealing
with the elderly or senior citizens’ needs for medical care, housing, and other
things.

Successful public health programs may bring about a marked change in
attitude toward previously deep-seated customs. The wearing ol charms of all
sorts is a remarkably common practice in this as well as many other countries.
Usually, they are not readily relinquished. Because ol the success of certain phases
of the technical assistance programs in health in Haiti, it has been found neces-
sary to place boxes at the treatment and health centers as receptacles for the
charms and fetishes which the now convinced patients are discarding in large
numbers.

One final example of an effect which public health activities may have upon
a society illustrates that the results may be not only quite unexpected, but even
undesirable. A truly effective venereal disease control program, like any other
special health program, should take into consideration the social behavioral
problems and attitudes of the people, and the social and cultural consequences
ol the activity. The many ramifications of a program of this nature were brought
out dramatically in a joint international attempt to eradicate venereal diseases.
Many United States soldiers were located in training camps close to communities
in another nation. Large numbers of these young soldiers when off duty had no
place else to go except those communities. Because of this, prostitution in its
worst form flourished, and large numbers of these soldiers were reported in-
lected with veneral diseases. United States public health officials got together
with their counterparts in the other government to solve the problem. From a
strictly scientific and public health standpoint, their jointly devised program
did solve it. However, some other things happened upon which they had not
counted. In line with recently developed antibiotic therapy and prophylaxis, the
basis of their approach was to require all of the regular prostitutes to receive
a large injection of residual penicillin each week, whether or not they appeared
to be infected. Failure to be able to present evidence of the weekly injection
meant a loss ol permit to work in the carefully regulated and registered houses
of prostitution. :

The first result was a very dramatic drop in the incidence ol new infection
among the United States soldiers, the local population, and the prostitutes.
Next, apparently as word ol the situation got around, it was realized that these
were desirable places in which to practice prostitution and relatively sale places
to visit for such purposes. Understandably, nonpublic health officials of the other
nation thereupon complained that the program was actually promoting and in-
creasing their prostitution problem. Finally, a totally unexpected result began to
appear. Many ol the prostitutes had been suffering from gonorrheal inflamma-
BEHAVIORAL SCIENCE [25

tions which had prevented their becoming pregnant. Now, with these repeated
routine injections of pencillin, those inflammations were cleared up and some
ol them became pregnant by totally unknown [athers. The social welfare aspects
of this problem are obviously enormous.

We should always be conscious of the very delicate balance in which society
operates. This applies particularly to activities in a field that may have as prompt
and far-reaching influence as does public health. While it is axiomatic that
progress in one cultural direction inevitably results in progress in other aspects
of a culture, it is equally true that the artificial stimulation ol great sudden ad-
vancements in one phase of a culture alone may bring about at least a temporary
social difficulty if not even chaos. Thus we may actually be wielding a two-edged
sword il we suddenly, rapidly, and exclusively apply all of our present public
health knowledge to a situation. If we do so without considering the other basic
social needs of the additional people, there is real danger of causing irreparable
distortion and harm to a culture or a society. There may develop increased food
problems, social and economic imbalance, and political unrest, to mention but
a lew potential results. We need not be pessimistic about this, however. The
important thing is to realize the potentialities and the implications and to em-
phasize the absolute necessity for public health workers to move consciously ahead
hand in hand with workers in other fields, i.c., agriculturists, educators, political
scientists, social service workers, and many others, and the cultural anthropologist
can contribute greatly to this by indicating needs, ways and means.

Contributions of Behavioral Scientists to Public Health. In the Epic of
America, James Truslow Adams claims that America’s greatest contribution to
the total human culture is the “vision ol a society in which the lot of the com-
mon man will be made casier and his life enriched and ennobled.” Most certainly
a well-chosen and successfully pursued public health program is one of the sig-
nificant handmaidens to this goal of social order. But, as Kluckhohn warns:

Order is bought too dearly if it is bought at the price of the tyranny of any single
set of inflexible principles, however noble these may appear to be from the perspective
of any single culture. Individuals are biologically different, and there are various types
of temperament which reappear at different times and places in the world’s history.
So long as the satisfaction of temperamental needs is not needlessly thwarting to the
life activities of others, so long as the diversities are not socially destructive, individuals
must not only be permitted but indeed encouraged to fulfill themselves in diverse ways.
The necessity for diversity is founded upon the facts of biological differences, differences
in situation, varying backgrounds in individual and cultural history.*

It is part of the function of the behavioral scientist to study these differences,
to serve as pilot when in the planning and operation of our activities we attempt
to sail through the complex seas of societies and their cultures. Further, they can
send out storm warnings when we appear to be in danger of serious error because
of misunderstanding of the motivations of individuals and groups. Finally, if
we do find ourselves in inexplicable difficulty, the behavioral scientist, by virtue
of his somewhat different way of looking at things, may be able to find out why
and to point to a way out of our dilemma. For example, the health educator, as

*Kluckhohn, Clyde: Mirror for Man: The Relation of Anthropology to Modern Life, New
York, 1949, Whittlesey House, p. 269.
126 INTRODUCTION: PUBLIC HEALTH B B B
Paul'® describes, may approach his assignment with the preconception that his
job is merely to convey information to people who are “uninformed.” If he
does so, he is not too apt to succeed whereupon he may conclude that the slow
acceptance of his ideas is attributable to intellectual deficiency or willful stub-
born resistance on the part of those he seeks to benefit. In most if not all instances,
his job is really to help people reorganize their existing conceptual system. As
Paul states “knowledge of the local beliel system enables the imaginative edu-
cator to present his data in such order and in such a way as to be most readily
grasped by the recipients. It also enables him to anticipate the directions that
‘misunderstanding’ will take.”

Meltzer,?* has provided an excellent example or illustration of the manner
in which the approach to activity or program analysis suggested above may be
of value. The study relates to topical fluoride demonstration programs in six
communities; three were successful and three were failures. The purpose was to
determine if possible the reasons for the failures as well as for the successes. By
way of introduction, she complains that, “We in public health work have an
unfortunate habit of talking and writing only about our successes, ignoring our
failures, and seldom examining the principles we were trying to use when we
failed. It does little good to study the methods that led to program success in one
community, if we forget that the identical methods have failed miserably in
other similar communities. When that happens, it is a case of using methods
based on untested assumptions, rather than on sound principles.”* In the analysis
of the dental programs, as might be expected, it was found that there was neither
one reason for success, nor one reason for failure, since each of the six communi-
ties was a case unto itself with its own cultural pattern. The failures were ul-
timately attributed to a variety of reasons, including inadequate communication
between the public health workers and the public, the impression that the pro-
gram was a self-contained short-term experiment, that it needlessly disrupted the
school routine without real purpose, and that some significant groups in the
community were not brought into the planning. The example illustrates that
action teams such as groups of public health workers often define the reaction
or the anticipated reaction of a community in their own way and according to
their own standards. They see the community and interpret the situations they
encounter according to their own preconceptions, which of course are rooted in
the subculture of their own professional as well as social class. This need to
understand and overcome cultural differences as Paul'® emphasizes “applies not
only in the case of a health mission operating in a foreign country, but also in
the case of a team working in a community within its own country. The difference
in the two cases is one of degree.”

The relevancy of the subject to public health has been formally recognized
by the American Public Health Association in a resolution unanimously adopted
at its Eighty-First Annual Meeting in New York on November 11, 1953:

*Meltzer, Nancy Starbuck: A Psychological Approach to Developing Principles of Community
Organization, Am. J. Pub. Health 43:199, Feb. 1953.
BEHAVIORAL SCIENCE 127

 

WHEREAS, the field of health education is concerned basically with human behavior,
its nature and how it may be altered for the improvement and promotion of in-
dividual and community, health, and

WHEREAS, the social sciences contribute to knowledge of human nature and be-
havior, therefore be it

RESOLVED, that the American Public Health Association encourage collaboration be-
tween public health workers and social scientists to better promote the utilization
of social science findings toward the solution of public health problems.

In discussing the ways in which behavioral science may be ol significance
to the field of public health, Foster®* has presented a list of factors to be considered
which he warns are intended to be merely suggestive and illustrative and not a
definitive catalog. The list is sufficiently thought-provoking, however, to merit
repetition here:

Although it is desirable to know as much about a culture as possible, there are
obviously strict limitations as to what can be known. Social scientists have barely made
a beginning in the formidable task of describing the elements of the cultures of the
world and interpreting their significance. It must be assumed that for any given pro-
gram there are certain categories of information about the culture in which the work
is to be carried out which are of primary importance, and others that are of lesser
importance. A “trial run” in compiling a list of primary classes of data for public
health programs gives the following picture.

Folk medicine and native curing practices. The importance of this has been dis-
cussed at some length above and need not be commented on further at this point.

Economics, particularly incomes and costs of living. Since in the final analysis the
success of public health programs rests upon major changes in the habits of people
with respect to diet, housing, clothing, agriculture, and the like, knowledge of the
economic potential of an area is paramount.

Social organization of families. A bride often lives in her husband’s home, under
the domination of her mother-in-law. There are cases in which pregnant women failed
to follow, or had difficulty in following, health center recommendations because these
conflicted with what the mother-in-law thought was best.

Men and women who live together are frequently not legally married. Under such
circumstances, a man is less likely to recognize obligations to his companion and their
children, and it is therefore more difficult to persuade him to come to the health center
for venereal or other treatment. Recognition of these and similar problems makes the
responses of patients more intelligible.

Education and literacy and comprehension. Ability to comprehend the real nature
of health and disease, to profit by health education, and to understand and follow the
physician's instructions depends on the education and literacy of the people.

Political organization. Local conditions under which physicians and other staff mem-
bers are appointed, the local attitude toward nepotism, bureaucratic rules which govern
operations, and the like, are factors which will affect public health programs. In one
country, for example, a large health center, not yet placed in operation, was seriously
threatened by the conflicting interests of the state governor, the local nurses’ union, and
other bureaucratic factors.

Religion. A basic analysis of religious tenets is not essential, but some parts of the
religious philosophy of the people should be known. Are there any beliefs which hinder
or directly conflict with proposed programs? Is death, for example, at any age considered
a welcome relief from a world of suffering? Are there food taboos based on religious
sanction which should be taken into consideration in planning diets?

Basic value system. What are the goals, aspirations, fundamental values, and major
cultural premises, consciously or unconsciously accepted, which give validity to the lives
128 INTRODUCTION: PUBLIC HEALTH

of the people in question? What is the practical significance, for example, of a fatalistic
approach to life and death? What part does prestige play in determining customary
behavior patterns of the people? Is male vanity and ego a factor to consider? What are
the ideas of bodily modesty? What are the types of stimuli and appeal to which people
respond most readily?

Other types of data. Planners and administrators of public health programs should
also have at hand such information as credit facilities and money usages, labor division
within the family, time utilization, working and cating schedules, cooking and dietary
practices, and the importance of alcoholism.

Categories of culture in which precise knowledge would appear to be of lesser im-
portance include agriculture, fishing, and other primary productive occupations, in-
dustrial techniques (except as working conditions may affect health), trade and com-
merce, religious fiestas and church observances, wedding ceremonies, burial customs,
and music and folk tales.*

In bringing to a close this briel consideration of behavioral science, it is

appropriate to call attention to one final value which it has for public health
workers. It has been stated by Murdock®! in the following manner: *. . . One
ol the greatest potential contributions ol anthropology is to make those who are
professionally concerned with health problems aware ol the broad sweep of cul-
ture history and of their position in it.”

REFERENCES

5.

~1

Leavell, Hugh R.: New Occasions Teach New Duties, Pub. Health Rep. 68:687, July 1953.

Koos, E. L.: New Concepts in Community Organization for Health, Am. J. Pub. Health
43:466, April 1953.

Skinner, B. F.: Science and Human Behavior, New York, 1953, The Macmillan Co.

Kluckhohn, Clyde: Mirror for Man: ‘The Relation of Anthropology to Modern Life, New
York, 1949, Whittlesey House.

White, Leslie A.: Man’s Control Over Civilization, An Anthropocentric Illusion, Scient.
Month. 66:238, March 1948.

Benedict, Ruth: Patterns of Culture, New York, 1934, The New American Library of World
Literature, Inc.

Carothers, J. C.: The African Mind in Health and Disease, World Health Organization
Monograph Series, No. 17, 1953, Geneva.

Gittler, J. B.: Man and His Prejudices, Scient. Month. 69:44, July 1949.

Bernard, Jessie: Can Science Transcend Culture, Scient. Month. 71:270, Oct. 1950.

Paul, Benjamin D.: Respect for Cultural Differences, Community Development Bull, Uni-
versity of London Inst. of Educ. 4:42, June 1953.

Hoyt, E. E.: Tiquisate: A Call for A Science of Human Affairs, Scient. Month. 72:114, Feb.
1951.

Miller, W. S.: Some Observations on Enteric Infection in a Delta Village, J. Egyptian Pub.
Health A. 25:45, 1950.

. Wier, J. M,, and others: An Evaluation of Health and Sanitation in Egyptian Villages, J.

Egyptian Pub. Health A. 27:55, 1952.
Bogue, R., and Habashy, Aziz: Health Education Pilot Project in Three Villages in Egypt,
Unnumbered Publication of World Health Organization Regional Office, Alexandria.
Paul, Benjamin D.: American Medicine on the Island of Yap, Harvard School of Public
Health, 1951 (unpublished paper).

*Foster, G. M.: A Cross-Cultural Anthropological Analysis of a Technical Aid Program,

Smithsonian Institution, Washington, July 25, 1951, pp. 855-856.
16.
17.
18.

 

BEHAVIORAL SCIENCE [29

Hyde, H. V.: Education and World Health, Progressive Education, March 1949.

Whorf, B. L.: Languages and Logic, Techn. Rev. 43:250, April 1941.

Foster, G. M.: Use of Anthropological Methods and Data in Planning and Operation, Pub.
Health Rep. 68:853, Sept. 1953.

. Schneider, D. M.: In Paul, B. D.: Health, Culture, and Community, New York, 1955, Russell

Sage Foundation.

Erasmus, C. J.: An Anthropologist Views Technical Assistance, Scient. Month. 78:148, March
1954.

Murdock, G. P.: Anthropology and Its Contribution to Public Health, Am. J. Pub. Health
42:8, April 1952.

Leavell, Hugh R.: Contributions of the Social Sciences to the Solution of Health Problems,
New England J. Med. 247:885, Dec. 4, 1952.

Foster, G. M.: A Cross-Cultural Anthropological Analysis of a Technical Aid Program,
Washington, 1951, Smithsonian Institution.

Meltzer, Nancy Starbuck: A Psychological Approach to Developing Principles of Com-
munity Organization, Am. J. Pub. Health, 43:198, Feb. 1953.
chapter 6

Social pathology and public health

 

Introduction. Having viewed public health in relation to cultural behavior
and the development ol society, it is now important to consider some of the
social factors which play significant causal, effectual, or companionship roles
with regard to the state ol health or illness ol the group or society. Simmons
and Wolll! neatly state that “culture sets the stage, ascribes the parts, and defines
the terms whereby society’s drama is enacted.” On the other hand, society is the
instrument, the mechanism, the organization which provides the environment
for a culture to develop, grow, and manifest itself. This is an area to which in-
sufficient attention has been given, not only by public health workers, but also
by those in other disciplines who think, plan, and strive lor the protection and
promotion of the total well-being ol society.

Paradoxically, as far as public health is concerned, the appearance ol the
great era of bacteriology actually resulted in delaying broad effective progress.
The discovery that very specific living organisms were related to plague, to
anthrax, and to many other disease conditions, and that these clinical syndromes
could not occur in the absence of their respective causative organisms, brought
about a great flush of enthusiasm and hope. An unfortunate result, however,
was the development of an attitude on the part ol some that effective bacterial
exposure was the alpha and omega ol disease causation. Indeed, this had much
to do with the broad acceptance and support of certain sanitary measures in the
late nineteenth and the early twentieth century, since it became recognized that
bacteria could invade the town house and the palace through the servants’ quar-
ters and that the Corynebacterium diphtheriae could strike the children ol the
wealthy and privileged as well as the children ol the poor.

As long as etiology was still indeterminate or uncertain, men tended ol
necessity to cast about widely in their search for causal relationships. Once a
“scientific” or, better yet, a “laboratory” answer was forthcoming, there was a
tendency to close the issue with a Q.E.D. This comparative attitude was well
put by Stern? in a discussion of living conditions and health:

In contrast with the narrower focus of public health work after the modern science
of bacteriology had developed, the objective of the pioneers of public health included

130
SOCIAL PATHOLOGY 131

 

demands for better housing conditions, nutritious food, unpolluted water, cleaner

streets and improved working conditions. These men anticipated the fundamental truth

of modern preventive medicine, that the health of the individual is intimately and

indivisibly tied up with the social as well as the physical environment in which he

resides. *

The reader is asked to refer back to Chapter 2 on history and to note that
it was no coincidence that the mid-nineteenth century reports and recommenda-
tions of men like Southwood-Smith, Edwin Chadwick, and Lemuel Shattuck
were so extensive and far reaching. Similarly, it was no coincidence that they
“fell flat from the printers hands,” and were underrated or cast aside, appearing
when they did on the eve of the era of great bacteriological discoveries. They
simply had to wait until the more palatable and more easily dealt with vogue
had run its course. It is equally interesting to note that those diseases, for which
etiological agents were difficult to determine or were matters of controversy,
continued to be related to some extent to social conditions and to environmental
factors. This was true, for example, of tuberculosis, pneumonia, and influenza.
One might state as an axiom that the easier it was to determine a specific rela-
tionship between a microorganism and a disease, the more social and environ-
mental [actors were ignored.

In recent years, it has been increasingly realized that man in his entirety
is a combination of physical, psychological, social, and cultural factors. If the
recognition and acceptance ol this is to be at all meaningful, practitioners of
public health and medicine must cease to evaluate and treat man by the first
of these factors alone. Sir Farquhar Buzzard? Regius Professor of Medicine at
Oxford has stressed that our aim should be:

. to expose the sources and bases whence arise ill health and disability, by in-
vestigating the influence of social, genetic, environmental, and domestic factors on the
incidence of human disease . . . [taking into consideration] . . . such varying agents as
heredity, nutrition, climate, and occupation . . . [as well as] . . . the part played by
the individual and mass psychology.t

A similar conclusion was reached by Ryle! who alter thirty years as a stu-
dent and teacher of clinical medicine accepted the chairmanship of the first
Department of Social Medicine (Oxford, 1942). He contemplated that during
those thirty years he saw discase studied ever more thoroughly but not more
thoughtfully, as il through the high power of the microscope, and more and more
mechanically. He commented:

Man, as a person and a member of a family and of much larger social groups, with

his health and sickness intimately bound up with the conditions of his life and work—

in the home, the mine, the factory, the shop, at sea, or on the land—and with his

economic opportunity, has been inadequately considered in this period by the clinical

teacher and hospital research worker.t [And may I add—by a large number of public
health workers!]

*Courtesy of Ciba Symposia 9:871, 1948.

tBuzzard, Sir Farquhar: The Place of Social Medicine in the Reorganization of Health
Services, Brit. M. J. 1:703, June 6, 1942.

iRyle, J. A.: Changing Disciplines, London, 1948, Oxford University Press, p. 19.
132 INTRODUCTION: PUBLIC HEALTH
In his prefacing statement Ryle avers:

We no longer believe that medical truths are only or chiefly to be discovered under
the microscope, by means of the test tube, and the animal experiment, or by clinical
examination and increasingly elaborate pathological studies at the bedside. Psychological
and sociological studies have as important a part to play. Even so, it is not yet appre-
ciated how intimately disease and social circumstance are interrelated. The whole natural
history of disease in human communities, as well as in individuals, is ripe for a fuller
and more exhaustive study. *

Reference has now been made to social medicine and to social pathology.
These terms are much better known and understood in Europe than in America
as a result of the outstanding writings of Pettenkofer, Neumann, and Grotjahn
of Germany, Sand ol Belgium, and Southwood-Smith, Chadwick, Simon, Buzzard,
and Ryle of Britain. Nevertheless, the relationships between factors in the social
environment and disease have long been matters of concern in the United States,
although it is only relatively recently that they have been considered under the
term “social medicine.” Unfortunately, in this country, the term is often con-
fused with “socialized medicine” and its content similarly confused with concerns
about the organization and economics of the provision of medical care. Some
have tried to solve this dilemma partially and indirectly by the use ol the term
“comprehensive medicine.” In its present form, this tends to limit itsell essen-
tially to the relationship between an individual's physical illness and his psycho-
sociological stresses. This is done essentially toward the ends of diagnosis, treat-
ment, and the prevention of recurrence of the particular case.®% The United
States does have its share ol names ol those who have contributed notably to the
philosophy of the fields of social medicine and social pathology albeit not always
by their European designations. Among those who may be mentioned are Shat-
tuck, Smith, Sydenstricker, Mountin, and Winslow. More recent contributions
of significance have come from Galdston, Dunham, Rosen, and Wolff.

The need to recognize the reality of the fields ol social medicine and social
pathology becomes more imperative in view of the twin revolutions now being
witnessed in medicine and in society. Merely as examples, attention is directed
to the dramatic changes in the types and extents ol illnesses and deaths, and
in the resources with which to combat them. Thus, the rate of major medical dis-
covery has accelerated from one per century before 1900, to one per decade be-
tween 1900 and 1940, and to one or more per year since 1940. In the United States
at the time of this writing, 90 per cent of the prescriptions written are for sub-
stances which did not even exist ten years ago.!" The nature and extent of the
social revolution is discussed in Chapter 32, The Past as Prologue. Suffice to point
out here the tremendous increase in the population, its significant aging, the
dramatic extent ol urbanization and mechanization, and the marked increase and
equalization of the standard of living.

*Ryle, J. A.: Changing Disciplines, London, 1948, Oxford University Press, p. viii.

iFor historical review the reader is referred to The Concept of Social Medicine as Pre-
sented by Physicians and Other Writers in Germany 1779-1932 by Kroeger,” Social Pathology and
the New Era in Medicine by Ryle The Meaning of Social Medicine by Galdston® and Ap-
proaches to a Concept of Social Medicine by Rosen.
SOCIAL PATHOLOGY 133

Definition. There have been numerous attempts to define social medicine
and social pathology. One of the earliest and still one of the best definitions
was that of Grotjahn!2 who approached the problem of definition by enunciating
several principles which, as he saw it, were necessary considerations in the proper
study of a disease. These principles may be summarized as follows:

1. The social significance of a disease is determined primarily by its fre-
quency. This emphasizes the importance ol accurate medical statistics.

2. The most common form of a disease, its sociopathological prototype, is
also of social significance—more significant than its unusual or compli-
cated but rarer forms.

3. The etiology ol every discase includes both biological and social factors.
The latter may affect a disease in several ways—they may be causative,
predisposing, or they may influence the transmission or the course ol
illness.

4. The prevalence and outcome ol disease may be influenced by attention
to social and economic factors as they relate to the individual and the
group.

5. It is important to determine the influence of successful treatment ol a
disease upon the subsequent prevalence and upon other social factors.

6. Diseases may themselves affect social conditions for the individual or
for the group through recovery, predisposition to other illnesses, chronic
infirmity, degeneration, or death.

More recently the British Journal of Social Medicine attempted to clarify
the issue by stating:

Social medicine is that branch of science which is concerned with: (a) biological
needs, inter-actions, disabilities, and potentialities of human beings living in social
aggregates; (b) numerical, structural and functional changes of human populations in
their biological and medical aspects. . . . Social medicine takes within its province the
study of all environmental agencies, living and non-living, relevant to health and ef-
ficiency, also fertility and population genetics, norms and ranges of variation with re-
spect to individual differences and finally, investigation directed to the assessment of a
regimen of positive health. *

The importance of statistics of mass phenomena and relationships has again
been stressed by Wolff'# in his definition of social pathology:
The relation between disease and social conditions is the content of social pathol-
ogy; its method is necessarily a sociological description of this relationship which, for
simplicity’s sake is mostly based on a statistical analysis of the quantitative findings.f

It is obvious that, in the discussion so lar, the two terms social medicine and
social pathology have been used almost interchangeably. Although similar and
related, they are however different. The following definitions are suggested there-
fore in an attempt to synthesize and simplify the several statements to which
reference has been made and to indicate the relationship and the difference be-
tween the two terms:

~*Editorial: Brit. J. Soc. Med. 1:3, Jan. 1947.
Wolff, G.: Social Pathology as a Medical Science, Am. J. Pub. Health 42:1576, Dec. 1952.
134 INTRODUCTION: PUBLIC HEALTH

1. Social pathology is a state ol community imbalance evidenced by signifi-
cant prevalence ol disease and its related social disorders.

ro

Social medicine is the study ol the manner in which disease may result
from, cause, or accentuate social problems and of the ways in which
medical and public health efforts may contribute to their solution.

Man and Environment. Even the most cursory consideration results in the
empiric conclusion that there is some direct interrelationship between undesir-
able living circumstances and various types ol problems. This is especially true
and especially evident in urban situations by dint of sheer numbers and because
crowding accentuates all such problems. The numerous social difficulties of
cities are commonly observed to be concentrated particularly in the slum or
substandard sections. Here, houses tend to be small and crowded together with
a maximum amount ofl the area devoted to profitable subsistence living space.
Little or no consideration is given to recreational needs. Often, and through no
accident, industry is located nearby—close to a supply of labor usually anxious
for employment. The crowding of buildings, the generally narrow streets, the
absence ol open recreational area, and the smoke ol factories limit considerably
the amount ol sunshine and [resh air. Cleanliness and sanitation are difficult
to maintain. Death or injury is invited by the narrow trafhc-laden streets,
rickety abandoned structures, and the poorly planned flammable dwellings. Both
education and nutrition also tend to be substandard and combine with insani-
tation and overcrowding to maintain a high incidence ol illness. Lack of privacy
encourages immorality and is conducive to a lowering ol self-respect. This and
other psychological maladjustments in the developing child and adolescent breed
attitudes of hopelessness, constant frustration, cynicism, resentment, and ex-
plosive pent-up hostility. Responsibility and initiative appear pointless, and what
seem to be the only roads to self-expression and escape are socially undesirable.
There tends to occur undesirable positive reactions of rebellion such as destruc-
tiveness or crime, or negative reactions ol defeat such as addictions or prostitu-
tion. It is perhaps not coincidental that the word for town dweller (pagani) has
the etymological root that it does.

These relationships have been repeatedly and conclusively shown to exist.
Much of the writings ol Southwood-Smith and Edwin Chadwick dealt with this
subject. Earlier in 1828, Villerm¢, one ol the originators of social statistics, pre-
sented a memoir to the French Academy ol Medicine, comparing the death rates
of the rich and the poor. Studies during the early 1930's in the United States
showed about 20 per cent ol the land area of a number ol metropolitan areas
to be of a substandard blighted or slum quality. These areas, aside from factories,
included the living quarters of a third of the populations of those cities. How-
ever, they accounted for 35 per cent ol the fires, 50 per cent of the disease in
general, 65 per cent ol the tuberculosis cases, 55 per cent ol the juvenile de-
linquency, and 50 per cent of the arrests. Although they contributed only 6 per
cent ol the tax revenue ol the cities, they required 45 per cent of the cities’ ex-
penditures.!*
SOCIAL PATHOLOGY [35

In the study of a specific community, Cleveland, Ohio in 1934, the rela-
tionships shown in Table 10 were found to exist in connection with a slum sec-
tion.

Table 10. Slum Section. of Cleveland, Ohio, 1934, Compared
With Entire City

Per Cent of
Total in

Slum Section

| Cleveland
Population 2.5
Homicides 21.0
Prostitution | 26.0
Tuberculosis deaths 12.0
Illegitimate births 10.0
Police protection expenditure 4.5
Fire protection expenditure | 14.5
Health department expenditure 8.1

As in other studies, while the area contributed only $225,000 per year in
taxes, it required eight times that amount or $1,970,000 per year to sustain it.

With specific reference to the relationship of general environment to dis-
case and death, a considerable body of data has now accumulated. Several ex-
amples may be worth while for purposes of illustration. One is a study in
Liverpool, England (1923-29) which showed the comparisons presented in Table
11 with regard to the effect of the social environment upon health.

Table 11. Deaths By Social Area, Liverpool, England, 1923-1929

Crude Tuberculosis Infant
City of Liverpool Death Rate Death Rate Mortality
-
Entire city | 13.9 123 98
Corporate tenement area 18.2 164 131
Slum area

28.4 | 299 171

About the same time, the National Health Survey in the United States
brought to light many correlations between environment and health. Thus, for
urban white persons the relationships of crowding to amount of illness was found
to be very significant (Table 12).

The incidence of tuberculosis was found to be almost twice as high in group
C as in group A, pneumonia was about one and a half times as [requent, and
diphtheria occurred almost three times as often.

In a search for “the causes behind the causes of death” in the City of Cin-
cinnati, Ohio in 1949-1951 it was found that while significant declines in illness
136 INTRODUCTION: PUBLIC HEALTH

Table 12. Illness and Crowding, United States, 1934

| Degree of Crowding | Per Cent of Persons with Illness
Group | (Persons Per Room) | One Week or Longer
—_—
A | 1 or less | 14.8
B | 1tollg | 15.7
C more than 115 17.8

and death had taken place throughout the community during the previous quar-
ter century, the death rates still varied considerably from section to section. This
was emphasized by the Basin area, the oldest section, which comprised about
one seventeenth of the city’s area but contained one fourth of the population.
Most of the dwellings were substandard. In the Basin area, infant mortality was
twice as high, home accident fatalities were three times as high, the pneumonia
death rate was eight times as high, and the tuberculosis death rate was thirty
times as high as the corresponding rates for the remainder of the city. Interest-
ingly, there were no appreciable differences in the rates inside and outside of
the Basin for the noncommunicable diseases of the older ages.

Admittedly, it is dificult to determine direct cause and effect relationships
between poor housing and ill health. Nevertheless, the consistency of their occur-
rence together cannot be ignored. As Pond'® has reasoned:

A cautious and critical analysis of available data relating to the effects of housing
on health leads to but one conclusion: one cannot state that substandard housing alone
begets ill health. However, no reasonable student of the subject has yet stated that bad
housing is compatible with good health. In the absence of irrefutable proof that housing

has no ill effect on health, it may reasonably be hypothesized that good housing pro-
motes the attainment of good health. *

The quality ol housing is, ol course, only one reflection ol socioeconomic
status, and there are a number of other indicators of the latter which may be and
have been used [or comparative purposes. Thus, Lawrence!” followed a significant
number ol persons and families over a period of twenty years. He divided them
into five socioeconomic groups and determined the prevalence of chronic illness
as shown in Table 13.

A similar relationship has been [ound to hold true with regard to infant
mortality. Altenderfer and Crowther! studied 973 urban places of 10,000 or more
population in order to determine the relationship between socioeconomic status
of families and infant mortality. Some of their results are presented in Table 14.

Even more striking were the results of a more recent study in Aberdeen,
Scotland by Baird.'® His method of distinction was to compare women who could
afford delivery in private nursing homes with those who could not and were
therefore delivered as charity patients in the Aberdeen Maternity Hospital. He
found the results shown in Table 15.

*Pond, M. A.: How Does Housing Affect Health? Am. J. Pub. Health 61:667, May 1946.
SOCIAL PATHOLOGY 137

Table 13. Prevalence of Chronic Illness in Families by
Socioeconomic Status*

 

 

Adjustedt Per Cent 111

 

Socioeconomic Status

 

| 1923 | 1943
| |
Well-to-do | 27.7 29.3
Comfortable 47.3 | 39.8
Moderate 55.0 | 41.1
Poor 57.7 50.6
Very poor 61.3 | 44.0
|

*Modified from Lawrence, P. S. : Chronic Illness and Socio-economic Status, Pub. Health,
Rep. 63:1507, Nov. 19, 1948.

tRates adjusted for age and family size.

Table 14. Hospital Delivery, Infant Mortality, and Income,
United States, 1940*

 

 

 

Tr 7 i
Quartile by Rank of Per Capita Per Cent of Births | Infant Deaths Per
Infant Mortality Rate Income | in Hospital | 1000 Live Births
— _— oo — _
Lowest | §722 | 86.5 | 27.8
Second | 727 | 78.9 [ 39 4
Third | 686 | 72.4 | 49.0
Highest | 595 | 55.8 | 73.2
Total $682 | 73.4 47.4
| | |

*Modified from Altenderfer, M. E., and Crowther, B.: Relationship Between Infant Mor-
tality and Socioeconomic Factors in Urban Areas, Pub. Health Rep. 64:331, March 18, 1949.

Table 15. Infant Deaths by Place of Delivery,
Aberdeen, Scotland, 1950

 

 

Stillbirth Neonatal Combined
Place Delivered Rate Death Rate Death Rate
|
— |
Charity hospital | 2.23 Cons 1.01
Private nursing home | 0.99 | 0.50 1.49
138 INTRODUCTION: PUBLIC HEALTH

Especially interesting is Baird's comparison of the characteristics of the two
groups of mothers. He points out that all the women received the same standard
of antenatal and postnatal care so that the differences in results are due to dif-
ferences in health, physique, and intelligence. His epitomization is summarized

in Table 16.

Table 16. Comparison by Income Group of Women at Delivery,

Aberdeen, Scotland, 1950

Characteristic Low Income Group | High Income Group

|
|

Stature Small | Tall

Physical grading Poor Good

Pelvis Flat Round or long

Functional grading Poor Good

Hygiene Poor Good

Knowledge Limited Adequate

Prenuptial conception Frequent Seldom

Housing Poor Good

Premature labor Frequent Infrequent

Fetal deaths | High Low

Repeated pregnancies | Frequent, unplanned even when Limited, planned

contraindicated
Premature aging Commonly Seldom

 

 

If one looks for them, relationships with factors in the social environment
may be found with regard to almost all diseases. Their significance varies both
with regard to the particular group of individuals and their social environment
and with regard to the particular disease. In the cases of some diseases, such as
tuberculosis, silicosis, or gastric ulcer, the relationship may be readily evident,
whereas in others it may be somewhat obscure. The number of social factors
potentially related to disease is undoubtedly legion. Furthermore, they are of
several different types and affect health in a number of different ways—some di-
rectly, some indirectly. Certain factors such as tendencies to develop certain
mental conditions, physical malformations, or blood dyscrasias are inherent in the
members of the group. Others such as exposure to silicious dust or to fumes are
related to occupation. Some such as overcrowding or proximity to brothels are of
danger because they are conducive to exposure. Still others such as certain dietary
habits or infant feeding customs are related to cultural factors.

In their stimulating discussion of social science in medicine, Simmons and
Wolff present the interplay of the several aspects of man and his social and
physical environment in an unusually descriptive manner well worth repeating:

. as an organism man is borne along by his physical environment, but he is
also buffeted about by some of its elements. As a member of society, he is supported
and reinforced by some fellow agents, while he may be frustrated, handicapped, or even

vanquished by others. Similarly, as a personality, he is both a product of his culture
and a potential victim of its compelling or conflicting norms and codes.
Anyone may be carried along comfortably in his milieu for awhile, only to be torn
down miserably after a time as these various environmental components of his life con-
verge and impinge upon him. During long stretches of time, harmful and helpful forces
may blend and balance, permitting him a workable and safe equilibrium amid many
minor fluctuations. What is most important for us to realize, however, is the possibility
that the scales may be tipped critically at a particular time by a clustering of forces
from any one area, or from a combination of the triad of environmental pressures,

SOCIAL PATHOLOGY

 

and that, for the individual, a landslide of ill effects is started.*

139

The following represents one possible classification ol a few of the many
group and social factors which may be related to disease. It is admittedly gen-
eral and is presented merely to illustrate the variety and to provoke consideration

of others.

I. Factors in the members of the group
A. Inherent characteristics

B.

1. Group susceptibility

2. Tendency to inherent defects
Cultural characteristics

I. Racial, national, or religious customs
2. Agricultural customs and methods

3. Dietary habits or customs

4. Educational limitations

5. Linguistic barriers

6. Traditional family size

7. Relative status ol sexes

8. Relative status ol age groups

9. Relative importance of [amily in total social lile

IT. Factors in the activities of the group

A.

B.
i. Economy

D.

F.
G

Political

1. Stability

2. Quality

3. Honesty

4. Foresight of leadership
Occupation and income

1. Basis

2. Stability

3. Trade

Leisure behavioral pattern
Mobility

1. Travel

2. Migration

Traditional household habits

. Traditional purposes ol household

*Simmons, L. W., and Wolff, H. G.: Social! Science in Medicine, New York, 1954, Russell
Sage Foundation, p. 109.
140 INTRODUCTION: PUBLIC HEALTH

III. Factors in the environment of the group*

A. Geologic and climatic
1. Severity of winters and summers
2. Amount of rainfall and available water
3. Mineral content of soil
1. Degree ol geographic isolation

B. General environment
1. Atmospheric pollution
2. Soil and water pollution
3. Amount of arable land available
4. Proximity to deterimental factors (railroads, highways, industries,

brothels, bars, fire hazards)

5. Availability ol recreation areas and facilities

C.. Home environment
I. Inadequate size (persons per room)
2. Dilapidation
3. Type ol structure
I. Inadequate sanitary [acilities
5. Insufficient natural and artificial light
6. Insufficient ventilation

It is well to give constant consideration to these social and environmental
influences in order to emphasize the importance of regarding public health work
for what it really is, i.e., an applied social science, through which is brought to
bear appropriate medical, engineering, nursing, educational, and many other
disciplines. It is only by considering the social and environmental conditions
under which people live, sleep, work, recreate, procreate, and rear their young,
that we can hope to understand and control disease in the most complete sense.
It is only in this way that we can eventually grasp the meaning of total health.

Modern Development. Over a long period, social action to combat or remedy
the various types ol social problems was fractionated into separate, more or less
insulated activities. This was natural since the recognition of each specific prob-
lem and its espousement [or public action usually originated with one or several
visionary individuals. Sometimes these persons were dedicated to the ameliora-
tion ol a particular problem because ol some personal or familial experience.
This was the cause above all causes which motivated them and those they gathered
about them. The result was a parochialism ol interest and action evidenced by
separate health reforms, housing reforms, penal reforms, and so on. Gradually,
a relationship among all ol these apparently unrelated social problems became
recognized on more or less theoretical and empirical grounds, but attempts to
correlate remedial action lagged essentially up to the present generation.

Perhaps the single most significant contribution to this recent development
has been the recognition of and emphasis on the family, in contrast to the indi-
vidual, as the basic social integer. Thus, it is now accepted that the individual

 

¥For a much more complete list, see Basic Principles of Healthful Housing, ed. 2, New
York, 1939, American Public Health Association.
SOCIAL PATHOLOGY 141

cannot be considered apart from his family or from the various and many forces
in the physical and social environment which may influence his family. Further,
it is increasingly recognized as usually [utile to attempt to treat an individual
problem without taking into consideration the family situation and all the forces
which may affect it. This is even recognized to apply to the lone single individual
on the basis ofl his having come [rom a family, living in a family-substitute, and
subsequently entering or establishing a family. In this regard, Richardson®! wrote:
The individual is a part of the family, in illness as well as in health . . . the idea
of a disease as an entity which is limited to one person . . . fades into the background,
and disease becomes an integral part of the continuous process of living. The family is
the unit of illness, because it is the unit of living. *

It is interesting to consider momentarily the multifaceted functions of the
family. It provides, of course, the sole means ol continuity and growth of the
human species. As Ackerman=* explains, it accomplishes this by providing a
socially supported group pattern for the sexual union of man and woman and a
stable situation which encourages a quality of parental partnership essential to
the care ol the resulting offspring. As he describes it, “The family is literally the
cradle for the infant's tender mind as well as his body.” The family, when prop-
erly established and conducted, presents a circumstance for the provision of food,
clothing, shelter, and other materials necessary to life, lor the proper emotional
development of children and of their parents, for the guided evaluation of per-
sonal identities, for the development of normal and acceptable sexual patterns,
for the establishment ofl social and ethical standards and the ability to accept
social responsibility, and for the acquisition ol knowledge and creative ability.

Children who grow up in a family setting acquire not only the general pat-
terns of the culture of their particular society but also their parents’ unique in-
terpretation of it. Thus, although all children of the same generation ol a society
develop in a more or less similar manner, the children in each family are some-
what different from those in other families. Part of the role of the amily, there-
fore, is not only to nurture a new generation that fits into its society, but also to
provide the great variety of personalities necessary for the society and its biolog-
ical and cultural evolution.

Many psychiatrists and sociologists have emphasized that one of the greatest
values of the family is as a stabilizing force, for the individual member, on the
one hand, and for society on the other. It accomplishes this by means ol two
apparently conflicting mechanisms. For purposes ol long term security, the family
tends to resist change. However, in times ol trouble or emergency, it provides a
psychic and social cushion, a means for sharing difhculty, and a basis lor ac-
commodation to change. Unfortunately, all family structures are not such as to
ensure this. As Ackerman? states, “In the meeting of new problems and crises,
some families are weakened and others grow in solidity and emotional strength.
Some families grow and learn from experience; others seem unable to do so
because they are too inflexible and tend to disintegrate.”

*Richardson, H. B.: Patients Have Families. New York. 1945, The Commonwealth Fund.
The Harvard University Press, p. 76.
142 INTRODUCTION: PUBLIC HEALTH

A subject for particular concern is the tendency to small, urban families.
As Bossard*# says, “The very size of the family unit is important to the child . . .
for the same reason that the size of the ledge from which we view the precipice
below affects our sense of security.” In families with one or few children and
no grandparents, uncles, or aunts the child has few upon whom he may depend,
and a single or, at most, a few difficulties may spell disaster.

In addition, as Schottstaedt® has emphasized, decreasing the number of
people in the home tends to increase the frequency and intensity of emotional
reactions because there are fewer people to absorb impacts and [rictions. Further-
more, support tends to be concentrated in one wage carner since there are
fewer people to contribute to the common family needs. Similarly, the house-
hold duties and responsibilities of the housewile are increased in a relative
sense since such work must be done whether there is one or a number in the
house, and are increased in an absolute sense because there are [ewer or none to
share the work with her. Compounding this are the numerous extrafamilial dis-
tractions and demands upon the parents in the urban situation. Schottstaedt also
points out how the burden and the risk are greatly increased in the small family
when illness strikes one of its members. There are fewer people to perform nurs-
ing functions and fewer to assume the customary responsibilities of the one who is
ill. As he states, “Available home resources for nursing chronically ill members
of the family are therefore decreased and the percentage ol people who require
hospitalization, nursing home care, or institutional care is increased.” With regard
to the latter point, Parsons and Fox?! have suggested that the growth and in-
creasing use of hospitals is not due merely to advances in medical knowledge
and its application in an increasingly exacting technology but is also a response
to a shift in family structure which is itsell linked to the occupational structure.

Such considerations go far in explaining some of the difficulties encountered
in the handling of certain types of illnesses and certain types of individuals. They
provide, for example, one reason why in a substantial number of cases medical
treatment alone of chronic diseases is ineffective, because of tangential relation-
ships to the family economy and other aspects of family and social life.?> Because
of the differences in the amount and types ol stress on the male in our society,
they explain, in part, the excess of gastric and duodenal ulcers in males and fur-
ther provide a logical reason for recent increase in this condition among women
since their social and occupational “emancipation.” Also, as has been shown by
several investigators, the diabetic fares less well in the competitive industrialized
urban situation with frequent and often intense stress. Thus, stress threatens se-
curity, and the emotional response results in an increase in ketone bodies in the
venous blood, and fluctuations in blood sugar level.?¢2" Anyone who has worked
with older age groups is familiar with the frequent difficulty of maintaining their
health or indeed an interest in it. Left to their own devices, because they have
passed their biologically and economically productive years, they tend to feel
they are useless and unwanted. One result is a tendency to neglect themselves.
Matters of personal hygiene may not be observed. Nutrition may suffer because
of defective teeth, the development of vicarious food preparation and eating hab-
its, and a lack of appetite caused by feelings of depression. As Schottstaedt® sum-
SOCIAL PATHOLOGY [43

 

marizes the situation, “Manv of the diseases of older age are related to three
things: nutritional deficiencies, circulatory disturbances, and general disuse.”

Interrelationship of Social Problems. From what has gone before, it would
appear evident that neither man nor his problems exist in vacuums. By virtue
of being a product of a family and a participant in a society, innumerable ex-
ternal factors, both for good and for evil, impinge upon him as an individual.
Some act to cause difficulty and problems; others serve to provide support and
solution of problems. Thus, it is now recognized that the state of personal or
familial health or disease is the result of many interacting biological, physical,
and social factors. Depending upon the nature of the disease and circumstances,
any one of these may be primary and the others contributory. Furthermore, given
a state of disease, these same factors are involved in the chances for and mecha-
nism of recovery and rehabilitation. This has led to disease in the individual
being considered more and more as a social phenomenon involving a number of
people and especially those immediately related to and around the patient. As
Richardson®! has put it, “Illness is one form of family maladjustment.” An at-
tempt to illustrate these relationships insofar as disease is concerned has been
made in the previous discussion of man and his environment.

This leads to a still more significant aspect ol the subject which requires con-
sideration—the intimate interrelationships among a number of seemingly diverse
types of social problems which may affect an individual, a family, and a society.
One way to approach the subject is to consider the example of a man suffering
with pneumonia who is brought into a hospital. Physical and radiographic exam-
inations may conclusively determine the clinical diagnosis. Sputum examination
may clearly implicate the Diplococcus pneumoniae as the causative organism.
However, is it as simple as this? Several questions remain unanswered. It is known
for example that many more people are exposed to this organism than become
clinically ill. Why did this particular individual become ill with pneumonia?
True, he could not develop this particular disease in the absence of the organism.
Nevertheless, a valid question may still be raised as to what actually caused the
illness. Investigation may elicit circumstances such as the following. The patient
suffered from overexposure because on the preceding night he had slept on a park
bench in the rain. He slept on a park bench because he did not know what he
was doing. He did not know what he was doing because he was under the in-
fluence of alcohol. He had indulged in an excess of alcohol because of discourage-
ment and despondency over a bitter argument with a complaining wife. His wife
had complained because her husband was unemployed and had no income. He
may have been unemployed because of inadequate training, because of intrinsic
inability, or because of some complex interplay of business economics. Which of
these factors caused his pneumonia? Obviously, they all did.

Similarly, consider the case of an adolescent apprehended by the police as
a juvenile delinquent. The immediate circumstance may have involved being
caught breaking into a store. Was the child intrinsically antisocial and was the
fault exclusively his? Investigation may bring out that he is only one of a group
of similar adolescents who have formed an antisocial club or “gang.” It may be
144 INTRODUCTION: PUBLIC HEALTH

discovered that the group is sexually promiscuous, that venereal infections and
abortions are common, and that alcoholism and narcotic addiction is present
or incipient. In fact, the crystalizing store-breaking incident may have occurred
to obtain money [or alcohol or drugs. Why did this boy, or for that matter, any
of the others, belong to the gang and engage in such antisocial behavior? More
often than not, discussion with a parent will result in the statement: “I just
can’t do anything with him.” Deeper inquiry and study, however, are certain to
bring out a number of other causative factors, most of them relating to the family
and the social environment. Often, the family bonds are discovered to be [rayed
or parted. The home may be single-parented because of illegitimacy, divorce,
separation, illness, or absence of one or both parents due to their employment.
In such instances, the “gang” is often a substitute family situation, i.e., some-
thing to belong to, in which to socialize and exercise self-expression. On the
other hand, both the parents and the children may live together. However, the
home, because ol economic stringencies due to ignorance, misfortune, or other
reasons, may consist of just a few crowded rooms of a substandard quality with
little or no privacy, ample opportunities for bickering and quarreling, and few
lacilities for cleanliness. Such a situation offers little incentive for the develop-
ment of a sense ol dignity, pride, or responsibility. The most intimate personal
and sexual acts may be commonly observed, which encourages a cynical attitude
toward them; there is little opportunity or reason to develop respect [or the prop-
erty ol others even within the family; education, virtue, frugality, and social re-
sponsibility may be derided; dependence upon public welfare and public assist
ance may be the cornerstone of the family finances, and parental bouts of alco-
holism and physical as well as verbal abuse may be so common as to establish
themselves as the standard of behavior. Under such circumstances one may prop-
erly ask: Why did this boy attempt to steal? Why was he sexually promiscuous?
Why did he have gonorrhea? Why, perhaps, was he on his way to being an alco-
holic or a drug addict? Why had he no respect or use for the concepts ol family
and society? Obviously, the answers to none ol these questions can stand alone;
they are all interlinked. And they all devolve into the three fundamental ques-
tions: Where and how did it all begin? How can this chain be broken? How can
similar complex situations be prevented from occurring in others?

One ol the conclusions which such cases bring out forcefully is that the pri-
mary diagnosis of a situation is not always in the same field as that under im-
mediate or initial consideration. Social problems tend to exist together like dif-
[erent vegetables in a stew, as it were, and occasionally a particular problem
erupts on the surface of the simmering stew. Regarded singly and momentarily it
gives a very limited and quite fallacious impression. To appreciate the total situ-
ation fully, one has to stir the stew, sample it, and observe it over a period of time.
In terms of such an analogy, it is important to realize that although each vege-
table when dredged up and examined in the ladle appears to be discrete, it is
meaningful only in relation to the total stew and, if spoiled, can affect all other
parts of the stew. Caudill*® has stated this in more pedantic terms as the basic

conclusion of a presentation of the Effects of Social and Cultural Systems in Re-
actions to Stress.
SOCIAL PATHOLOGY 145

. stress can manifest itself in one or more of a number of linked open systems,
and . . . the strain on one system can be transmitted to others so that several become
involved in the process of adaptation and defense. These linked open systems may be
thought of as: physiology; personality; relatively permanent meaningful small groups,
e.g, the family; and wider social structure, e.g., community and the nation or, variously,
economic and political structures .. . .*

Following this he pointed out:

. in very few studies [and it might be added parenthetically, in very few action
programs] has the research design taken account of more than two of the possible
systems as variables. Physicians have found relations between physiological phenomena
and conditions that have been conceived as psychological (fear, rage), psychodynamic
(unresolved dependency, anxiety), and environmental (cold, imprisonment). Social scien-
tists have shown relations between the structure of the family and its position in the
cconomic or social class system, and have attempted to work with a concept of basic
or modal personality in relation to the patterns of child rearing found in a culture.
But only a few studies have examined three such variables as more than static back-
ground phenomena . .. *

Simmons and Wolfl' have attempted to present the concept ol some ol these
interrelationships in tabular form. The essential point made by them is that
physical, social, or cultural events or forces may constitute either or both sources
or consequences ol strength or weakness, good or evil. Thus, a particular physical
source, event, or force may have physical consequences, social consequences, or
cultural consequences. This is similarly true ol social and cultural sources, events,
or forces. It is also important to recognize that the resulting consequences may
in turn become sources or forces themselves. This method of presentation is
adapted here to illustrate many ol the issues raised in the preceding paragraphs.

With regard to the interrelationships among negative or undesirable sources,
events, or forces and consequences, we may consider as sources the following
examples:

(a) Physical: Disease, congenital defect, or injury to face
(b) Social: Sudden industrialization with an influx of young adult workers
(¢) Cultural: Development of an urbanized living pattern

Each ol these may have undesirable physical, social, and cultural conse-
quences as shown in Table 17.

In a similar manner, sources, events, or forces may be of a positive nature
and result in desirable consequences. To illustrate this, the following sources may
be used:

(a) Physical: Improved nutrition, public health, and medical care
(b) Social: Development of social security and medical care plans
(c) Cultural: Provision of improved education

Each of these may have desirable physical, social, and cultural consequences
as shown in Table 18.

*Caudill, W.: Effects of Social and Cultural Systems in Reactions to Stress, New York, 1958,
Social Science Research Council, pp. 1-2.
146

INTRODUCTION: PUBLIC HEALTH

Table 17. Interrelationships of Undesirable Physical, Social,

Undesirable Sources
or Events

Physical:
Disease or injury

Social:
Industrialization

Cultural:
Urbanization

 

and Cultura

Physical

Facial deformity

Increased venereal
disease

More accidents and
insanitation

 

| Factors*

Consequences

Social

Inability to obtain
employment

Free intersexual rela-
tionships and
promiscuity

Overcrowding
Development of gangs
Alcoholism

 

Cultural

Misanthropy
Condemnation of
parenthood

Changes in attitudes
toward marriage
and family

Breakdown of kinship
and family bonds

*Modified from Simmons, L.. W., and Wolff, H. G.: Social Science in Medicine, New York
1954, Russell Sage Foundation, p. 111.

Table 18 Interrelationships of Desirable Physical, Social,

Desirable Sources
or Events

Physical:
Improved nutrition,
public health,
and medical care

Social:
Social security
plans

Cultural:
Improved educa-
tion

 

and Cultura

| Factors*

Consequences

 

Physical

Less illness and
longer life

Fewer complications

Earlier diagnosis, pre-
vention and
treatment

 

Social

Cultural

 

Greater productivity

Less pauperization of
sick and aged

Demand for better
public health and
medical care

 

Stronger family and
social responsibility

Changed attitude to-
ward aged

Rational understand-
ing of sickness and
health

*Modified from Simmons, L. W., and Wolff, H. G.: Social Science in Medicine, New York.
1954, Russell Sage Foundation, p. 111.
 

SOCIAL PATHOLOGY 147

Multiproblem Families. Everything that has been said thus far in the sub-
ject of social pathology points to the veracity of the common saying that “misery
likes company.” This is true in the sense that people and families in difficulty
tend to be concentrated geographically, especially in urban situations. It is also
true in the sense that difhiculties seldom occur singly. In recent years this phenom-
enon has been described in several ways, one of them by the use of the phrase,
the disease-dependency-delinquency syndrome. This gives recognition to the fact
that at any time in a society, there are a certain number of individuals and, more
significantly, families which get caught in a vortex of contributory social prob-
lems, each ol which complicates the others in turn, making it more and more
difficult to escape. For some, the situation becomes so extreme and hopeless that
there results an eventual condition which has been referred to as cumulative
degradation.

There would appear to exist at least three types of families or situations,
which differ from each other essentially in the degree of ability to respond to as-
sistance successfully. There is one group of multiproblem family which under
ordinary circumstances is sell-sufficient and which goes along reasonably well
until some catastrophe or crisis (medical, economic, or otherwise) sufficient in
magnitude to throw the family off balance occurs. This crisis, if unsolved, even-
tually gives rise to problems in other areas. Unless some assistance is forthcom-
ing, this type of family is in danger ol irreparable damage and may become a
permanent multiproblem family. If, on the other hand, significant assistance is
rendered, with regard to the original or to each of the several accumulated and re-
lated problems, this type of family is able to rehabilitate itself and assume and
maintain its proper and desired role of sell-sufficiency.

A second type of family is somewhat similar to the first. It has good inten-
tions and wants to be self-sustaining but lacks good management and ‘staying
power.” As a result, every once in a while it slips below the surface. 1f appropri-
ately aided, it is able to climb back and operate on a relatively even keel until
some new crisis occurs. Then it slips again and must be helped back again.

The third type of family is the most discouraging to deal with. Either because
of overwhelming crises and catastrophies for which it has received no help, in-
sufficient help or, important to this discussion, unilateral help, or because it is an
intrinsically defective family, no extent or type ol assistance seems to enable it
to achieve recovery. Often, the desire for recovery, i.e, for a different way of
life, is lacking, unacceptable. or incomprehensible. The roots of the difficulties of
these so-called “hard core” problem families go very deep. They are almost ir-
retrievably caught in an exceedingly difficult situation which might be referred
to as the syndrome of the seven Ds:

Disease Dependency

Deficiency (often both Despondency
nutritional and mental) Delinquency

Destitution Degeneracy

Williams2® summarized the same situation with regard to England in the
following terms.
148 INTRODUCTION: PUBLIC HEALTH

. . after the Industrial Revolution with its child labor, cheap alcohol, poor wages,
and bad landlords, there must have been a much higher proportion of our working-
class families living under conditions far worse than anything we see today.

As social amenities became more readily available to the people so the great
majority took advantage of the benefits and improved their conditions of life . . . Yet
one finds a small minority, either through a temperamental instability or a mental
defect, who fail to keep pace with the advancing times. *

He cites five surveys, conducted by the Eugenic Society ol Great Britain,
which [ound an average incidence of such “hard core” families to be 3 per
thousand families. He adds that, “We find that a large number ol these people
are in early middle life, able-bodied and capable of regular manual work, who
have difhiculty in adjusting themselves to the recognized standards ol life.”

In the United States, a number of significant investigations ol this problem
have been carried out in recent years. They too have clearly indicated the im-
portance ol the family as the basic unit ol social significance, the simultaneous or
successive occurrence ol social problems, and the existence of a small “hard core”
ol multiproblem families.

The most comprehensive and illuminating of these investigations was the
study of St. Paul, Minnesota, a more or less typical American city.*» The study
was carried out by a group of consultants from the fields of health, maladjustment,
dependency, and recreation, with the cooperation ol 108 public and private com-
munity agencies. About 41,000 families, representing 40 per cent of the total in
the city, had contact with one or more agencies during the study month of
November, 1948. The types ol problems lor which services were rendered are
summarized in Table 19.

Table 19. Incidence of Social Problems, St. Paul, Minnesota,
November, 1948

Type of Problem for Which | Per Cent of Families Per Cent of Families

Assistance Was Rendered Studied in Month | in City
Financial 17 7
Maladjustment | 26 10
Health 38 | 15
Recreation 46 | 18

It should be noted that health problems were among the most common en-
countered. In fact, during the month studied, about 16,000 lamilies, a rate of
147 per thousand [amilies, received some services Irom the 12 public and 18
private health agencies in the community. About one hall of these services were
in relation to a chronic disease or handicap. With regard to age distribution ol
those receiving services for ill health, 32 per cent were reported to be under 20
years, 41 per cent were between 20 and 64 years, and 22 per cent were over 65

*Williams, H. C. M.: Rehabilitation of Problem Families, Am. J. Pub. Health 45:990,
Aug. 1955.
SOCIAL PATHOLOGY [49

 

years. Between one half and two thirds of those who suffered {rom chronic handi-
caps or diseases were heads of families. Thus their ailments inevitably affected
the family income, prospectives, and behavior.

A simple totaling of the figures in the table indicates that a number of
families must have required and received aid [or more than one type of problem.
Upon investigation the facts substantiated this beyond expectation. Of the fi-
nancially dependent families 77 per cent had problems of ill health and/or mal-
adjustment; 56 per cent of the families with problems of maladjustment had
problems of ill health and/or dependency; and 38 per cent of the families with
health problems had problems of dependency and/or maladjustment.

The most striking finding of the St. Paul study was that there was a group
ol about 6,500 lamilies, only 6 per cent of the total in the city, who suffered from
such an essentially continuing complex of problems, that they absorbed 46 per
cent ol the health services, b5 per cent of the adjustment services, and 68 per cent
ol the dependency services. This finding was further refined by the discovery
that only 4 per cent of these “hard-core” multiproblem families were financially
dependent because of unemployment. Of the 6,500 families 58 per cent were de-
pendent because of ill health and/or maladjustment which rendered them unable
to be self-sustaining.

The question naturally arises as to reason for the development of multi-
problem families, especially those that form the “hard core” in a community.
Analysis of the reasons is even more difficult than analysis of the problem. Prac-
tically all observers agree on one thing, i.e., that the qualities ol family stability
and cohesiveness are usually weak in such situations. In connection with con-
cern over the effects ol mobility on the [amily, Foster?® has itemized four [actors
which make for family solidarity. These are stability of location, with the de-
velopment of an empathy with and a stake in the surroundings; frequent con-
tacts among the members ol the family; homogeneity, resulting from common or
shared experiences; and finally an intangible “dynamic element” or “lile prin-
ciple” within the fabric of the family itsell. Foster makes the very important
point that this appears first as an ideal or common purpose shared by the two
people who get married and establish the family. He also expresses the opinion
that all four ol these basic factors have been subjected to weakening influences
during recent years.

It has been observed that multiplicity of problems tends to occur most fre-
quently among recent immigrants to nations or communities. That this would
be so is not surprising and is quite in line with the foregoing. With this in mind,
Simmons and Wolll state:

. when peoples migrate, many clements of the new homeland’s culture are
rapidly adopted while large parts of the original culture survive in the family or small
mobile group. Striking examples are found in first and second-generation immigrants

. who because of contemporary patterns of prejudice may be barred from full par-
ticipation . . . and become, in a sense, “marginal men” trapped between two cultures
and subject to the conflicts arising from both.*

*Simmons, L. W., and Wolff, H. G.: Social Science in Medicine, New York, 1954, Russell
Sage Foundation, p. 88.
150 INTRODUCTION: PUBLIC HEALTH

 

Their statement continues in a sense which gives some hint regarding the
development of multiple social problems in another group, i.e., the residual

aging group.

Furthermore, a person in the same physical surroundings . . . may continue to cling
to attitudes, habits, and goals acquired in his youth, while the cultural norms are
changing rapidly, with the result that he is not in harmony with the newly evolved
patterns within his own society. He may be left as one stranded with his own personal
and outmoded cultural values and attachments. The sweeping tides of cultural change
frequently produce new areas of stress in personalities and not seldom leave their
marks on the organism .*

All human beings engage to varying extents in a search for status and goals.
In recognition of this, Simmons and Wolff present a graphic picture which de-
scribes the genesis of a third type of individual who tends to become enmeshed
in a tangle ol multiple problem situations. Approaching the subject from the
standpoint of medicine they say:

Clinicians will often find, at the other type-extreme from the creature of culture,

the socially deviant individual who also strives, although perhaps unconsciously, for

“wayward” goals and who follows his own atypical and partly false clues in response

to his life situation. His adaptations are out of harmony with socially approved be-

havior, as well as inappropriate on a physical basis. Under such circumstances social

penalties are added to the physical injuries, and stress may be compounded in a kind

of “vicious cycle,” for the more the subject reacts the worse becomes his plight. Follow-

ing his false clues, he simultaneously impairs his body and his social relationships, per-

haps even alienating the very persons best qualified to help and support him and whose

rejection leads to further deviation. t

The last sentence of this statement might well be re-read occasionally by
persons engaged in social improvement, including those in the field of public
health. Too often, it is feared, the natural or emotional reaction to confusion and
despondency is hastily grasped as an excuse for taking the easy way out by con-
demnation of individuals as intrinsically bad or worthless.

Another interesting possibility that is worthy of consideration, especially in
view ol recent developments in psychosomatic medicine, is the use of illness as
a response to social difficulty or dissatisfaction. It is known that some individuals
who cannot achieve satisfaction and fulfillment in positive or socially acceptable
channels, turn in their search to negative or antisocial channels. These may take
the form ol alcoholism, sexual deviation, dependency, or crime. It is entirely pos-
sible that, for some, still another solution is illness, alone or in company with
one or more of the other negative forms ol behavior. In fact, of these various
solutions, “sickness” used in this sense has the advantage ol being the most ac-
ceptable and ol eliciting the most sympathy and ready assistance. Furthermore,
it provides other individuals and groups in society an opportunity for the
achievement of their sense of fulfillment and self-satisfaction.

*Simmons, L. W., and Wolff, H. G.: Social Science in Medicine, New York, 1954, Russell
Sage Foundation, p. 88.

Simmons, L. W., and Wolff, H. G.: Social Science in Medicine, New York, 1954, Russell
Sage Foundation, p. 148.
SOCIAL PATHOLOGY [51

One final aspect of the subject must be mentioned. It is entirely possible that
on occasion the exercise of unilateral zeal on the part of public health workers
may actually give rise to social problems in families and may contribute to the
establishment and continuation of a vicious social cycle. For example, the public
health worker knows that tuberculosis is communicable and may insist on prompt
hospitalization of a wife and mother if she has this disease. Without question,
this is scientifically the correct thing to do. It is “best” for the patient, for her
family, and for society. Best. that is, from the public health viewpoint. If, how-
ever, at the same time that hospitalization of his wife and mother is arranged,
the public health worker neglects to work intimately with the total family and
with other sources of assistance in the community, good intentions may lead to
ultimate greater evil. Public health workers must recognize that hospitalization of
a parent interferes with family structure and relationships. Removal ol maternal
care and guidance may result in decreased family cohesiveness and supervision
which may lead to delinquency on the part of the children. Prolonged absence of
wifely companionship compounded by concern over increased expenditures for
medical care and housekeeping may lead to alcoholism and philandery on the
part of the husband. These in turn may lead to lowered income. Eventual dis-
solution of the family with firm establishment ofl a disease-delinquency-depend-
ency syndrome is by no means an impossibility. If the woman’s tuberculosis is
successfully arrested or cured, the pleased stafls ol the institution and the health
agency may discharge her to quite a grim future with an excellent chance of re-
lapse. And worst of all, the undesirable set of circumstances which has been set
in motion may very well carry over into a number of future generations. There-
fore, at the risk of redundancy, it must be emphasized that public health workers
should be most circumspect when considering any measure that may interfere
with the integrity of the family, its economic base, or its social relationships.
Public health workers should always ask themselves il a program or an action
might in any way contribute to the disintegration of the family, even though it
might aid the family or society in other ways. All such situations call for careful
consideration ol all possible alternatives, exhaustive attempts to educate those
who may be guilty of infractions of sanitary and health regulations, and the
use of a multidisciplinary approach to the existing and potential needs and
problems of the total family unit.

Points for Action. Fortunately, there exist in most communities a wide
variety of resources which may be called upon for assistance. For some time,
attempts have been made to provide for some degree of joint planning and
action. Usually these take the form of a Council of Social Agencies or a Com-
munity Health and Welfare Council in which there is membership by many
of the agencies active in these fields. However, on one hand, any joint activity
which occurs is often general and on a high level, quite distant from the [amily
in need; on the other hand, most health and welfare councils are too limited,
agency-wise and substantive-wise. Not all of the health and welfare organiza-
tions in a community are members of the Council and do not participate in the
joint planning. Furthermore, a number ol other types of agencies should be
involved. Among those often absent are agencies for recreation, rehabilitation,
public assistance and law enforcement, and the courts.
152 INTRODUCTION: PUBLIC HEALTH

Another source of partial solution has been the Social Service Relerral
Center to which representatives ol member agencies (and sometimes others) may
refer cases for certain specific investigations or for certain specific services. One
common difficulty is that individuals and families sometimes get “lost” in the
referral system. Sometimes they are never referred back to the initiating agency
for follow-up or for resumption and completion ol care that may have been
instituted but interrupted in order to provide time or opportunity [or solution
ol a secondary or contributory problem. Mention must be made also of an un-
fortunate practice occasionally indulged in, consciously or subconsciously, by a
lew agencies. This is to avoid referral of cases lor additional or auxiliary services
because ol fear that a sort ol “right of proprietorship” over the case might be lost
and that this would reflect poorly on the agency when the time came to publish
an annual report or to engage in a fund raising activity based upon case load.
Obviously such an attitude, however rare, is totally unwarranted and inexcus-
able if it detracts in any way [rom the earliest possible and most satisfactory so-
lution of a family’s problems.

In England, several different approaches have been attempted. * In South-
ampton, a Rehabilitation Committee consisting of heads of pertinent municipal
departments was established. This committee in turn established a subcommittee
ol principal ofhcers concerned with the operation ol various social welfare and
reliel programs and ol representatives ol various voluntary agencies. Weekly
meetings are held under the chairmanship of the Medical Officer ol Health as
coordinator. Any member may bring up specific cases on the basis ol their com-
plexity or because inadequate action has been taken. Responsibility for action is
clearly placed and followed up. It is [elt that this procedure results in considera-
tion ol all aspects ol the family problem, places responsibility, results in el-
ficient use of home-visting personnel, and results in action. It is interesting that
a committee ol experts on delinquency, called together by the World Health
Organization and consisting ol forensic, general and child psychiatrists, psy-
chologists, prison directors, criminologists, social workers and a judge, suggested
that jurists, psychiatrists, psychologists and sociologists should collaborate as
a sort’ ol “Treatment Tribunal” to decide the nature of the diagnosis and course
of treatment.*! In many cases a public health worker might also be ol assistance.
In Bristol, Liverpool, and Manchester, Family Service Units were established
alter the war. The work is done from hostels by recently graduated social science
workers. In addition to using the hostels for clubs, meetings, cleansing, and [eed-
ing, the workers help in the homes and gain the confidence of the [amilies so
that more effective service and referral is possible. These methods have resulted
in about a 10 per cent rate ol rehabilitation of problem [amilies. Williams?
concludes that “Although the methods ol dealing with problem families appear
at first sight to be fairly costly, it is far cheaper than leaving the problem
untackled.”

In reviewing the findings of the St. Paul and similar surveys, Kandle?? con-
cludes that two things are necessary. First, the application of the principles and

*See pp. 992 and 995 in Rehabilitation of Problem Families by Williams.
SOCIAL PATHOLOGY 153

methods of epidemiology to chronic diseases, disabilities, dependency, and mal-
adjustment. Second, the development, by specialists in health, family services,
mental hygiene, social casework and other related fields, of more effective means
ol working together in order to achieve sound and complete collective diagnosis
and a coordinated form of treatment.

Essentially, what is called for is a synthesis ol philosophy, interest, resources,
and effort to be applied to total social problems of the community through its
families. Certain specific suggestions may be made. Professional parochialism
must be broken down. This might be accomplished in part by the provision of
more intimate working relationships among the various disciplines and agencies
involved. Health departments and health centers should at least provide office
space lor liaison personnel [rom certain other public and private agencies and
in turn should assign public health personnel to other agencies for the same
purpose. Multidisciplinary and multiagency committees or councils for case plan-
ning and review should be established as well as committees concerned with pro-
gram planning and review. Some ol the community agencies and services that
might be included or at least consulted are health, welfare, public assistance, hos-
pitals, police, courts, fire protection, voluntary health agencies, and the social
service agencies. Family reporting and filing systems should be used wherever
possible instead ol individual reporting and filing systems. All health and other
social agencies should participate in a central Social Service Relerral Center es-
tablished on a family as well as on a case basis. Every problem should be studied
and handled with the family considered as the unit, and every proposed solution
must be regarded in terms ol possible undesirable effects.

Since social problems, including health problems, are inevitably family
problems and since it is the concensus that most multiproblem situations have
their roots in the early period ol married life, health and other social agencies
should make more use ol marriage reports as a means ol contact with certain
types ol individuals and groups before trouble has an opportunity to occur.
Undoubtedly some relatively limited assistance in the establishment ol a house-
hold, alerting a newly married couple as to sources of assistance and counseling,
would prevent the unimpeded progression ol numerous problem situations. From
the over-all community standpoint, concentration ol multiproblem [amilies in
one area, whether the problems are incipient or [fully developed, should be
avoided il at all possible. Crowded together, they tend to maintain each other as
problem families and groups. Separated, they tend to learn and improve by con-
tact with more stable [amilies.

Much experimentation is needed along these and many other lines. Most
encouraging at the moment are three large demonstration projects which were
begun in 1954 as an aftermath of the St. Paul study.?® All three have the same
objectives of defining and identifying problems, using the family as the approach
to diagnosis and treatment, integrating services through existing channels, de-
veloping and testing new methods and techniques, and evaluation of results. The
interesting departure is that each is deliberately approaching multiple problems
from a different initial approach. The demonstration in Winona County, Min-
nesota was focused on the problem of dependency; that in San Mateo County,
154 INTRODUCTION: PUBLIC HEALTH

California was focused on the problem of disordered behavior; and the project
in Washington County, Maryland was focused on indigent disability. Undoubt-
edly these three related studies will be most interesting to watch, and they should
contribute much to the more successful and practical handling of the multi-
problem situation.

By now the reader may [eel that he has been led somewhat afield from the

basic issue of public health. If so, he might do well to recognize with Koos?*:

. community organization for health is in no sense an activity divorced from
other forms of activity for community welfare . . . all community organization is inter-
woven in a common effort. Health, says modern research, is not to be found apart from
a general welfare of the individual and the community. It consists not only of an ab-
sence of disease but also of a sense of general well-being, of adjustment to all of the
forces that make up the intricacies of the society in which we live.*

REFERENCES

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11.
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13.
14.
15.
16.
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19.

20.

21.

Simmons, 1. W., and Wolfl, H. G.: Social Science in Medicine, New York, 1954, Russell Sage
Foundation.

Stern, B. J.: The Health of Towns and the Early Public Health Movement, Ciba Symposia
9:871, May-June 1948.

Buzzard, Sir Farquhar: The Place of Social Medicine in the Reorganization of Health Serv-
ices, Brit. M. J. 1:703, June 6, 1942.

Ryle, J. A.: Changing Disciplines, London, 1948, Oxford University Press.

Schottstaedt, W. W.: Comprehensive Medicine in Relation to Public Health, Am. J. Pub.
Health 44:1340, Oct. 1954.

Steiger, W. A.: Causality and the Comprehensive Approach, J. M. Educ. 33:538, July 1958.

Kroeger, Gertrud: The Concept of Social Medicine as Presented by Physicians and Other
Writers in Germany, 1779-1932, Chicago, 1937, Julius Rosenwald Fund.

Ryle, J. A.: Social Pathology and the New Era in Medicine, Bull. New York Acad. Med.
23:312, June 1947.

Galdston, 1.: The Meaning of Social Medicine, Cambridge, 1954, Harvard University Press.

Rosen, G.: Approaches to a Concept of Social Medicine, Milbank Mem. Fund Quart. 26:7,
Jan. 1948.

Item, AMA News, Dec. 29, 1958.

Grotjahn, A.: Soziale Pathologie, Berlin, 1915, August Hirschwald Verlag.

Wolll, G.: Social Pathology as a Medical Science, Am. J. Pub. Health 42:1576, Dec. 1952.

Sydenstricker, E.: Health and Environment, New York, 1933, McGraw-Hill Book Co.

Allen, F. P.: People of the Shadows, Cincinnati, 1954, Public Health Federation.

Pond, M. A.: How Does Housing Affect Health? Am. J. Pub. Health 61:667, May 1946.

Lawrence, P. S.: Chronic Illness and Socio-economic Status, Pub. Health Rep. 63:1507, Nov.
19, 1948.

Altenderfer, M. E., and Crowther, B.: Relationship Between Infant Mortality and Socio-
economic Factors in Urban Areas, Pub. Health Rep. 64:331, March 18, 1949.

Baird, D.: Social and Economic Factors Affecting the Mother and Child, Am. J. Pub.
Health 42:516, May 1952.

Basic Principles of Healthful Housing, ed. 2, New York, 1939, American Public Health
Association.

Richardson, H. B.: Patients Have Families, New York, 1945, The Commonwealth Fund.

*Koos, E. L.: New Concepts in Community Organization for Health, Am. J. Pub. Health

43:466, April 1953.
29.

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SOCIAL PATHOLOGY 155

Ackerman, N. W.: Psychological Dynamics of the Family Organism, Pub. Health Rep.
71:1017, Oct. 1956.

Bossard, J. H. S.: The Sociology of Child Development, New York, 1954, Harper & Brothers.

Parsons, T., and Fox, R.: Illness, Therapy, and the Modern Urban American Family, J.
Social Issues 8:31, April 1952.

Buell, B., and others: Community Planning for Human Services, New York, 1952, Columbia
University Press.

Hinkle, L. E. Jr, and Wolf, S.: Studies in Diabetes Mellitus: Changes in Glucose, Ketone,
and Water Metabolism During Stress, A. Res. Nerv. & Ment. Dis., Proc. (1949) 29:338,
1950.

Rosen, H., and Lidz, T.: Emotional Factors in Precipitation of Recurrent Diabetic Acidosis,
Psychosom. Med. 11:211, July-Aug. 1949.

Caudill, W.: Effects of Social and Cultural Systems in Reactions to Stress, New York, 1958,
Social Science Research Council.

Williams, H. C. M.: Rehabilitation of Problem Families, Am. J. Pub. Health 45:990, Aug.
1955.

Foster, R. G.: Effect of Mobility on the Family, Am. J. Pub. Health 46:812, July 1956.

Psychiatry and the Treatment of Delinquency, Chron. of World Health Organ. 12:330,
Oct. 1958.

Kandle, R. P.: In Modern Philanthropy and Human Welfare, New York, 1952, Grant
Foundation.

Eller, C. H., Hatcher, G. H., Buell, B.: Health and Family Issues in Community Planning
for the Problem of Indigent Disability, Am. J. Pub. Health (suppl) 48:Nov. 1958.

Koos, E. L.: New Concepts in Community Organization for Health, Am. J. Pub. Health
43:466, April 1953.
 
part 2

administrative considerations

in public health

As stated in the preface, the knowledge and abilities ex-
pected in modern public health administration are many and
varied. Ordinarily the basic professional training prepares the
individual [or only a small part of the duties he must perform
in his daily work. In fact, public health work and society have
become increasingly so complex that the functions of the health
officer and ol many of his stafl are now primarily those of public
administrators and only secondarily related to their original pro-
[essions. In order to meet these responsibilties adequately, public
health workers must now have an appreciation of the many
factors with which other public administrators have long since
been concerned. Predominant among these, and discussed in the
following chapters, are the organizational, personnel, fiscal, legal,
governmental, and public relations aspects of the public health
program.

157
chapter 7

Governmental aspects of public health

 

Governmental Structure. Since most public health work is carried on under
government auspices, it is fundamental that those engaged in it have a sound
understanding of at least the elements of political science. Justifiably or not,
it is assumed that American citizens by the time they reach adulthood are ac-
quainted with the basic facts concerning the governments under which they live
and work. It is the intention, therefore, to limit the following discussion as
much as possible to interlevel governmental relationships and trends that in-
fluence the public health program and have been influenced by it. The subject is
introduced with only a brief consideration of the various governmental structures.

Federal and State Government. Many, in [act probably an increasing num-
ber of people, think of the United States of America as one nation. As borne out
by its name, this is not absolutely correct. In a very real sense it consists at the
present time of fifty quite different countries each with its own history, law,
economy, and customs. Individually they are called states rather than countries or
nations. Some of them in the past actually spent part ol their existence as distinct
entities. For example, the present state of Vermont was an independent nation
between 1771 and 1791. The eastern part of the present state of Tennessee was
a separate country, Franklin, between 1784 and 1789. Perhaps best known ol all
is the republic of Texas which from 1836 to 1854 had its own national govern-
ment and which exchanged diplomats with the government ol the United States.

It often is forgotten that it was not until the American Revolution was almost
won that the original thirteen colonies began to think seriously about possible
permanent union, and that during the formative period a considerable number
of influential people insisted that each colony should become a distinct and
separate nation similar to the situation on the European continent. In fact sev-
eral of the colonies had plans for transplanting members ol European royal
families in order to form the nuclei of American royal ruling classes. Ultimately
the Continental Congress solved the problem by settling upon the idea of a union
of states. The decision, incidentally, was made by a rather narrow margin ol
votes.

In so joining themselves into a union, the colonies, which were now called
states, by no means surrendered their individual rights and prerogatives, ol which

159
160 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
they were already intensely jealous and proud. Instead they took the attitude that
most governmental problems would continue to be best met and solved on a
separate and independent basis, only a relatively few matters of common interest
and concern requiring reference to the joint over-all Federal government es-
tablished by their union.

They recognized for example that “in union there is strength,’
had mutual interests in matters of defense against aggression, and that there
should therefore be established a single national army and navy made up ol men
from all of the states. Each state, however, organized and still maintains its own
militia. The expediency ol a single agency to deal with matters ol international
diplomacy was realized, and a Federal Department of State was organized. In
order to finance these activities ol common concern, a national treasury and

’

that they

taxing system were instituted. Subsequently, as additional common problems
developed or were recognized, appropriate Federal agencies were established.

From the beginning, the states were explicit with regard to functions and
authorities delegated to the Federal government, specifying them, fortunately in
relatively broad terms, in the Federal Constitution and its subsequent amend-
ments. All other activities and powers not so specified were retained by the states.
This influenced the development ol public health in America to a considerable
degree since no specific mention is made of public health in the Constitution or
its amendments. Accordingly, until recently, the Federal government has had
no authority to establish a Federal health department. Furthermore it was in no
way mandatory that the individual states establish state public health agencies
unless they wished of their own accord to do so. However, a time was reached
when each state recognized such action as logical and necessary.

The states comprising the United States of America [unction individually
as democratic forms of government with the people directly electing their ofh-
cials. The Federal government, however, is a republic since the citizens them-
selves do not vote lor national ofhcers or decide national issues. Instead, this
is done by individuals who are elected by the voters of each state and sent to
the seat ol the national government as their representatives. Actually, therelore,
national policy may be decided and affected by a relatively small group ol people.
Considering the entire population of the nation, only those who are citizens
have the right to vote. Age eliminates a large percentage of these. In states re-
quiring a poll tax, economic status eliminates not a few more. Rigid requirements
with regard to residence in the state or election district eliminate others. Espe-
cially unfortunate is the failure of many to vote because ol registration require-
ments, procrastination, or sheer indifference. As a result, the choice of repre-
sentatives to the national government as well as to the state and local govern-
ments is very olten determined by the votes ol a relatively small proportion ol the
population.

Winston Churchill once made a striking speech in which he dwelt upon
the fact that the democratic countries had extended the electorate so far beyond
the limits of those politically interested that they were increasingly becoming
governments of minorities. He pointed out that those who are entitled to vote
are in a very large measure not interested in doing so, and that as the questions
GOVERNMENTAL ASPECTS 101

with which government has to deal become increasingly of a complex economic,
industrial, and financial nature, the proportion of the electorate competent to
give close attention to understanding and to express a reasoned conviction will
not grow much larger. Unquestionably a large number, if not the majority of the
people of America, are allowing decisions to be made for them by minority
pressure groups and lobbies. What [ault exists is not logically inherent in the
form ol the government but rather in the human [railties ol lassitude and
procrastination.

Although government in America may be considered as operating on three
different levels, i.e., national, state, and local, considerable similarity exists be-
tween the structures that have developed on each level. Very early in our his-
tory an ingenious system of checks and balances was devised and became an im-
portant part ol our political tradition. Typically on all levels, functions of gov-
ernment are lound distributed among three branches, the executive or adminis-
trative, the legislative or policy making, and the judicial or review and control.
On the national and, with one exception, on the state level, in order to give
consideration to population as well as area, legislatures are divided into two
chambers, a senate and a house ol representatives.

Local Government. Local government in the United States is effected by
means ol a vast multiude ol official units and areas of many types. So confusing
is the situation that no one knows with exactness the total number ol separate
units of local government. According to the latest data, there are 102,282 units
ol government in the United States. Included are 3,050 counties, 17,183 cities,
17,198 townships, 50,446 school districts, and 14,405 special districts." These
units of government possess the right to pass their own ordinances. Special dis-
tricts deal with schools, fire control, water, lighting, levees, flood control, drainage,
irrigation, bridges, sanitation, and health. The total cost ol operating these many
units ol local government is enormous. In 1957 it amounted to $47,626,000,000.
The sources of these funds were as follows:

State government $16,916,000,000
Local government $30,710,000,000

Of the cost ol local government, $5,463,000,000 were expended by counties,
$12,626,000,000 by municipalities, $1,180,000,000 by townships, $9,615,000,000 by
school districts, and $1,825,000,000 by special districts. The magnitude of these
figures is best brought out by the fact that the total when prorated is equivalent to
$237 per year for every member of the population.?

Municipal Government. For practical reasons, as well as for convenience,
local government is best considered in two categories, urban or municipal and
rural or county and township. A municipality may be defined as an aggregation
ol people living and working under circumstances of close proximity and con-
siderable social and economic interdependence, the boundaries of the munici-
pality being relatively narrow, legally defined and incorported. It represents a
condition of urbanity. By the year 1958, 64 per cent of the population of the
United States lived and worked in such areas, the criterion, as defined by
the Bureau of the Census, being incorporated places with a population of over
1602 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
2,500 people. Considering that the state is sovereign and that in the last analysis
local areas as well as the Federal government derive their powers from state
governments, it is evident that municipalities in the legal and governmental sense
are creatures of the state.

As an increasing number of people settle and multiply in a particular
locality, determined perhaps by a crossing of highways and railroads, a confluence
of streams, or proximity to natural resources, it is ultimately realized that pe-
culiarly acute problems exist locally, quite different from those of the state as a
whole. The need for paved streets and sidewalks soon becomes apparent and
with it, because of the increased possibility of crime, the need for street lighting.
Homes and other buildings take up most of the land area, making individual
water supplies and excreta disposal systems impractical and dangerous. The
hazard of fire is greatly increased and the potential significance of a case ol
communicable illness greatly magnified. These and other problems eventually
cause the residents to approach the state government with a request for certain
special privileges necessitating a certain degree of self-government. This is ac-
complished when the state grants a charter permitting the local area, now strictly
defined, to be incorporated as a self-governing and self-serving unit.

The charter itsell may originate in one ol three ways. A special act of the
state legislature may grant the charter. On the other hand under the home rule
plan, the city is considered the best judge ol its needs and a charter convention is
called by the voters. A charter is proposed and developed by the convention and
submitted as a referendum to the voters, a majority making it effective after ap-
proval by the state. The optional charter plan is an intermediate approach
wherein the state government draws up several different charters, and the munici-
pality then chooses the one most suited to its needs and wishes.

Before incorporation, an area is part of the sovereign state and shares in
the benefits and legal exemptions of its sovereignty. On receiving a charter, the
municipality becomes a corporation and as such can have a corporate name and
seal, can own and convey real and personal property, can raise monies by taxa-
tion, by borrowing or by issuing bonds, can make and enforce its own local
laws, and can sue or be sued under its corporate name. It differs, however, [rom
other corporations in that it has two kinds of functions. There are on the one
hand certain public functions in which the municipality acts for the sovereign
state and concerning which it cannot be sued without its consent. In most states
fire protection, police protection, and public health activities are considered
public functions. There are, on the other hand, many activities in which a
municipality is engaged primarily or exclusively for its own interests. Examples
of these are the construction and maintenance of pavements, municipally owned
and operated street railways, water, gas and electricity plants. In most instances
a municipality is considered subject to suit concerning these.

The distinctions between private and public functions are varied. For ex-
ample, while county highways are considered public, city streets are usually
considered a private function. The construction of sewers is usually considered
a public function, in contrast to their maintenance, which is usually considered
a private function. Very often the deciding factor is whether or not the indi-
GOVERNMENTAL ASPECTS 103

 

vidual citizen makes a payment for maintenance such as sewers or for a com-
modity such as water. The trend has been to make the municipality liable in
case of doubt.

Since the state government creates the municipality, it may also change or
abolish it. Certain legal restrictions are involved, however, the complexity and
significance ol which are well illustrated by the case of Mobile v. Watson.? The
city of Mobile, Alabama, was incorporated by the grant of a charter from the
state of Alabama. Subsequently the city became financially bankrupt. Chartered
private corporations are protected by the Federal Constitution against subsequent
alteration by a state, but a city charter, as has been pointed out, forms a public
corporation which may be abolished or changed by the state. Accordingly the
legislature of the state of Alabama rescinded the city charter of Mobile, substi-
tuted the name “Port of Mobile,” and then announced that claims against the
former incorporated city were not collectable since the corporation no longer
existed. The United States Supreme Court considered otherwise, however, and
ruled that although the city was a state-created corporation with public func-
tions, it also carried out private functions concerning which it could be sued and
held liable, and that although the state had a right to abolish the city corpora-
tion, such an act in no way relieved the citizens of their debts.

Considering cities as the most prominent example of incorporated areas,
their government may take one of several forms. The oldest type is what
has been termed the “weak mayor-council” plan. In this plan the citizens elect
by popular vote a mayor and usually a bicameral council of considerable size
consisting of councilmen at large plus a number of aldermen from each ward or
district of the city. The latter, because of the customary partisanship, soon be-
came designated as ward bosses. The mayor in such instances often holds what
might be considered an honorary social office, serving largely as the officiating
representative of the community and very little else. Although the oldest type
ol municipal government in America, because it has been [raught with inefficiency
and chicanery it is rapidly becoming outmoded, and more efficient plans are being
substituted for it. The “strong mayor” plan of local government is an adaptation
ol the older form. Here the council is reduced to a single chamber, usually with
[ar fewer members, all elected at large. The mayor is still elected for a limited
term but is given greater executive powers and prerogatives, including increased
power of appointment of departmental heads and other officials and greater
control over the budget. In practically all instances the council may reduce
budget items proposed by the major but may not add or increase items.

Recent years have seen the development of two new forms of city govern-
ment attempting to approach the management of civic affairs on a more busi-
nesslike basis. The first of these, the commission plan, came about as a result of
the devastating earthquake and flood of 1900 at Galveston, Texas. The corrupt
and inefficient weak mayor-council government found itself completely incapable
of coping with the emergency situation and literally collapsed. Through the
efforts of prominent citizens, a substitute form of government was established
on the basis of the essential services and activities required by the community.
Civic affairs were organized in a small number of departments, such as public
104 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

safety, public works, public health, finance, and a legal department. Under this
plan a functional commissioner is elected by popular vote for each department.
In lieu of a mayor and council, the commissioners run the city government some-
what like the board ol directors of a business corporation. Although numerous
communities adopted this form ol government, experience subsequently indicated
that while theoretically an excellent plan, it had practical disadvantages. In
many instances, lor example, agreement among the several commissioners be-
came impossible, and often departmental cliques came into existence, jeopardiz-
ing the effectiveness ol the total government. In other instances the commissioners
in charge ol public finance or of the legal department [ound themselves in a
position to thwart or control the activities and plans of the other departments.
As a result, the past three decades have seen a gradual rejection of the com-
mission plan of government.

Interestingly enough, the fourth or city manager type of government de-
veloped as an aftermath of another catastrophic flood, this time in Dayton, Ohio,
in 1913. The experience of Galveston was duplicated and in the place of the in-
effective weak mayor-council system, there was substituted a plan whereby only
a relatively small council was elected. This council of perhaps twenty to twenty-
five laymen has no administrative duties, technical qualifications being therefore
unnecessary. Their meetings usually require little time, their chief functions being
the determination of general community policies and the employment for a
salary of a city manager whose tenure usually depends on satisfactory service.
Again this is an attempt to operate a city government like a business corporation
with the employed city manager acting in an administrative capacity similar to
that of the general manager ol a private corporation. In many ways his position
reminds one of the German burgomaster. Like the commission plan of govern-
ment, the use of this plan has been confined almost entirely to small and inter-
mediate-sized cities. The extent of its adoption, however, has continued to in-
crease, and already some counties, particularly on the West Coast, have adopted
it.

County Government. The American county is the one almost universal unit
of American government.* County government has been called by some writers
“The Dark Continent of American Politics.” To some it is anachronistic. How-
ever, counties are more or less convenient areas ol administration laid out by the
states for the decentralized local performance ol certain governmental [unctions,
regarded as primarily of state concern. Originally, the boundaries ol counties
were determined to a considerable extent in terms ol the distance a constituent
could ride on horseback or in a buggy from his home to the county seat and
back again within one day. While at the present time it is possible to traverse
several states in one day, these old established county boundaries are still jealously
adhered to.

The entire land area of the United States is divided into counties, 3,099 of
them, with spectacular variation in size and population. Considering area, they
vary from Arlington County, Virginia, with a mere twenty-five square miles, to the
20,000 square miles of San Bernardino County, California, which is larger than
the states of New Hampshire, Vermont, Massachusetts, Rhode Island, and Con-
SS - oo ] GOVERNMENTAL ASPECTS 105
necticut combined. In terms of population, at one end of the scale is Armstrong
County, South Dakota with only fifty-two people and at the other extreme Cook
County, llinois, bulging with 5 million. Several states, such as Georgia, Illinois,
Kentucky, Kansas, Missouri, North Carolina, and Virginia, have one hundred
or more active county governments, while the state of Texas possesses two hun-
dred fifty-four. Delaware has only three, and Rhode Island has five counties from
which all powers have been removed. In the other New England states, county
government is ol secondary importance. The five counties ol New York City
are relatively unimportant, having given way to the single city government. City
and county governments are merged in Baton Rouge, Denver, Philadelphia,
Boston, New Orleans, and San Francisco. This is also true in twenty-seven smaller
cities in Virginia. In South Dakota, five county areas are attached to other coun-
ties for governmental purposes. Alaska, one of the newer states, hopes to over-
come some of the organizational difhculties of the older states. By specific man-
date ol its constitution, at the present time there are no counties in Alaska.
When all ol these exceptions are deducted, 3,050 counties ol independent func-
tional significance remain. Of these, four fifths have no incorporated area of
10,000 or more people. It is substantially correct, therefore, to say that the typical
county is rural and that its government deals with the government of farmers.
Certain legal differences exist between rural and municipal governments. County
governments are regarded in most instances as quasi corporations. This term has
little definite meaning. It indicates, however, that while the county may for some
purposes have an independent existence, it is primarily an agent of the state
with no private functions. All of its [unctions are public in nature, having been
delegated to it by the sovereign state. Accordingly, the rules governing its negli-
gence or the torts of its officials are those that apply to the states rather than those
applying to a city government or to private corporations. A county, therefore,
cannot be sued in the absence of permission [rom the state. In recent years, how-
ever, there has developed a tendency to hold counties liable for contracts or neg-
ligence of their officials. At any time a state may extend the degree of county
liability by constitution or statute. It appears then that county administration is
handicapped by its legal relationships with the state. The flexibility which gen-
erally makes it possible for a city to frame a charter and determine its form of
government and its policies in line with its needs does not usually exist for
counties. Instead they must accept whatever pattern of government the state leg-
islature allows, often without regard for the limited financial resources of the
counties. As a result, larger counties often must operate through a governmental
structure which has long since been outgrown, while small counties are saddled
by law with a system they do not need and cannot afford.

Problems of rural areas are simpler than those of an urban area. The eco-
nomic and social life is geared primarily to agriculture. Life and behavior is more
uniform, with less demand for luxury items, although recent trends have been
effecting much change in this regard. Improved roads, the ubiquitous automobile,
more convenient shopping centers, and television and radio have tended to
make yesterdays luxuries commonplace in many rural areas. Except for the
southern states, in most although not all rural situations there are no complex
166 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

nationality or racial problems and the customs and inherited attitudes of thought
present less variation. This is not meant to imply that the rural population is
homogeneous. During the past few decades there occurred the widespread eco-
nomic depression of the 1930's, the World War II of the 1940's and their con-
comitant industrial, social and economic effects. These have brought about con-
siderable equalizing among the regions. Nevertheless, distinct and evident regional
differences still exist.

With a lesser density ol population than in cities, people living [urther apart
attend for the most part to their own aflairs and self-maintenance, with the de-
velopment of considerably less social [riction. They have little in the nature of
private local interests. Social and economic as well as governmental activities are
more in the nature of [ractions ol larger areas ol the state as a whole. For ex-
ample, while city streets exist primarily for the inhabitants of the city, roads in
rural areas are necessary for all travelers as well as [or those residing locally.
True, the difference is one of degree, but it is nevertheless so great as to have
received recognition in the courts.

Beyond the problems of the individual household and farm, the county seat
commands most of the attention of the rural population. To most, it represents
the prime social, recreational, educational, governmental, economic, and shopping
center. The last ol these is perhaps the most significant. Galpin,” in his studies
of life in rural Wisconsin, concluded: “It is dithcult, if not impossible, to avoid
the conclusion that the trade zone about one of these agricultural civic centers
forms the boundary ol an actual, if not legal, community, within which the ap-
parent entanglement of human life is resolved into a fairly unitary system of in-
terrelatedness. The fundamental community is a composite of many expanding
and contracting feature communities possessing the characteristic pulsating in-
stability of all real life.” * Beyond this, except in unusual circumstances, state and
national affairs are of decidedly secondary import except in so far as they affect
the county itself.

The results of these differences between rural and urban areas are reflected
in the form of local government. Rural governmental machinery is simpler. Fewer
officials, boards, and commissions are needed to enforce the simpler local regula-
tions, to carry on the limited administrative work, and to conduct the small num-
ber of social welfare activities. Incidentally, the officials, boards, and commis-
sions as do exist are usually subject to little or no supervision. Since counties
really require for the most part state functions on a smaller scale, much of the
administrative work is either performed or supervised by state officials. The in-
terest ol the state in local rural affairs differs from its interests in municipal al-
fairs. County boundaries are laid out by the state government with its own ad-
ministrative convenience in mind and without regard to the special interests,
wishes, or needs of any single area or group. The powers of local rural com-
munities likewise are delegated by the state as a parceling out of its own admin-

*Galpin, Charles J.: The Social Anatomy of an Agricultural Community, Research Bulletin
34, University of Wisconsin Agricultural Experiment Station, Madison, University of Wisconsin
Press.
GOVERNMENTAL ASPECTS 167
istrative functions and not, as in the case of an incorporated municipality, with
the idea of creating an independent political entity.

The functions of the county are, therefore, colored strictly by the circum-
stances of its origin. In the political field it conducts elections to provide the
basis for local representation in the state legislature. Its own legislative powers
are practically nonexistent except for a quite limited authority to enact certain
local ordinances. In the fields of administration and service, it serves as the basis
for the state financial levy, assessment, and collection, administers relief to the
poor and public welfare, directs many school affairs, constructs and maintains
roads and bridges, provides public health service, engages in licensing, the letting
of local contracts, the making of local appropriations, and the determination of
salaries of local officials. As will be brought out subsequently, many of these func-
tions are gradually being assumed by the state governments themselves. Reasons
for this include the increase in cost of road construction and the increasing pro-
fessionalization, expansion, and improvement in public health, public welfare,
and public school services. In terms of judicial functions, the county, through its
court, probates wills and registers deeds. It presents a convenient unit ol area
[or the local administration of the state law. As pointed out elsewhere the local
justice of the peace is actually the lowest rung on the state judicial ladder. Coun-
ties also serve as the territorial units for the establishment of courthouses, penal
institutions, and for the Federal post offices.

Perhaps the greatest ol all deterrents to good county administration is the
almost universal lack of centralized administration. In all but a few rare in-
stances, there is no chief executive to correspond with a mayor or a governor,
and the local supply ol individuals qualified to serve in the various political ca-
pacities is exceedingly limited. Thus Phillips® refers to it as the “no executive”
form of local government. As he points out:

There are, in general, two principal types of county governmental systems, but
modifications are so numerous and sometimes so extensive that generalization is
dangerous. The first . . . has a small board of from three to five commissioners or
supervisors, which has considerable administrative authority and limited legislative
or ordinance-making power. The second . . . has a relatively large board of from
fifteen to one hundred and fifty members, with authority somewhat similar to that of
smaller boards. The average size of the larger boards is approximately twenty-five
members.

The “no executive” type of local government is so called because the board of com-
missioners or supervisors must share administrative authority with a comparatively large
number of separately elected officers, such as the sheriff, coroner, treasurer, clerk, at-
torney, assessor, surveyor, recorder of deeds, registrar of wills, superintendent of schools,
and in a number of cases, auditors, and other officials. Since these officials are elected
and are thus directly responsible to the electorate, and since they derive their authority
from constitutional or statutory provisions, they are subject to very limited control,
if any at all, by the board of commissioners or supervisors.*

The voter, therefore, is faced with the demoralizing task of choosing from a
roster of miscellaneous public officials so lengthy that he can hardly know the

*Phillips, J. C.: State and Local Government in America, New York, 1954, American Book
Co., pp. 406-407.
ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
names ol all of them, much less their qualifications. The result is an authority and
responsibility so diffused and uncoordinated as to make efficient administration
difficult or impossible. To a very real degree an official may administer his office
simply within the limitations ol his own conscience, often with disastrous effects
for the public as a whole. This being the case, it is not surprising that partisan
politics, inefficiency, and corruption are so rampant in American county govern-
ment. All too olten, appreciable proportions of funds appropriated for public
benefits have found their way into private pockets rather than being used for the
intended purpose.

The basis of county government is a large number of individuals elected
Irom small subdivisions of the county, variously referred to as judicial districts,
magistratial districts, militia districts, townships, and hundreds. As might be ex-
pected, the majority of those elected are farmers with no legal training or back-
ground in government. When meeting together at the county seat they constitute
a body of very local governmental representatives referred to as the county board
ol supervisors (example, Michigan), the county board ol commissioners (ex-
ample, New Mexico), the county court (example, Tennessee), the police jury
(example, Louisiana), and other designations. Within the limitations imposed
by the state, they have the authority to levy and collect taxes and to borrow
money [or the construction and maintenance of county roads, bridges, a court-
house, a jail, and other public property. They have the responsibility of pro-
viding relief for the poor, the establishment and operation ol polling places and
canvassing of the returns. They appoint certain local officials, impanel juries,
and carry out numerous other miscellaneous activities. All local executive and
legislative functions are in the hands of the county boards, some of which exer-
cise a few judicial functions as well. Except for some counties in New Jersey which
have administrative supervisors, the county judge in Arkansas, the ordinary in
Georgia, and the few counties with qualified county managers or county admin-
istrators, notably in California, it cannot be said that the American county has
a chiel executive comparable in position to the mayor ol a municipality.

The types ol other elected county officials vary somewhat in different parts
of the country, but certain ones are found in practically all instances. The county
sheriff is elected to protect life, liberty, and property, and to carry out the judg-
ments of the court. He has the authority to appoint deputies as needed. The
office ol county coroner involves the performance ol autopsies and the holding
ol inquests over the bodies ol persons who have died suddenly or violently, with-
out medical attention, or under suspicious circumstances. A most important offi-
cial is the county clerk, whose [function it is to collect and safeguard public
records, including in many instances vital statistics, to issue licenses, to open
and adjourn court sessions, and to keep a record of their proceedings and the
proceedings of meetings of various county boards. If any elected county official
is necessary and worthy of his salt, it is the county clerk. In some places a separate
recorder of deeds is elected to keep a record of land titles.

A prosecuting attorney is usually elected to prepare evidence for the juries
and to prosecute accused persons on behalf ol the county. The county treasurer
has the responsibility for receiving, recording, and disbursing all funds expended
GOVERNMENTAL ASPECTS 169

 

 

by the county, usually regardless of their source. An assessor is necessary to list
taxable persons and property and to assess them at a fair evaluation. In a few
states a special tax collector is elected, and, in many, a county auditor to peri-
odically audit county funds and expenditures. In some states this latter function
is carried out by the county board itself or by its financial committee. The invita-
tion to fiscal folly involved in the election of an auditor or in the execution of
this important function by any group of elected officials should be obvious.
School boards are usually elected either at large or by district representation
separately from the rest of the county government. The superintendent of schools
is generally elected by popular vote although in some states he is appointed
either by state authorities or by the county school board. In not a few instances
he is the highest paid and most influential official in the county. Many miscellane-
ous officers may be elected because of provincial need or tradition. Among these
are county surveyors, fence viewers, engineers, road commissioners, and poor
commissioners.

Last but not least among the county officials is the county health ofhcer.
In most instances he is unique in not being locally elected. The tendency has
been to consider this position the most professional of all local public positions
and one that can be entrusted only to a specially trained and well-qualified
person. Frequently, local governments have experienced considerable difficulty
in filling this position and with increasing frequency have turned of necessity
to outside agencies such as state health departments, civil service commissions,
or schools of public health, for assistance. As a result of this and other factors,
there has developed a tendency for many local health officers to feel more respon-
sible to the state than to the county government which they serve.

Township Government. Discussion of local government would be incom-
plete without mention of township government as found in the New England
states. This last remaining epitome of democracy functions around the town
meeting, which consists of all the citizens entitled to vote.* Here the citizens
themselves constitute the true local legislative agent. The nominal administra-
tive agents are the selectmen or the township board of supervisors chosen by
popular vote at the town meeting. In some places where no regular township
meeting is held they serve also as the legislative agent. The functions and activi-
ties of the township and its officers are quite similar to those carried out else-
where by county governments. Within the townships are found the governments
of smaller urban groups such as villages and boroughs. These are usually organ-
ized by means of groups of elected representatives variously termed councils,
burgesses, and boards which serve as legislative agents. In addition, they usually
elect a single executive who may be designated as mayor, president, burgess, super-
intendent, or chairman to serve as the administrative agent. The functions of
these governments are those of an embryonic urban community.

From the foregoing it is evident that many reforms are indicated in local
government, especially on the county level. One of the most pressing is the need
for consolidation. It is inevitable that this should come about eventually and

*For a brief descriptive and pictorial presentation see New England Town Meeting by John
Gould.’
170 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
symptoms are already evident in certain fields of public service and in certain
parts of the country. The provision of public health services in many places on a
multicounty basis furnishes one example of this trend. Another is the growing
interest in the analysis and attack of social problems on a regional basis.!® The
leading role in this latter movement has been taken by the Committee on South-
ern Regional Studies and Education with permanent headquarters at the Uni-
versity of North Carolina. Strow!! has defined the region as “a large area with
natural boundaries wherein there are many resemblances among the inhabitants
and their culture.” Health regions may be considered to be “major areas with
distinct health conditions identifiable with the arcal limits and caused by the
natural and human factors operating within the natural boundaries.” The re-
gional approach may be of considerable value in the definition and location of
public health problems, in revealing causal factors, in creating public conscious-
ness concerning them, and in arriving at methods for their solution.

Progress along these lines is necessarily slow. Consolidation of local govern-
mental units presents a most difhcult political task with many [actions ever alert
to oppose it. County voters and county lines as they now exist are important to
office holders, local merchants and bankers, political party workers, many prop-
erty owners and local newspapers, and for patronage purposes are important to
local, state, and federal political factions. Other indicated reforms include the
provision for county home rule, the use of the short ballot, smaller county boards
ol supervisors elected by proportionate representation, more widespread adoption
of the county manager or administrator idea, the transfer ol township functions to
the county, the consolidation of some city and county governments, the establish-
ment of sound accounting and budgetary systems with greater supervision and
control by the states, the adoption ofl civil service or merit systems by counties,
and the establishment and enforcement of state and national standards of gov-
ernmental conduct.

Revenues and Expenditures on Each Level of Government. The relative
needs of the different levels of government lor funds vary considerably. In 1957,
for example, the Federal government was responsible [or $30,993,000,000 or about
two fifths ol the $78,619,000,000 for general government expenditures, the forty-
eight states accounted for $16,916,000,000, and the approximately 100,000 units
of local government expended $30,710,000,000.122 These figures alone do not pre-
sent the complete picture since approximately one third of the Federal amount
and about one hall of the state amount was reallocated for use by local govern-
ments. Furthermore, the total sum spent by local governments is found to be
concentrated to a considerable degree in certain small sections of the total area
ol the nation. Thus the 482 cities with populations of more than 25,000 ac-
counted for 84 per cent of all city expenditures, the remainder being distributed
among 16,701 small cities. School districts represented over two thirds of the total
number of governmental units but accounted for only one fourth of all local
expenditure. The 17,198 townships were responsible for only 5 per cent of local
expenditure and the bulk of this was spent by urbanized townships. Much of the
expenditure by the 3,050 counties and 14,405 special districts was concentrated
in a small minority of large units. About 70 per cent of the total amount of
GOVERNMENTAL ASPECTS [71

 

money expended by government therefore involved the Federal and state govern-
ments and the larger part of the remaining 30 per cent was accounted for by a
few hundred local units of government. In other words, trends in public ex-
penditures are determined chiefly by a small minority of large units.*

The amounts of money required are influenced chiefly by two somewhat
related trends in public administration: first, the changing relationships among
and emphases placed upon the different levels of government as discussed sub-
sequently; and, second, the greatly increased demands by the public for more
and new types of service. Dewhurst'? pictures the growth of public service by
comparing government expenditures in 1913 a pre-World War 1 year, 1941 the
last pre-World War II year and 1952 a post-World War II year. In summary, he
found a ninefold increase in total public expenditures during the twenty-eight
years between 1913 and 1941, and a fourfold increase in the years between 1941
and 1952. These increases are broken down into constituent categories in Table 20.

Table 20. Increases in All Governmental Expenditures, 1913, 1941, and 1952

Public-to-Private Cash Transfers
Interest on Debt

|
Item | 1913 1941 1952
| |
Pay rolls | $1,500,000,000 | $7,400,000,000 | $29,800,000,000
Other Current Operations | 391,000,000 9,000,000,000 26,300,000,000
Capital Outlays | 722,000,000 6,200,000,000 24,900,000,000
|

185,000,000 2,500,000,000 13,900,000,000

6,600,000,000

| |
Co

The bulk of the $98,702,000,000 increase during these four decades is ac-
counted for by an increase ol $67,924,000,000 in general government expend-
itures, with government utilities and other similar enterprises accounting for the
remainder. Public-to-private cash transfers refer to public assistance, veterans’
pensions, old age and unemployment benefits, and public employee pensions.

In order to meet these increasing fiscal demands, units of government on all
levels are engaged in a constant search and struggle among themselves for addi-

tional sources of revenue. Each unit of government, maintaining its own taxa-
tion system, finds itsell increasingly in conflict with other units of government.
During 1933, for example, over 800 cases ol tax conflicts occurred between the
Federal and state governments, the number increasing each year.

In the early days of our history the most lucrative, stable, and accessible form
ol taxation was on general property. Since originally most governmental func-
tions and services took place on the local level, and because of early fears of
federalism, the general property tax was reserved largely for use by local gov-
ernments. As a result, even today the general property tax represents the major
source of income for local governments, accounting in 1956 for about 50 per
cent of the total revenue obtained by local governments. In terms ol percentage

 

 

*See America’s Needs and Resources by Dewhurst and associates.’
172 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

of total tax revenues the proportion was about 90 per cent!? (Fig. 1). In earlier
times, the states also depended to a considerable degree on the general property
tax, but, as newer and more lucrative sources of funds appeared, its relative im-
portance decreased on the state level so that by 1956 it accounted for only 3.5
per cent of all state revenues. The Federal government depends on it not at all.

Billions of Dollars
351

  

BE
R505]

 
  
  

        

30

 

Source: Bureau of the Census

25

20

 

 

 
  

     
   
       

 

 

 

 

 

 

 

 

  

 

 

 

5%
5
15 355
CXL
200
S0RHXXRS
2 N
10
5
0 i
Individ- Corpor - Sales, Property Death & License
ual ation Gross Gifts Permit
Income Income Receipts,
Customs

Fig. I. Governmental tax revenue by source and level of government, 1956.

With the great changes that occurred in our social structure and means of
earning a living, many new taxable items and activities appeared. The shift to
salaried income by a large proportion of the nation’s wage carners made a tax
on earned income practical. This soon became a source of considerable revenue
for the Federal and for some state governments. With the increased use of gaso-
line, tobacco, and liquor, easily applied at-the-source taxes on these items were
added by the Federal and to a lesser degree by state governments. In addition, the
Federal government found it convenient and productive to apply estate and
gilt taxes, customs, duties, payroll taxes, various excise taxes, and numerous other
means of income. Beyond the general property tax, cities and counties have access
locally only to fees [rom licenses, permits, assessments, fines and forfeitures, and
institutional funds and earnings. The tendency for a considerable period has
been for local governments, both city and county, to give way to the state and
Federal governments when new revenue sources are discovered or in cases of tax

conflict.
GOVERNMENTAL ASPECTS [73

This dilemma in which local governments now find themselves would not
be so acute if the general property tax had remained as useful as it once had
been. Unfortunately, however, this tax has become increasingly difficult to ad-
minister, has been repeatedly subject to personal and political manipulation, and
even if correctly applied may sometimes jeopardize individual property owners
upon whom it is levied. To assess the value of personal property honestly and
accurately is in itself a difficult and costly procedure. Added to this is the fact
that most tax assessors are local individuals who by virtue of their local election
are subject to feelings of indebtedness and favoritism. It is not surprising that the
administration of the general property tax has not only been lax and inefficient
but has often been used as a political tool.

Since ordinarily the need for revenue increases during periods of economic
stress, local governments are faced with the dilemma of having to increase as-
sessment, taxes, and collections on essentially the same people who, because of
general economic stress, need the most help. There occurs, therefore, the very
real possibility of taking from the right hand to pay the left and the possibility
that because of decreased ability to meet tax demands a considerable share of
private property will be turned over to government itsell by default, thereby
eliminating it as a source of tax revenue. As a result, when local tax monies are
most needed, collection becomes more difficult. A pointed example of this was
the state of Georgia where in 1936 over one third of county taxes were uncollecta-
able. That this problem was peculiar neither to rural areas nor to the econom-
ically unfavored southeastern states is shown in Table 21, which presents the
extent of tax delinquency in the 150 cities of over 500,000 population from 1930
to 1944.15

Table 21. Trend of Tax Delinquency 1930-1944,
Median Year-End Delinquency, 150 Cities Over 50,000 Population

Years | Per Cent Years | Per Cent

1930 10.15 | 1938 10.70
1931 14.60 1939 9.25
1932 | 19.95 1940 | 8.70
1933 26.35 1941 6.80
1934 23.05 | 1042 | 6.00
1935 | 18.00 1943 | 4.70
1936 | 13.90 | 1044 3.90
1937 |

11.30 | |

Another factor to be considered with regard to the general property tax is
that much property is exempt [rom taxes. Using Georgia again as an example,
the following are not subject to taxation: all public property, places of religious
worship and burial, charitable institutions, educational institutions, all funds
or property held or used as endowment by such institutions, the real and personal
174 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
estate of any public library and of any literary association connected with such
library, all books, philosophical apparatus, paintings and statuary of any com-
pany and association kept in a public hall and not held as merchandise or for sale
or gain, all farm products grown in the state and remaining in the hands of the
producer during the year following their production, and personal property up
to the value of $300 and of a $2,000 homestead upon application of the taxpayer.
In Georgia these account for 23 per cent of all real and personal property.'S As
a result, the bulk of real property tax is paid by farmers and small home owners
who as individuals are not organized as are other groups and are therefore un-
able to exert influence on tax determination bodies.

40.4

 

10 | i NN Local

State

Federal

8 I Source: Burcau of the Census \

NN

 

 

 

BILLIONS OF DOLLARS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 2. Governmental expenditures by function and by level of government, 1956.

The growing public demand [or governmental services and the resulting
increase in expenditures were previously referred to. A cursory study over a
period of years of itemized expenditures for various specific activities makes evi-
dent the fact that the greatest increases have occurred in relation to public serv-
ice and construction for public use. Looming large among the increased items
are those related to social security, including the prevention of illness and the
promotion of health, insurance against unemployment and illness, and other
similar social prophylactic measures. As a matter of fact, merely over the four-
GOVERNMENTAL ASPECTS [175

teen year period, 1941 to 1956, total expenditures on all levels of government
for health, hospitals, and sanitation multipled almost sevenfold, from $873,000,000
to $5,065,000,000. By now, health expenditures represent a significant item of
public expenditure. (Fig. 2.)

In order to overcome the inadequacies of state and local tax systems it has
been necessary to resort increasingly to intergovernmental transfers in the form
of grants-in-aid, shared revenues, payments for services, and other types of trans-
fers. Thus in 1957 not only was a total of $3,843,000,000 transferred from the
Federal to the state governments, but additional $428,000,000 was transferred by
the Federal government directly to local governments. In addition local govern-
ments received $7,179,000,000 [rom state governments. Health, hospitals, and
sanitation represented fields in connection with which significant amounts were
transferred: $109,000,000 Federal to state, $2,000,000 Federal to local, and
$253,000,000 state to local. The total expenditure for health, hospitals, and sani-
tation after intergovernmental transfers amounted to $4,169,000,000 of which
$1,032,000,000 was spent by Federal agencies, $1,652,000,000 by state govern-
ments, and the remaining $1,485,000,000 by local units of government.?17

As further illustration, Table 22 presents the sources of funds for the public
health budgets in certain states. It emphasizes the dependence upon outside funds
not only of local health departments but ol state health departments as well.
It brings out also the considerable variation in this dependence, ranging in this
sample from 20 to 50 per cent for the state health departments and from 9 to 56
per cent for local health departments. Imbalance in still another direction may be
pointed out by the [act that the funds of local health departments in Florida
are 29 per cent state and 3 per cent Federal in origin, in contrast to Idaho where
the corresponding figures are 1 per cent from the state and 37 per cent from the
Federal government.

Interlevel Relationships and Trends. Many people today are accustomed to
regard the Federal government as the ultimate source of power and money. While
they do so with increasing justification, this was by no means always the case.
The original concept of state supremacy has been briefly discussed. Suffice it to say
that in spite of recent trends the principle is not yet dead and it is doubtful that
its complete demise is inevitable. For a considerable period of our history the
Federal government was a somewhat distant or mythical creature to the average
citizen. This early relationship has been vividly described by Brogan's:

It should be remembered that it was quite casy for the settler in the Middle West
to have no dealings at all with the government of the United States. He paid no direct
taxes; he very often wrote no letters and received none, for the good reason that he
and his friends could not write. Yet the only ubiquitous federal officials and federal
service were the Postmasters and the Post Office. There were no soldiers except in the
Indian country; there were federal courts doing comparatively little buisness. True, the
new union had built the National Road, down which creaked the Conestoga wagons with
their cargo of immigrants’ chattels. It fought the Indians from time to time and it had
at its disposal vast areas of public lands to be sold on easy terms and finally given away
to settlers. But no government that had any claim to be a government at all has had
less direct power over the people it ruled. Politics was bound, in these conditions, to
be rhetorical, moralizing, emotionally diverting, either a form of sport or a form of
Table 22. Public Health Budgets in Certain States, 1958-1959
(Source of Funds by Per Cent)

 

921

 

 

 

 

 

|
State Health Department Local Health Department™® Totalt
State |
|
State Local | Private | Federal Total | State | Local | priate Feder] Total | State | Local Private Federal Total
| | | |
— —
Florida 798 00 0.1 | 20010 100 | 286 | 68.3 0.0 | 50 100 | 53.0 35.8 00 | 11.2 | 100
Idaho 61.1 54 1.4 | 32.1 | 100 | 1.0 61.8 0.0 37.2 C100 | 40.2 25.0 09 33.9 | 100
Kansas 49.6 35 149 32.0 100 157 791 00 52 100 339 385 | 8.0 19.6 100
Louisiana 75.6 00 0.7 L237 0 100 | 18.2 | 70.3 0.0 | 11.5 100 | 45.1 | 37.4 0.3 17.2 | 100
Michigan 79.6 1 0.9 | 0.6 | 18.9 | 100 | 3.41 90.6 | 0.3 | 5.7 | 100 | 26.6 63.3 04 | 9.7 100
Missouri 61.9 | 9.8 4.6 23.7 100 9.3 | 80.6 2.0 | 81 100 | 26.7 | 57.1 2.9 | 13.3 | 100
South Carolina 55.4 © 0.0 | 0.0 | 44.6 100 | 44.9 | 44.0 0.0 11.1 | 100 50.1 | 22.1 | 0.0 | 27.8 | 100
West Virginia 50.2 | 00 | 00 | 49.8 100 | 12.6 | 79.4 | 1.8 | 6.2 100 | 27.1 | 48.8 | 1.1 23.0 100
| | | | |

 

*Includes state health districts.
tExcludes tuberculosis hospitalization and general hospitalization.

HLTV3IH O1T718Nd NI SNOILVYH3IAISNOD IAILVHELSININGY

 
GOVERNMENTAL ASPECTS 177

religion. The political barbecue, the joint debates between great political leaders were
secular equivalents of the camp meeting and the hell-fire sermon. *

Even the inhabitants of the older seaboard states shared this relationship. As
Brogan continues:

Few things, on consideration, prove less surprising than the evaporation of federal
authority over the South once secession was adopted. Almost the only federal institution
that meant anything to the common man was the Post Officc—and by a statesmanlike
turning of the blind eye, the new Southern Confederacy continued to allow the federal
government to deliver the mail even after the seceding states had formally broken with
Union.

As time passed, with increasing urbanization, mechanization, travel, indus-
trialization, and interstate and international problems, the national government
came more and more into focus in the citizens’ eyes. It appears that at the same
time there began to develop a blurring of the image of local and particularly
of state government. There was a period when local governments were in a very
real sense self-sufficient, but gradually as the demands made upon them increased
they looked more [requently to the state governments lor assistance. Up to a
point these appeals for help were within the financial ability ol the states but
gradually they too became inadequate to meet many of the newer, more complex,
and more expensive problems. According to White!?:

The states as instruments of progress are definitely losing ground. Their leader-
ship, with rare exceptions, is mediocre; their administrative organization, again with
occasional exception, is inadequate . . . . It seems possible indeed that the future
structure of the American administrative system will rest primarily on the national

government and the cities, at least so far as the urban population (now approaching
60 per cent) is concerned. f

White points out that as early as 1918 Charles E. Merriman suggested:

Those interested in preserving the balance of powers between the national and
local governments might find the urban community a more effective counter weight

. than the feebly struggling states . . . A city would not be obliged to climb far to
go beyond a state. Already there are seventeen cities of a population over 500,000;
nine states with less population than that, and if economic resources and cultural
prestige are added to numbers, the contrast is more striking.i

Centralization. Originally the powers of the Federal government were
limited quite strictly to affairs of interstate and international concern. So intense
was the desire to restrict the scope ol these powers that they were referred to
explicitly in the Constitution and its subsequent Amendments. Innumerable
aspects of our social, scientific, industrial, and political development have led
in a direction that makes an increasing degree of centralization necessary, if not
also desirable, for survival. To allow this change and still maintain the basic
principles of our form of government presents a difficult problem indeed.

*Brogan, D. W.: The American Character, New York, 1944, Alfred A. Knopf, p. 15.

Brogan, D. W.: The American Character, New York, 1944, Alfred A. Knopf, p. 17.

tWhite, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co., p. 183.
178 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

In order to accomplish both purposes, Federal agencies in recent years, with
the tacit assent of the states, have increasingly resorted to indirect but consti-
tutionally permissible techniques resulting in increased centralization of power
in state governments themselves and more significantly in Federal agencies. This
movement received greater acceleration during the 1930s when the widespread
economic depression dealt a devastating blow to local and, to a great extent, to
state finances, rendering them incapable of meeting the demands placed upon
them. A procession of local governments, having fruitlessly appealed to their state
capitals for assistance, turned to Washington as the only source of relief. In the
light of the underlying social and economic causes, these trends toward centraliza-
tion are certain to continue and increase.

There are many methods short of total assumption ol power and [unction
that may be resorted to in order to achieve a practical measure ol centralization.
Perhaps the simplest is the offering of advice and information by a Federal agency
to the states or by the states to the local governments. This is so common in the
field of public health as to have become one of the prime activities of state and
Federal health agencies. It takes but a short step to move from the transmission of
printed advice and information to occasional visits of state and Federal con-
sultants followed by the loaning of personnel to serve as resident consultants,
especially in the face of local shortages in personnel. Increasingly, officers of
Federal agencies, originally intended as consultants, are found assigned on a
semipermanent basis to serve as directors of divisions ol a state health depart
ment. Field technical units, developed by state health departments for the
purpose of assisting the local units, in many instances assume the position of
supervising and even determining the programs ol local health departments.
Thus we see activities designed [or the purpose of rendering advice and informa-
tion develop into programs of cooperative or outright centralized administration.
A variation is a program of inspection and advice, olten without authority, to
bring about compliance with recommendations made. The inspecting and advis-
ing officials, for example, may merely report their findings to the central authori-
ties who may then promote additional legislation, often giving them increased
supervisory powers. This has occurred, for example, in the matters of hospital
construction and inspection of sanitary installations.

The requirement of periodic fiscal and service reports may appear innocuous
on the surface and is certainly justifiable in order to obtain and share informa-
tion concerning the general welfare. However, even this may have an indirect
centralizing influence of considerable impact. Theoretically a state or local
health department has the right to organize its records and reports any way it
sees fit to serve its purposes. However, on obtaining the right to require certain
reports, the next step is to standardize them. Beyond this, in more than one in-
stance, the requiring of a certain type of report has resulted in an actual change
in the local program itself, the local personnel following the path of least re-
sistance. This has occurred in varying degrees as a result of requirements for birth
and death records, reports of communicable disease, and the standardized fiscal
reports of health departments to Federal health agencies. An accelerating tech-
nique that may be employed is to give the local official a nominal appointment
} GOVERNMENTAL ASPECTS 179

as the local representative of state or Federal agency. Thus, we find most local
health officers with appointments as collaborating epidemiologists of the United
States Public Health Service.

In some areas local activities are subject to direct supervision and review
by the higher government. For example, local assessments often must be re-
viewed and approved by a state board ol equalization or by state tax commis-
sioners. Prior premission may be required and is especially effective when the
higher level of government participates in financing. It is rapidly becoming
accepted practice to require that plans for city, county, and state hospitals be
approved by state boards of health and national health agencies before the letting
of contracts is allowed.

Of a similar nature are approval requirements for the appointment and
removal of local officers. While in most states it is theoretically the prerogative
of local governments to select their own health officer, in practice this is often
not followed for various reasons discussed elsewhere. Not only is approval by
the state health officer usually required, but often selection is limited to lists pre-
pared by the state health department. In some states local health officers are ap-
pointed and removed directly by the state board of health. In Ohio, employees
ol health districts are appointed from state civil service lists and, il no eligible
individuals are available, from the register of local commissions. The require-
ment ol prior permission is sometimes rendered unnecessary by the determina-
tion of standards by a state or Federal agency.

The extent to which the average county health officer is affected by these
influences may be pictured somewhat as follows: In the first instance, he may be
recruited by and trained under the auspices of the state health department, using
Federal funds. His appointment, il not made directly by the state health officer,
will probably require his approval. Monthly reports of his activities and those of
his staff will have to be made to the state health department on standard forms
and a record of all work kept in a form book prescribed by the latter agency. By
virtue of his frequent designation as registrar he will have to report births and
deaths to the state health department on forms, this time prescribed by the Na-
tional Office ol Vital Statistics. Since in most instances he is appointed a collabo-
rating epidemiologist, it becomes necessary to send weekly reports of communi-
cable diseases to the United States Public Health Service as well as to the state
health department. His maternal and child health program may necessitate op-
eration, inspection, and approval of clinics and hospitalization facilities, using
standards developed and required by the Children’s Bureau which will also ask
for reports on standard forms. Arrangement for the use of x-ray equipment and
for hospitalization of persons with tuberculosis will in most instances be made
by him with the state agency. Finally, he will probably find it convenient if not
necessary to obtain education materials, biologics, and even office forms and
supplies through the state health department.

“While all this may appear on the surface to result in an effective emascula-
tion of the position of the local health officer, to be fair and practical it should
be pointed out that all of these various relationships actually represent effective
resources to which he may turn for assistance in order to carry out a much more
180 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

effective and satisfying program that he otherwise could. Considering the limited
resources on a local level, one might with justification answer those who disclaim
any concurrent limitation of local autonomy with the saw, “You can’t have your
cake and eat it too.”

Details ol contracts and design ol hospitals and health centers have been
specified as conditions for approval of plans by state and Federal agencies in order
to obtain Federal funds. More and more types of licenses are being placed within
the jurisdiction of state health departments and through them the United States
Public Health Service and the Children’s Bureau. The wartime program for the
provision of Emergency Maternity and Infant Care administered by the Chil-
dren’s Bureau through the state health departments presented many examples of
the centralizing influence ol the right to determine standards. The central agency
may be vested with the right to issue general regulations that are binding on the
locality or orders that result in a single centralized authority. Both measures are
widely resorted to in public health work. Here the initiative passes from the local
to the central agency. While common within states, this type of control is rare
in the Federal-state relationship.

A more complete method ol centralization is the partial or total assumption
of function. In some states the state health department has direct control of local
water and sewage facilities. In some the department of agriculture has complete
responsibility for food inspection. In one state the department of conservation
has authority over hotels, resort areas, taverns, and other similar places including
their sanitation. Not infrequently clinics and even complete programs dealing
with tuberculosis, venereal and other diseases are maintained and operated di-
rectly by the state health department.

Grants-in-Aid. What many consider to be the most potent factor tending
toward centralization is found in use of the fiscal technique of grants-in-aid, sub-
ventions, or subsidies. These have been defined as “sums of money assigned by a
superior to an inferior governmental authority.”?* Grants-in-aid represent one
form of transfer of public funds for the purpose of equalizing revenue among the
several levels of government and among the states and their contained local areas.
They are intended to improve the quality and expand the quantity of govern-"
mental programs in less affluent areas by augmenting their revenue with legal
transfers ol funds from more wealthy regions. No reasonable person would sanc-
tion the continuance, for want of adequate funds, of insanitary conditions and
inadequate public health programs in some areas that might adversely affect
others. This being the case it becomes necessary to provide some method for
assisting the smaller or less favored units of government to meet their obligations.
Another justification of the increasing use of grants-in-aid may be found in the
situation previously discussed, i.c., the local government units are more restricted
as to types ol revenue and are administratively in a disadvantageous position for
levying and collecting some of the more lucrative sources of funds. Few would
deny the right ol local governments to share in the fiscal benefits of automobile
excise taxes since the local areas must share in the building and maintenance of
the roads over which vehicles travel. It would be confusing, however, to say the
least, should each locality attempt to apply and collect its own automobile excise
GOVERNMENTAL ASPECTS [&!1

 

tax. A revenue such as this is obviously applied most efficiently by a higher level
of government. }

Another purpose of grants-in-aid is to provide some measure ol supervision
or control over the activities ol the lower units of government. Snavely?! com-
ments that on an intrastate basis, “state authorities, more frequently specialized
in their fields and free from local prejudices, can offer valuable suggestions and
advice to the communities. Advice, however, even of an official character, is often
unwelcome unless an immediate gain can be realized by its acceptance or a loss
sustained from its refusal. A double-barrelled gun of this nature, loaded with a
reward for compliant counties and with a penalty for recalcitrant districts is
available for the central governments in the form of State subventions.”* What is
said here with regard to state-local relationships applies perhaps even more in
the Federal-state relationship.

Related to this, and arising as a result of it is a fourth purpose of grants-in-
aid: the enforcement of minimum standards upon the recipient of the grant.
Undoubtedly few things have been as influential in promoting the employment
of qualified local public health personnel, for example, as have been the con-
ditions attached to grants by both the state and Federal health agencies.

The idea of grants-in-aid is by no means new, having been first applied in
this country in New York State in 1795 for the improvement of schools in the
poorer, particularly in the rural areas of that state. Federal grants to states began
as early as 1808 when Congress instituted an annual appropriation to assist the
states in the development of their respective militia.?> No conditions were at-
tached to these grants and no Federal supervision was exercised. Perhaps the
next development of significance was the passage in 1862 of the Morrill Act
which entitled each state to a grant of public lands based upon its total area.
States not containing public land were given scrip. The only condition was that
not less than 90 per cent of the gross proceeds was to be used for the establish-
ment, endowment, and maintenance of agricultural and mechanical colleges.
Subsequent acts added to the original provisions an annual grant of cash to each
state. In 1887 the Hatch Act was passed, providing $15,000 a year to each state
for the establishment of agricultural experiment stations. With this act there was
instituted the condition of submission of an annual financial report, followed
eight years later by provision for a Federal audit. This established a pattern
which has never since been altered.

Federal grants-in-aid for public health work began with the passage of the
- Chamberlain-Kahn Act of 1918. Stimulated by the increased threat of venereal
diseases resulting from the First World War, Congress provided an appropriation
of one million dollars for each of two years to be distributed to the states on the
basis of population. The program was administered, not by the Public Health
Service but by an interdepartmental social hygiene board. After the second
year, the appropriation was cut and then finally eliminated. As a result little
of a lasting nature continued in any but the wealthier states.

*Snavely, T. R., Hyde, D. C., and Biscoe, A. B.: State Grants-In-Aid in Virginia, New York,
1933, The Century Co., p. 14.
182 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

The next use of Federal grants for public health purposes was in the field
of maternal and child health. Again as a result of increased interest during the
war, the Sheppard-Towner Act of 1921 was passed, providing grants of $1,240,000
a year to the states for five years “for the promotion of the welfare and hygiene of
infancy.” Contingent upon certain conditions, chiefly the existence of a bureau
of maternal and child health, each state was eligible for a flat sum of $10,000 and
a share of the remainder on the basis of its proportionate population. The share
ol the remainder and one hall of the flat grant had to be matched by the state.
This act was the subject ol strenuous opposition, not only on the part ol states-
rightists, but also of many members of the medical profession who, as they did a
quarter of a century later in relation to the Emergency Maternity and Infant Care
Program, viewed it as an entering wedge toward state medicine. Since some pro-
fessional jealousy existed between the administering Children’s Bureau and the
Public Health Service, some criticism of the act was also forthcoming from the
latter. Alter extending the provisions ol the act for two years, Congress termi-
nated the grants in 1929.

Thus the second venture in Federal grants for public health programs was
short-lived and relatively unsuccessful. Despite this, many authorities consider
the need for Federal and state initiative and aid to be greater in public health
than in any other governmental function.

Experience has shown that local governments of rural communities in general will

not appropriate sufficient funds for the support of full time health units unless some

assistance is forthcoming from outside agencies. Since it is in the rural sections that

unsafe water supplies, unsanitary sewage disposal, inadequate medical attention and
malnutrition combine to spread disease, it is in these communities that the greatest
expenditures should be made. Despite the existing needs, the rural districts, even when

aid is offered them, frequently hesitate or refuse to expend their revenue for the protec

tion of health. *

The Federal government cannot dictate to the states the manner in which
they should organize their governmental structures, establish their policies, or
conduct their programs. However, actual dictation ol these matters is not neces-
sary in order for Federal agencies to play a part in the improvement and ex-
pansion of public health and other services throughout the nation. The sig-
nificance of holding the purse strings is well understood by all. As stated in an
old saw, “He who pays the piper calls the tune.”

Sums of money transferred may be granted either conditionally or uncon-
ditionally; Federal grants are usually of the former type, state grants more often
of the latter. Because of this, Federal grants are more apt to act as catalyzers
than are state grants. In the ideal situation the local taxpayers would constantly
exert whatever control might be necessary for the insurance of the proper use
of the funds and it would be unnecessary to attach conditions to grants. When
revenue is raised locally, this is more apt to occur than when funds come un-
fettered from without. By tying strings in the form of conditions to grants, there-
fore, the higher unit of government is in effect substituting for the controls that

 

*Snavely, I. R., Hyde, D. C., and Biscoe, A. B.: State Grants-In-Aid in Virginia, New York,
1933, The Century Co., p. 186.
~ GOVERNMENTAL ASPECTS 183
should ordinarily be exercised by the citizens themselves. There is danger, how-
ever, that conditions and standards may become too detailed or rigid to suit the
diverse situations existing in a complex nation such as this. As Maxwell} points
out:

Regional heterogeneity is of the essence of federalism, and . . . would seem to indi-

cate that federal grants should be conditioned and closely policed. In practical fact,
however, this would be an impairment of state sovereignty. Moreover, any detailed and
uniform set of conditions would be unsuited to the diversity of regional and state needs.
In a federalism, variation in standards of many governmental functions is common, and
therefore the federal government is likely to get into difficulties if it attempts to pre-
scribe common standards in grant programs . . . to surround federal grants with
numerous conditions is to assume a homogeneity in state governmental needs which
does not exist; to prescribe uniformity where there are deepsecated reasons for diversity is
an error. Here, then, is a dilemma of federalism.*

Usually, conditional Federal grants-in-aid require adherence to certain steps.
First, the state must formally accept the terms of the grant, sometimes by means
of legislation. Preparation for use of the grant must next be made by preparing
and submitting specific plans and by establishing whatever organizations or
agencies are indicated for their fulfillment. Plans are approved centrally by a
national administrative agency. Usually, but not always, Federal grants must be
matched by the state or local government. The program or project itself is car-
ried out by state or local agencies, but subject to central as well as local inspec-
tion and audit. On satisfactory completion ol the project or an agreed-upon part
ol it, payment is made to the state. Often, partial payment is made in advance.

A number of means ol central influence and control are evident from the
steps outlined above. The Federal agency may refuse to approve plans or to co-
operate financially in a state program because of unsatisfactory state organiza-
tion or procedure. Payments may be withheld il conditions ol agreement are not
observed. Furthermore, the state has little or no recourse beyond the Federal
agency administering the grant. The application of central influences such as
these has occurred frequently in the field of public health. In order to benefit
from grants-in-aid administered by both the Children’s Bureau and the United
States Public Health Service, the states have found it necessary to establish or to
remodel their personnel standards and merit systems to the satisfaction of these
Federal agencies. Record systems, auditing procedures, clinic and hospital con-
struction and maintenance standards, and many other factors have been simi-
larly affected.

The tendency toward centralization has been most evident in the three fields
ol highway construction, education, and social security. It is interesting to study
the similarities in the patterns followed in these three areas of public adminis-
tration. Of particular interest to those engaged in public health work may be a
comparison of the history of federal interest in public roads and in maternal and
child welfare. The national government first became concerned with highways
in 1893 when it established the Office of Road Inquiry, later the Office of Public

*Reprinted by permission of the publisher from Maxwell, James A.: The Fiscal Impact of
Federalism in the United States, Cambridge, 1946, Harvard University Press, pp. 38-39.
184 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

Roads. The original bill establishing this agency included the following state-
ment: “. . . it is not the province of this department to seek to control or in-
fluence said action (in building highways) except in so far as advice and wise
suggestions shall contribute toward it. . . . The department is to furnish infor-
mation, not to direct and formulate any system of organization, however efficient
or desirable it may be.” From the date of its establishment until 1912 the Office
of Public Roads restricted itself to experimentation, advice to state and local high-
way officials, the dissemination of information, and the construction of demon-
stration roads.

In 1912 an act was passed authorizing construction of post roads, followed
in 1916 by a more potent Federal Highway Act which set up a system of grants
to the states to assist them in meeting the increased demand for good roads and
the increased cost of building better types of roads. Where originally the local
county governments had the chiel responsibility for the construction and main-
tenance of highways, this major responsibility and its accompanying authority
passed first to the state and then to the Federal government. States now receive a
large proportion of their highway funds through Federal grants-in-aid, and the
Bureau of Public Roads as the Federal administering agent establishes the stand-
ards, approves plans, audits the accounts, and inspects the completed work. The
effectiveness ol these indirect forms ol control is indicated by the fact that in 1916
when the Federal Highway Act was passed, fifteen states had no highway depart-
ments. By the [ollowing year every state had a recognized highway department
acceptable to the Federal Bureau of Roads.

Compare with this the act of 1912 which established the Children’s Bureau
directing it “to investigate and report . . . upon all matters pertaining to the
welfare of children and child life among all classes of our people.” It was desig-
nated as a clearing house [or information on child health and was authorized
to carry on research and also field studies. During the first seven years of its ex-
istence, the Children’s Bureau adhered strictly to these specified functions. In
1921 with the passage of the Sheppard-Towner Act, the Bureau was authorized
to participate in the promotion of maternity and infancy programs throughout
the nation by means of Federal grants to the states. Here the Bureau received
its first major administrative responsibilities. As in the case of highways some
states anticipated the passage of the Maternity and Infancy Bill and created
maternal and child health bureaus or divisions to administer the funds they
would obtain if and when the bill became law. Accordingly by the beginning
of 1921 thirty-three such state agencies had been established and during the fol-
lowing two years fourteen more were created. By 1929 maternal and child hygiene
bureaus or divisions had been formed and were functioning in the territory of
Hawaii and in all the states except Vermont where the work was carried on under
the immediate supervision of the state health officer.* In administering the act
the Children’s Bureau, as had the Bureau of Public Roads, set standards, ap-
proved projects, inspected work within states, and audited accounts. Although
the functions involved in the Sheppard-Towner Act came to a halt in 1929, they
were essentially reestablished in an expanded degree by the provision of Title V
of the Social Security Act of 1935.
GOVERNMENTAL ASPECTS 185

 

Further comparison is possible by considering the passage in 1942 of a bill
(although temporary) to provide Emergency Maternity and Infant Care for wives
and children of men in the Armed Forces. This program, administered by the
Children’s Bureau through the state health agencies, made possible and paid for
personal medical care of patients.

Concerning roads one recognized authority has said:

Related expenditures on highways were thrown out of balance in 1933 and the
latter years of the depression as a result of the huge emergency expenditures for public
works and the resulting grants and loans to the states. From the fiscal point of view the
national government has emerged in the crisis as the senior partner in the firm.*

One might have cause to wonder if this is an indication of the ultimate effect
of the Emergency Maternity and Infant Care program and other war emergency
programs on the functional relationship between the local, state, and Federal
governments. A large part ol the considerable opposition to the Maternity and
Infancy program was on this basis.

The above may make the grant-in-aid appear as a power-thirsty annelid in-
creasingly draining off the life blood of local sell-initiative and independence.
Somewhat this viewpoint is expressed by Mustard,*> who said:

Directly, through broad interpretations of the Federal Constitution, and by new
laws, or indirectly through grants-in-aid, parity payments, benefits, and rewards, the
Federal Government is assuming prerogatives and accepting obligations, particularly
in the field of social security, that a quarter-century ago were regarded as lying ex-
clusively within the jurisdiction of the states. Pertinent in this connection is the fact
that public health activities are more and more being considered as an integral part
of the developing social security program and are receiving increasing federal attention.
Thus the Federal Government is at present a potent influence in public health. Perhaps
it is more virile than any other area of government for . . . many state governments are
static in this field, and leadership has focused in the United States Public Health Service.
The policy of federal grants-in-aid for state and local health work is becoming increas-
ingly popular, and apparently will be continued in spite of what the opponents of this
principle believe it implies sociologically and in terms of state and local autonomy.f

However, in [airness to the administering agencies several considerations
should be pointed out. First, it is doubtful that the promotion of bills to provide
subsidies for highways, education, and public health programs represented at
any stage determined premeditated attempts to transker power to a central agency.
When all aspects of the questions involved are reviewed, it would appear that
the acts were passed and the programs developed to meet public demands and
needs which could not possibly be fulfilled by the state or much less by the local
governments.

Local governments have an administrative ability for performance of functions

which is greatly in excess of their administrative ability for the collection of revenues.
The case of the national government is the other way around: it has an ability to make

*White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The

Macmillan Co., p. 149.
fMustard, Harry S.: Government in Public Health, New York, 1945, The Commonwealth

Fund, pp. 185-186.
186 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

cfficient collection of taxes which is greater than its ability to handle expenditure . . . .
It will not be necessary to suppose that all governmental functions are handled by the
national government. Local government will have tasks to perform, not because of any
defect in the national power, but for the sake of administrative efficiency.*

The second consideration that must be conceded by all is that these pro-
grams have resulted in a considerable improvement of service and facilities for
all the people. Speaking of highways, White comments:

It is no exaggeration to state that in the . . . years since the first federal highway
act a national highway system has been established at the direction of Congress by the
Bureau of Public Roads, and that the standards of construction and maintenance by
the states, and their subdivisions have been greatly improved as a direct result of national
intervention through the grants-in-aid device. It is impossible to conceive that the trans-
portation needs of the present could be met without coordination, guidance and super-
vision furnished by the national administration and the support of national funds.t

These conclusions could be applied with equal justification to the improvements
which have occurred in the field of maternal and child health as a result of the
activities engaged in by the Children’s Bureau. In fact, the first recognized medi-
cal specialty as represented by the American Board of Pediatrics owes its existence
to considerable degree to the persistent efforts of the Children’s Bureau.

An interpretation ol grants-in-aid quite different from that ordinarily made
was presented in a study of state aid in New York by Pond,?¢ who stated:

American government involves a system of checks and balances unique among the
societies of the world. A persistent effort to retain the maximum independence to the
individual and preserve to him the minimum of interference on the part of govern-
ment is clearly discernible. Every state has two opposite evils to avoid, on the one
hand over-centralization and on the other, local autonomy run riot. It is often taken
for granted that efficiency can be secured by excessive control over localities which largely
climinates the citizen's participation in local affairs. On the other hand, it is quite as
frequently believed that local autonomy is something sacrosanct, even when it results
in much greater evils than those arising from centralization. Many competent observers
believe that England stands alone in achieving both efficiency and a large measure of
local self-government. ‘This has undoubtedly been the result of grants-in-aid. And this
is a political mechanism which may fit in perfectly with our own system of checks and
balances.

Grants-in-aid are intended to promote progress and improvement in lower
governmental units by making it possible for them to provide better services and
facilities than they can from their own unaided resources. Sometimes, however,
this purpose is defeated by the system of distribution. Injudicious methods of
subsidization may demoralize a community by fostering overreliance on the
higher unit of government with loss of local initiative and sense of responsibility,

*Reprinted by permission of the publisher from Maxwell, James A.: The Fiscal Impact of
Federalism in the United States, Cambridge, 1946, Harvard University Press, pp. 38-39.

White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co., p. 149.

fPond, Chester B.: Special Report of the New York State Tax Commission, No. 3, 1931,
Foreword, Albany, N. Y., New York State Tax Commission.
GOVERNMENTAL ASPECTS 187

 

by causing them to indulge in lavish expenditures or by allowing them to use the
grants as an excuse for unwarranted reductions in local tax rates. Similarly there
is a risk ol pauperizing communities which happen to be poor in the first in-
stance by enticing them into increasing local taxation and even indebtedness in
order to raise funds for matching purposes.

The sound, effective, and equitable distribution of subventions, therefore,
presents a difficult problem indeed. Most plans result in proportionately and
absolutely more aid being allotted to wealthier communities than to those most
in need. By distributing grants on the basis of taxable capacity, either directly or
indirectly through complete matching requirements, by granting equal amounts
to all communities or even by granting on the basis ol population alone, there
is a tendency, il anything, to increase the inequalities rather than to solve the
problem.

The circumstances causing increased needs and high governmental costs are
the same as those which result in insufficient resources for meeting the needs and
costs. States and communities with proportionately many children, inadequate
sanitary facilities, high disease and death rates, and slum conditions have need
for more extensive and costly public services than the more salubrious states and
communities but find it less possible to provide them. In order to accomplish
their fundamental purpose, grants-in-aid therefore must be allotted, at least in
part, in inverse ratio to the wealth of the various recipient areas. In this way the
proportionate amounts received by communities tend to be in accordance with
their relative needs.

In distributing grants-in-aid there exists the possibility of taking funds from
some areas and giving them to others which may be just as able to finance them-
selves as those providing the funds. One method ol avoiding this involves cor-
recting the apparent taxable capacity of communities to a true common denomi-
nator by determination of equalized assessments, which is difficult to do, or by
the use of assessment ratios to provide estimated true valuations.

A plan of distribution based on actual financial needs, supplemented by
additional grants to encourage compliance with minimum standards, will pro-
vide some assistance to all communities and in addition will give consideration
to those unable to raise funds enough of their own to supply the necessary
services. If the superior governmental unit allots only a partial share of the
maximum possible subsidy to those areas failing to raise the estimated amount
of revenue as determined by the use of assessment ratios, this will act as a power-
ful incentive to provide local funds more in keeping with local financial ability.
A plan like this is admittedly more difficult and costly to administer but in the
long run will justify itself in terms of greater general improvements and
satisfaction.

The Social Security Act of 1935 provided for federal-state cooperation in
public health matters on an increased and more or less permanent basis. It pro-
vided for annual grants “to assist states, counties, health districts and other politi-
cal subdivisions of States in establishing and maintaining adequate public health
services.” The annual sum of 8 million dollars which was subsequently increased
($38,879,300 for the year 1952) was to be distributed among the states by the
1858 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

Table 23. Grants-In-Aid, Public Health Service (Fiscal Year 1959)

 

 

 

Purpose Type of Grant Amount
| Venereal Disease Special Projects $2,400,000
| Tuberculosis Control 4,000,000
General Health 15,000,000
Mental Health 4,000,000
Heart Disease Control 2,125,000
Cancer Control 2,250,000
Water Pollution Control 2,700,000
Alaska-—Disease and Sanitation Investiga-
tion and Control 638,000*

$33,113,000

Grants to States Construction:

Hospitals $150,000,000
Medical Facilities |
Diagnostic or Treatment Centers 7,500,000
Chronic Disease Hospitals 7,500,000
Rehabilitation Facilities 10,000,000
Nursing Homes 10,000,000

$185,000, 000

 

 

 

 

 

 

Waste Treatment Works $50,000, 000f
| Total Grants to All States $268,113,000
Grants to Interstate Agencies Water Pollution Control $300,000
Grants Available to Public |
Agencies Only | Air Pollution Demonstration Projects $40,500
Grants Available to Individuals
Directly or Through
Institutions | Training:
Public Health Personnel Under Title I,
| PL 911, 84th Congress $2,000,000
Grants Available to Individuals,
Public Agencies, and Training
Institutions Training:
Air Pollution $100,000

 

*In addition, $1,000,000 is available in Fiscal Year 1959 for a mental health program, and
$6,500,000 for the construction of mental health facilities is available until June 30, 1960.

tAppropriation is for $45,000,000 but appropriation act provides that allocations to states
be based on $50,000,000.
GOVERNMENTAL ASPECTS [89
Surgeon General of the United States Public Health Service on the basis of three
factors: population, special health problems, and financial need. The relative
weight given to these factors was left to the discretion of the Surgeon General
after “consultation with a conlerence of the State and Territorial health
authorities.” =?

Grants-in-aid by the Public Health Service for fiscal year 1959 were as shown
in Table 23.

The failure to specify more exactly the method of distribution of funds ap-
propriated by legislatures has given cause for objection [rom many quarters. Thus,
a report of the Municipal Finance Officers Associations states:

The federal government has never had a continuing relief policy. The total amount
of grants available has hinged primarily upon vacillating concepts of necessity. In
addition, allocation of individual grants has been based upon wide administrative dis-
cretion. Such a procedure has hardly contributed to predictable municipal budgets
.... The financial aid of the upper levels of government has undoubtedly saved many
localities from complete disaster. Yet the unstable aid policies which have accompanied
the greater reliance upon state-collected, locally shared taxes and grants-in-aid have
served to accentuate revenue fluctuations for many local governments. *

In like manner, many health officers have complained of the difficulty involved
in attempting long-range programs due to the uncertainty surrounding the
amount of both Federal and state funds that might be counted on for budget
planning.

An attempt has been made by the Public Health Service to determine indices
of financial need and of special health problems, but the results have not been
completely satisfactory and the relative bases of distribution have been somewhat
variable. Thus, in the first year, 1936, 57.5 per cent was distributed on the
basis of population, 22.5 per cent on the basis of special health problems (judged
by the number of deaths from all infectious and parasitic diseases and from
pneumonia but not including venereal disease for which a separate grant is
made), and 20 per cent on the basis of financial need. But, for the year 1941,
funds were distributed on the basis of 29.4 per cent for population, 41.2 per cent
for special health problems, and 29.4 per cent for financial need.

The Public Health Service has tried to consider other factors such as the rela-
tive cost of rendering health services in each state and the existence of special
programs in particular states. Of the amount distributed on the basis of special
health problems, one half has been based on mortality, one fourth according to
relative costs of services, and one fourth as a remainder. Financial need has been
based essentially on per capita income as computed by the United States Depart-
ment of Commerce.

Matching requirements have been a result of administrative decision rather
than of legal specification. In general, at the present time, the States must pro-
vide one dollar for each two dollars of Federal funds. This is true in the programs
for general health, mental health, heart disease, and cancer. Tuberculosis funds
must be matched dollar for dollar. The requirements for hospital construction

*The Support of Local Government, Municipal Finance Officers Assn., Chicago, 1939, pp.
18-19.
190 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

funds are variable. In any case, the Federal share must be not more than two
thirds or less than one third.

The conditions under which states make grants-in-aid to localities vary in
the extreme. This was brought out by several papers and discussions at the Na-
tional Conference on Local Health Units held in Ann Arbor, Michigan, in Sep-
tember, 1946.2 The policies of state health departments in this matter varied
from no specific predictable basis of distribution to the use of complex mathe-
matical formulas which, incidentally, were admittedly sidestepped more often
than not. One conclusion was that no standard formula could be applicable to
all of the states and that each would have to work out its own solution to its own
satisfaction. A summary of a number of current state plans may be of illustrative
interest.

Florida

Per capita grant varied by population size, with required per capita local contribution
(50¢ considered basic) and system of bonus for excess local contribution and penalties for
deficiencies in local contributions. One per cent is added to or deducted from basic State con-
tribution for each cent above or below 50¢ per capita from the county—not to exceed more
than 50 per cent of original basic state contribution. The State retains the right to add or
subtract b per cent or less of this.

Allocations may be made for special needs not subject to formula.
Georgia

Percentage of State participation varies with population with most populous areas receiving
30 per cent and least populous receiving 75 per cent.
Illinois

One dollar subsidy for three dollars local money or 30¢ per capita, whichever is the lesser.
Special need subsidy added in poorer counties to equalize available resources to approximate
$1.20 per capita state-wide.

~ Louisiana

Total amount available for allocation to local departments is divided by population—this
per capita amount is used as general basis and then modified by past progress, health and
financial need of area.

New York

In counties and cities over 50,000 population on basis of 50 per cent of cost of public health
services, except where a county health department is established in which event State aid is
given in amount of 75 per cent on first $100,000 expended and 50 per cent on balance of
expenditure.

North Carolina

Based on population, financial needs, and specific program needs.

The most progressive state action in this regard is the Public Health Assist-
ance Law passed by California. This law became effective September 19, 1947
and provides an annual sum for local health services which is allocated ac-
cording to a formula written into the law. Each county receives either a basic
allotment or a capitation, whichever is less. The remainder, after subtraction of
7.5 per cent of the total for administrative and consultative services and train-
GOVERNMENTAL ASPECTS [91
ing, is allocated to health departments meeting standards on a straight per capita
basis.?0

It is of further interest to note that this act officially provides for a California
conference of Local Health Officers which, among other things, must approve
standards relating to local health service before they can be established by the
State Department of Public Health. This plan warrants close study by the Federal
agencies responsible for the distribution of grants to state and local governments,
since it appears to go far in eliminating many causes for dissatisfaction.

The rising tide of Federal influence in state and local affairs is well illustrated
by another phase of social security, the relief of dependents. Traditionally the
care of such individuals in America has been a local and often a private affair.
The economic depression of the 1930's changed all this, when, because ol lack
ol funds, first private charity then local governments and in turn state govern-
ments found themselves quite incapable ol meeting the tremendously increased
demands. Only one other source of assistance remained—the national government.
As a result, numerous alphabetically designated Federal agencies were estab-
lished, [orming lor the first time a basis of a broad system of Federal social
security, concerned with the unemployed, the handicapped, dependent children,
and the aged. This soon crystallized to a permanent legally established program.
Again it should be pointed out that this represented not a premeditated design
or plan ol Federal officials but merely evidence ol the increasing incapabilities
ol governmental units of lower levels to meet problems which essentially were
those ol the nation as a whole. Some writers have pointed out that even il the
Federal government were to withdraw from this field ol activity a definite change
in attitude on the part of the public has occurred and the psychological loss of
prestige by the states is practically irreparable.

The changes that have occurred in the relationship between the Federal and
the state governments have also resulted in some change in the relationship be-
tween state and local governments and local and Federal governments. The-
oretically, the national government has no relationship with cities. However, even
antedating the depression there had appeared signs to indicate closer contacts
between national and municipal authorities. In 1925 Anderson?! pointed out
numerous instances in which national agencies played a significant role in the
determination and management of municipal affairs. A more detailed study of
Federal service to cities was made in 1931 by Betters®? who commented: “The
wide range ol activities of the national government which touch intimately on
current problems of municipal administration may surprise many.” He pointed
out that Federal agencies already developed standards in weights and measures,
trafhe and safety, zoning and building, highway construction and milk sanitation,
and carried out studies and surveys on local education, finances, crime, vital sta-
tistics, and public health. In addition, Federal agencies were actively engaged in
a cooperative sense in food and drug administration, municipal water supplies,
sewage disposal, and in other fields. Again the depression and the subsequent
Second World War accelerated the intimacies of these relationships. Although
the Federal agencies operated [or the most part through the state governments as
192 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

an intermediary, they did in some instances deal directly with cities. The possible
revolutionary consequences of this caused White to comment:

The extent to which actual control of municipal affairs was lodged in Washington
as a result of these emergency measures is not easy to define. The federal government
did not attempt to weaken the control of the state over its political subdivision, and
no change in the legal status of the city was imposed . . . contacts between cities and
the national government were broad and in their extent spectacular; but the states
were not dispossessed of their traditional constitutional position as guardians of munici-
pal government. The change has been a change in climate rather than a change in
topography. Future lines of development are not clear, but it seems likely that the re-
search and advisory services of the national government to cities are destined to increase
in importance. So far as the cities enter into debtor-creditor relations with Washington,
an clement of fiscal supervision may appear. . . . Movement has been rapid since 1933,
and a federal bureau of municipal relations is much more within the realm of the
practical than it was before the events of the depression. Here is an aspect of central
tendencies which in the case of the great urban centers may be of special significance,
for they have little to derive from the state capitols as they have much to gain from
in Washington. *

The rural areas ol America were not absent [rom this scene ol changing
governmental relations. Except for the financing ol the county agent program
and aid to rural education and agricultural research, contact between the Fed-
eral government and the rural areas was lacking until the establishment ol the
Agricultural Adjustment Administration. With its establishment in 1933 the
Federal government entered into cooperative programs with the farm population,
involving the adjustment of farm production to nationally established quotas and
the direct payment to individual farmers for compliance with contracts with re-
gard to certain crops. County production control associations were established,
covering practically all parts of the rural area of America and including several
million cooperating farmers. In the process the state governments were largely
ignored. Associated with this program were activities such as the national nu-
trition program which had a direct bearing on the health not only ol the farm
families but of the nation’s population as a whole.

REFERENCES

I. Government in the United States, Census of Governments, Washington, 1957, Bureau of the
Census, vol. 1, No. 1.

2. State and Local Government Finances in 1957, Washington, 1958, Bureau of the Census,
G-GGA No. 8.

3. Mobile v. Watson, 116 U.S. 289 (1886).

4. Wagner, Paul (editor): County Government Across the Nation, Chapel Hill, 1950, Uni-
versity of North Carolina Press.

5. Gilbertson, H. S.: The County, The Dark Continent of American Politics, Chicago, 1917,
The National Short Ballot Organization.

6. Local Government Under the Alaska Constitution—A Survey Report, Chicago, 1959, Public
Administration Services.

 

*White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co., pp. 166-167.
7.

20.

21.

99

23.

GOVERNMENTAL ASPECTS 193

Galpin, Charles J.: The Social Anatomy of an Agricultural Community, Research Bulletin
34, University of Wisconsin Agricultural Experiment Station, Madison, University of
Wisconsin Press.

Phillips, J. C.: State and Local Government in America, New York, 1954, American Book
Co.

Gould, John: New England Town Meeting, Safeguard of Democracy, Brattleboro, Vermont,
1940, Stephen Daye Press, Inc.

Odum, H. W., and Jocher, Katharine: In Search of the Regional Balance of America,
Chapel Hill, 1945, University of North Carolina Press.

Strow, C. W.: Regionalism in Relation to the Health of the Public, Am. J. Pub. Health
37:808, July 1947.

Statistical Abstract of the United States, Washington, 1958, Burcau of the Census.

Dewhurst, J. F., and others: America’s Needs and Resources, New York, 1955, Twentieth
Century Fund.

Conflicting Taxation, Interstate Commission on Conflicting ‘Taxation, 1935.

Bird, F. L.: The Trend of Tax Delinquency, 1930-1944, New York, 1945, Dun and Brad-
street, Inc.

Hughes, M. C.: County Government in Georgia, Athens, 1944, University of Georgia Press.

Summary of Governmental Finances in 1957, Washington, 1958, Bureau of the Census,
G-GFS7.

Brogan, D. W.. The American Character, New York, 1944, Alfred A. Knopf, Inc.

White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co.

Feiner, Herman: Grants-In-Aid, Encyclopedia of Social Sciences 7:152, 1932.

Snavely, T. R., Hyde, D. C., and Biscoe, A. B.: State Grants-In-Aid in Virginia, New York,
1933, The Century Co.

Annals of Congress of The United States, 10th Congress, Ist Session, 1808.

Maxwell, James A.: The Fiscal Impact of Federalism in the United States, Cambridge,
1946, Harvard University Press.

The Seven Years of the Maternity and Infancy Act, United States Children’s Bureau, 1931,
United States Government Printing Office.

Mustard, Harry S.: Government in Public Health, New York, 1945, The Commonwealth
Fund.

Pond, Chester B.: Special Report of the New York State Tax Commission, No. 3, 1931,
Albany, N. Y., New York State Tax Commission.

Social Security Act, Section 602 (c).

The Support of Local Government, Municipal Finance Officers Association, Chicago, 1939.

Proceedings of the National Conference on Local Health Units: Supplement to Am. J.
Pub. Health 37:1, Jan. 1947, New York, American Public Health Association.

Halverson, W. L.: Fiscal Relationships Between the State and Local Health Departments
in California, Am. J. Pub. Health 38:922, July 1948.

Anderson, William: American City Government, New York, 1925, Henry Holt & Co., Inc.

Betters, Paul V.: Federal Services to Municipal Governments, New York, 1931, Municipal
Administrative Service Publication 24.
chapter 3

Legal considerations in public health

 

Definition of Law.* Many books have been written dealing exclusively with
the question of the nature and definition of law. It is interesting that, although
the average citizen probably considers law as an exact and strictly defined field,
its mere definition presents the members of the legal profession with perhaps
their most difficult problem. Law, at least in a democracy, depends in the last
analysis on the collective wishes of the people, and the type and extent of their
wishes vary through place and time. It should be realized that human behavior
is subject to a never-ceasing process of evolution as are also the social [actors
determining or influencing it. However, law is not unique in this, since definitions
are not easily forthcoming in many other fields such as literature, art, or, from
the point of view of our immediate interest, public health. Perhaps under such
circumstances the essential goal should be to arrive at some reasonably satisfactory
definition which might serve as a point of departure for a practical pattern ol
behavior. An example might even be as simple as the immortal statement ol some
unknown character who said, “There is plenty of law at the end of a night stick.”

In order to guide our thinking it might nevertheless be well to consider the
definitions promulgated by some of the outstanding legal theorists in history.
For example, Blackstone? considered law as a “rule of civil conduct prescribed
by the supreme power in a state, commanding what is right and forbidding what
is wrong.” It is to be noted in passing that this greatest of all jurists refrained
from including in his definition the criteria involved in determining “right”
or “wrong” at any particular time. Wilson* extended himsell somewhat further
in his definition by considering law as “that portion of established thought and
habit which has gained distinct and formal recognition in the shape of uniform
rule backed by the authority and power of government.”

Characteristics of Law. A law implies an actual or potential command, and
a command signifies nothing more or less than a wish or desire. However, the
commands and desires of law differ from ordinary personal commands and de-
sires in that they (1) represent community desires or commands, (2) are ap-
plicable to all in the community, (8) are backed by the [ull power of the govern-

*For more detailed discussion see The Nature and Sources of Law by Gray" and The Nature
of the Judicial Process by Cardoza.*

194
LEGAL CONSIDERATIONS 195

 

ment, and (4) provide for all people the administration of justice under these
laws. Wilson's definition might be considered to be more desirable since it either
states or implies all of the characteristics mentioned.

Purpose of Law.* The primary purpose of law might be said to be the pro-
motion of the general good by the regulation of human conduct in order to
protect the individual from other individuals, groups, or the state, and vice
versa. In order to effect such protection it must be possible for the individual, the
group, and the state to predict within reasonable limits the probable course of
judgment in the event of an infringement of the law. Therefore, another purpose
of law is to assure, insofar as possible, uniformity of action in order to prevent
errors of judgment or improper motives or actions on the part of judicial officers.
It is often said that the wheels of justice turn slowly. The rate would be im-
possibly slow if the accumulative experience of earlier judges were not available
to the people and to the courts. This also is a purpose of law.

The most fundamental means by which law endeavors to carry out its
purposes is the definition of rights and duties existing between individuals or
groups. Legal relationships form the essential subject matter of law, and rights
and duties are the most important of legal relationships. A legal right is a power,
privilege, or interest of an individual or group that is recognized and protected
by law. Simultaneously, the law imposes upon all others the obligation to refrain
[rom violation of the right. Thus, the possession of a right by one person always
implies a corresponding duty on the part of some other person or persons to
respect that right. For example, A and B enter into a contract. Their legal rela-
tionship may be expresesd as: either A has a right that B perform an act or
B owes A a duty to perform an act.

Rights are of two kinds, primary and secondary. Primary rights are those
which result merely from an individual's existence as a member of society. A
citizen holds these primary rights against the entire community individually and
collectively, and the community and each of its individuals owe him a corre-
sponding duty to refrain from violating them. Thus, a citizen's person and prop-
erty are held to be inviolate; that is his primary right, and all others owe him
a duty to respect it. Such rights exist not by virtue of any action taken or decision
made, but are the kind of rights which were termed “natural rights” by eighteenth
century legal theorists. They are sometimes spoken of as “rights in rem” and
“rights ol ownership.” Their violation is considered a civil wrong, a tort, or a
crime, depending upon their magnitude and upon whatever statutory law de-
clares them to be. Libel, slander, trespass, negligence, and the like are civil
wrongs or torts.

Secondary rights are those superimposed upon primary rights as a result of
individual action and decision. They are not held against all other persons
generally, but only against a specified person or group. These rights arise as a
result of contract. For example, A and B enter into a contractual agreement.
Before the contract, their legal relationship, consisting of rights and duties owed
each other, was fixed and equal. Now, due to the contract, their legal relation-

 

*For more detailed discussion see Sociology of Law by Gurvitch.?

’
190 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
ships are quite different. A’s previous primary rights are now increased by a
secondary right that B carry out the action agreed upon in the contract. This
new right differs in kind from primary rights, first, because it is not due simply
to A’s existence but results from a mutually agreed upon contract, and, second,
because it is a right held against B alone and no others.

Remedial rights are sometimes referred to as a third form of rights. They
come into existence on the violation ol the legal primary and secondary rights
discussed above. In other words, they are rights resulting [rom a personal in-
justice and are held against the individual committing the legal wrong. What
they really amount to is a right of reparation, usually in terms of money damages.
In other words, all that is meant by saying that a person has a remedial right
is that if he appeals to the court, he will, in all probability, be rendered a favor-
able verdict. As Justice Holmes observed, a remedial right is in the nature of a
prophecy.

Systems of Law—Development.® The concept of law has gone through many
changes throughout the centuries of recorded history. With primitive man, it
apparently originated as a combination ol gradually developing customs based
on tradition, and supposedly divine dictates. Perhaps the chiel function of the
patriarchs ol a tribe was to define the practices evolved and followed by their
predecessors, and these customs were gradually given the significance of estab-
lished precedent and law. As to the meaning or reason lor such laws, it was the
theory of the Hindus and Chinese that laws were an essential necessity of human
society; that due to the innate depravity ol man, as evidenced by his nature, laws
were necessary to prevent violence and injustice. Therclore, it became a primary
duty first of the tribal leaders and ultimately of their successor, the state, to
formulate and enforce rules ol human behavior and conduct.

The Grecian theory of law was somewhat different and followed in general
the basic philosophical pattern of their civilization. They argued that all neces-
sary social laws really existed in nature and were merely waiting to be discovered,
similar to the principles ol physics. In fact, nature was thought ol more or less
as an expression ol the total of all universal law. This concept that law exists
perennially, waiting to be discovered as natural truths, held sway through over
seventeen hundred years, passing through Stoic philosophy, Roman law, the
pirnciples of the Christian Church and on through the medieval civilizations and
governments. It is significant, [rom our present point ol view, that the men who
founded the American Republic and formulated the Declaration of Independence
and the United States Constitution with its Bill of Rights had as their legal
background the natural theory of law. It is noteworthy that the basic idea of the
Declaration of Independence deals with the “natural rights” of men, which are
to be “secured” rather than granted by government.

Since the establishment of the republic, our concept or theory of law has
undergone considerable change, especially since the beginning of the twentieth
century, so that we now see legislation merely as a man-made device for the

 

*For more detailed discussion sce The Growth of Law by Cardoza® and The Quest for Law
by Seagle.”
LEGAL CONSIDERATIONS [97
regulation and control of human conduct in order to assure the ultimate wishes
ol the greatest number or of the dominant groups in the community.

Statutory Law. At the present time practically the entire Western world is
governed by a combination of two distinct systems of law, (a) statutory law which
is based especially on the Roman civil law, and (b) the common law of England.
Roman law began its development very early in the Roman state. The first
authentic legal records were established in 450 B.c. as the Twelve Tables. To
these were added innumerable unwritten laws which, ultimately, as a result of
the Institutes of Justinian and others, were codified into a system ol written law
so perlect that even today it operates as the basic law of most European countries.
Its geographic adoption was related, ol course, to the paths of Roman conquest,
which brought the Roman legal code into practically all parts ol the continent.
Following the decline of the Roman Empire, the resulting daughter nations
retained the Roman legal system since they had but little other pattern to follow.
Later, states such as the members of the American Republic provided legisla-
tures to make whatever laws were necessary for government, and the resulting
collections ol legislative acts constitute the statutory law. For a time the attempt
was made to adhere rather strictly to statutory law but as societies became more
complicated, especially as a result ol urbanization and industrialization, innumer-
able additions had to be made in the form of specific interpretations, court de-
cisions, and rules and regulations. The result is that at the present time, in the
United States for example, written or statutory law constitutes only a small part
(about 2 per cent) of all existing laws.

Common Law.* It was recognized at an carly date that statutory law was in
many cases too general to be directly applied to particular cases. As a result, there
followed the development of courts, the judges ol which were expected to be
guided in their specific decisions by the established customs of the community.
England took particular strides in this direction. Essentially this recognition of
the legal importance of custom represents a practical recognition of the rights
ol a people to take part in the making of the rules and laws governing their
conduct and relationships. This was a great step toward liberty. A custom, in
order to be entitled to consideration in law, must meet certain conditions. First,
it must have existed lor a long time or, as Blackstone put it, “have been used
so long that the memory of man runneth not to the contrary.” It must have been
followed continuously, that is, constantly observed and respected whenever an
occasion for its observance or respect arose. It must have a peaceful purpose
and be reasonable and not inconsistent with the general spirit of the law. It
must be definite rather than vague and must be considered binding on all people.
Finally, it must be consistent with all other customs of society.

Stare Decisis. With the gradual development and extension ol use of the
common law courts, another practical procedure soon became indicated. The
administration of justice would have become impossibly slow were it necessary
to judge every particular controversy directly against existing written law and
custom. There developed, therefore, the doctrine ol “stare decisis” (the decision

*For more detailed discussion, sce The Common Law by Holmes.”
198 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH i
stands) whereby a rule of law, whether based upon custom or upon being recog-
nized by the courts and thereby applied to the solution of a case, formed a
precedent which should be followed in all similar cases thereafter, unless subse-
quently deemed absurd or unjust or unless repealed by the legislature. As sum-
marized by Kent,” “A solemn decision upon a point of law arising in any given
case becomes an authority in a like case, because it is the highest evidence which
we can have of the law applicable to the subject and the judges are bound to
follow that decision unless it can be shown that the law was misunderstood or
misapplied in that particular case. If a decision has been made on solemn argu-
ment and mature deliberation the presumption is in favor of its correctness; and
the community has a right to regard it as a just declaration or exposition of the
law, and to regulate their actions and contracts by it. It would, therelore, be
extremely inconvenient to the public, il precedents were not duly regarded and
implicitly followed.” *

The American colonies, having been settled primarily by people of Anglo-
Saxon origin, had as their original legal basis the written law existing in England
at the time of their migration, plus the vast volume of common law which had
evolved in England up to that time. It naturally followed that there was super-
imposed upon these an additional and ever-increasing amount of common law
based upon the social customs which evolved on the new continent. For example,
the law governing the state of Indiana consists ol:

First. The Constitution of the United States and of this state.

Second. All statutes of the general assembly of the state in force, and not inconsistent
with such constitutions.

Third. All statutes of the United States in force, and relating to subjects over which
congress has power to legislate for the states, and not inconsistent with the Constitu-
tion of the United States.

Fourth. The common law of England, and statutes of the British Parliament made in
aid thereof prior to the 4th year of the reign of James I (except the second section of
sixth chapter of 43rd Elizabeth, the eighth chapter of 13th Elizabeth, and the ninth
chapter of 37th Henry VIII) and which are of a general nature, not local to that king-
dom and not inconsistent with the first, second and third specifications of this section.?

Added to this is all the common law evolved in Indiana since the inception of
its statehood. Statements similar to this are to be found in the constitutions or
statutes of each of the American states with the exception of Louisiana.

Equity or Chancery. Up to the time of William the Conqueror (a.p. 1066),
the administration of justice was limited to the application of existing laws.
However, William the Conqueror assumed the doctrine that the sovereign was
the ultimate source of all justice and that he, himself, was above the law. Hence,
the well-known saying, “The king can do no wrong.” Therefore, he and the
English rulers who followed him for a considerable period dispensed justice as
they considered desirable or expeditious.

Thus, if some wrong were committed for which the law offered no true
remedy or il the plaintiff felt that the law had not given him complete justice,

*Kent’s Commentaries, Lecture 21.
tSection 1-101 (244) Burns Indiana Statutes Annotated 1933.
LEGAL CONSIDERATICNS 149

 

the king could be appealed to lor assistance beyond the power of the courts. As
common law courts came to depend more and more on precedents as guides in
their dispensing of justice, they became more and more rigid. Accordingly, the
king was appealed to with increasing frequency, so much so that the king's
chancellor, who was otherwise spoken of as the keeper of the king's conscience,
was made responsible. This was eventually followed by the establishment of
separate courts of chancery or equity, the essential purpose of which was to render
as complete justice and restitution as possible, going beyond the dictates of exist-
ing laws il necessary. As time went on, such courts became strictly limited to situ-
ations where no adequate remedy or solution was offered by the regular law
courts. Eventually, however, as chancellors and their courts rendered more and
more decisions and judgments, they too, as a matter ol course, became more or
less bound by precedents, sometimes defeating the original purpose of their
existence.

This system of equity as a supplement to the written and common law was
also brought to America and established as a part of our legal structure. Separate
chancery or equity courts still exist in a few states along the eastern seaboard
and in the southeast. Otherwise, for practical purposes, the same court sits now
as a court of law, dispensing strictly legal judgments, and again as a court of
equity, administering relief in cases for which the law, as it exists, offers no
remedy. Equity serves as the basis for the proper administration of justice in
many cases of public health concern, reference to a few examples of which will
be made.

Certain principles have been laid down to define the natural sphere of in-
terest and applicability of equity. They may be summarized as follows:

Equity will not suffer a wrong without a remedy. This is very fundamental considering
the reason for the development of equity.

Equity delights to do justice and not by halves. Thus, it is the intention of equity that
all interested parties be present in court and that there be rendered a complete judgement
adjusting all rights for the plaintiff and preventing future litigation. An example of this is
presented by a case’ questioning an amendment to a Wisconsin statute relating to the licensing
of restaurants. A subsection had been added providing that no permit should be issued to
operate or maintain any food-serving business where any other type of business was conducted
unless the facilities dealing with the preparation and serving of food were separated from such
other business by substantial partitions extending from the floor to the ceiling and with self-
closing doors. The provisions of the subsection were applicable only to restaurants commencing
business after the effective date of the subsection. In a mandamus proceeding in which it was
sought to compel the state board of health to grant a permit to conduct a restaurant, it was
contended by the complaintant that the added subsection was void under the Federal and State
constitutions in that it denied due process and equality before the law. The basis for licensing
the business involved, said the court, was for the protection of the public health and safety.
“If protection of the public health and safety requires partitions in case of a business subse-
quently to be commenced, then by the same token it requires them is case of existing businesses;
and if one operating an existing restaurant is not required to maintain the partition, and one
about to establish a restaurant is required to maintain one, then manifestly the latter is denied
equal protection with the former.” On this basis the supreme court sustained the contention of
the complainant, declared the amending subsection void but the existing statute to remain in
force, and instructed the board of health to grant the requested permit, thereby adjusting all
rights and preventing future litigation.
200 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

Equity acts in personam. A law court may merely render a judgement against a person's
property rather than against the person himself. For example, the court may command a sheriff
to seize and sell enough of the unsuccessful defendant's goods and turn over to the plaintiff
sufficient of the proceeds to meet the money judgment of the court. Equity, on the other hand,
commands an individual to do, or to refrain from doing, whatever acts constitute the subject of
the litigation. Such an action by a court of equity is known as injunction. Failure to obey the
command of the court places the defendant in contempt of court and, thereby, subject to per-
sonal punishment. Thus, if the sewage from the premises of one houscholder gives rise to an
intolerable situation on the property of another, the ordinary court of law can merely render
a judgment for money damages in favor of the offended property owner. This, however, does
not solve the problem since the original nuisance still exists. In equity, however, not only may
there be rendered a judgment of cash restitution for damages already done but, in addition, the
court may issue an injunction directing the person responsible for the nuisance to abate it and
to prevent it from recurring in the future.

Equity regards the intention rather than form. This constitutes a weapon against legal
decision. Law concerns itself with a strict interpretation of a form of a law transaction, or con-
tract, but equity considers also the intent. This is illustrated by a case’ involving the question of
whether common-law marriages which do not necessitate a license were included under a state
law requiring premarital examinations as a prerequisite for marriage licenses. The superior
court said that the act was clearly a public health measure designed to assist in the eradication of
syphilis, to prevent transmission by a diseased spouse, and to prevent the birth of children with
syphilitic weaknesses or deformities and should be construed so as to effectuate its purpose if at
said the court, “the legislature never intended that such an important

all possible. “Certainly,
hygienic statute could be circumvented by the simple device of the parties entering into a
common-law marriage without first obtaining a license.”

Equity regards that as done which ought to be done. If a contract is broken, the court
of law may only render a money judgment for damages, whereas equity will order or command
(mandamus) that the contract be specifically performed. This is illustrated in the case of ¥. W.
Woolworth Company v. Wisconsin State Board of Health, et al, previously cited.

Equity recognizes an intention to fulfill an obligation. If an individual promises or con-
tracts to do a thing, or if he has done anything which might be regarded as at least a
partial fulfillment of the promise or contract, equity will assume that he intended to do it until
the contrary is shown. This has sometimes served as a stumbling block to public health officials.
For example, a person maintaining a public health nuisance may necessitate numerous fruitless
visits and inspections on the part of public health workers. Finally, as a means of last resort,
the wrongdoer may be brought to court. If he can demonstrate to the satisfaction of the court
that in some, although inadequate, manner he has followed the suggestions or commands of the
public health official, the court may dismiss the case saying in effect, “Why do you bring this
man to court when he is taking steps to meet your requirements?”

Equity follows the law. In accordance with this maxim an eqiuty court will observe
existing laws and legal procedures, in as far as possible, without hindering its own function in
the administration of justice.

Where there is equal equity, the law must prevail. "This means that if both parties to
the litigation are judged to have equal rights, the case will be sent back to the law courts where
the party with a right in law will have that right enforced.

The logic of these two principles is obvious, considering the purpose for which equity was
established, that is as an adjunct to law rather than as a substitute for it.

He who comes into equity must do so with clean hands. In other words, if he claims
a wrong, he himself must be free from a related wrong or the equity court will not listen to him.
This was a factor in the well-known Chicago drainage canal case™ where in a court of equity,
the city of St. Louis was refused a judgment against the city of Chicago. partly on the basis of
St. Louis itself contaminating its own public source of water.

He who seeks equily, must do equity. This is similar to the above in that not only must
the plaintiff have clean hands, but he must be and have been willing to do all that is right
and fair as a part of a transaction or a judgment.
LEGAL CONSIDERATIONS 201

Equity aids the vigilant, not the indolent. This is known as the doctrine of laches and
calls into effect the statute of limitations which fixes definite intervals within which legal
action may be instituted after the cause for action has occurred or becomes complete. These
time intervals are not the same for all actions and vary further among the states. If a person
wishes to receive relief from an equity court, he must be prompt in applying to it. In other
words, he must not “sleep on his rights.”

Administrative Law. In the statutory legislation of an carlier day dealing
with comparatively simple social and economic structures, the understandable
attempt was usually made to include in the written statutes a considerable amount
ol detail with reference to the problem at hand. However, in more recent times,
with the accelerating complexity ol our social and economic systems and with
ever increasing knowledge in all fields, it has become obviously impossible to
include within the statutes sufficient detail to cover adequately all of the situa-
tions that might arise in the practical application of the true intent ofl the law.
At the same time, our governmental structure has become more and more com-
plicated and has had more and more demands placed upon it in the form of
public services and regulatory [unctions previously undreamed of. The relative
recency of the modern public health program provides a good example ol this.
To meet the situation, there have been established by government, on a statutory
basis, a considerable and increasing number ol administrative agencies set up for
the purpose ol putting into effect the intent of legislation.

The procedure was evolved of passing enabling legislation written in more
or less general terms and including a clause delegating administration and en-
forcement to a new or existing administrative agency, giving the agency the
power and responsibility to formulate whatever rules, regulations, and standards
were necessary lor carrying out the purpose of the law. It naturally follows that
such powers and responsibilities must be in conformity with all existing laws of
the community, the state, and the nation. Thus, although the legislative branch
ol government is the only body that may actually formulate and enact a law
and, although this power cannot itself be delegated, the legislature may delegate
the power to make whatever rules and regulations as are necessary to carry out
the intent of the law. (In some states even administrative rules and regulations
must be reviewed and approved by the state attorney general.) All such adminis-
trative rules and regulations, when properly formulated and when not in conflict
with existing laws of the state and nation, have all the force and effect of law
even though they arise from an administrative agency and not [rom the legislature
itsell. However, their interpretation by the courts tends to be somewhat more
rigid than the interpretation placed upon the enactments ol the legislature itsell.

Classification of Law. From the point of view of consolidation, it might be
desirable to include a few words on the classification of law. Perhaps the two
simplest methods of classilying laws are (1) by origin and (2) by application.

From the point of view of origin, law may be divided into:

Constitutional law—law developed by specially designated bodies or legislatures convened
for the purpose of framing or amending a constitution.

Statutory law—legislation which may arise from either representative assemblies or by the
process of initiative and referendum.
202 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

Decree or administrative law—rules, regulations, standards, orders and so forth, issued
by executive or administrative boards or officers within the sphere of their legal competence
and responsibility in order to carry out the intent of statutory laws.

Common law and equity—decisions made by courts in specific cases.

Considering application, legislature may be divided into:

Public law—law concerned with the establishment, maintenance and operation of govern-
ment; the definition, relationships, and regulation of its various branches; and the relationship
of the individual or of groups to the state.

1. Constitutional law—deals with the basic nature, structure and function of the state,
considering the powers of the various branches of government, and sometimes including
a bill of rights.

Administrative law—as discussed previously.

3. Criminal law—concerned with offenses or acts against the public welfare and safety, such
being considered as offenses against the state and varying from petty offenses and mis-
demeanors to felonies.

He

Private law—law concerned with the rights and duties of individuals and groups in relation
to each other. Originally it was based largely on common law but increasingly has become
subject to statutes.

Courts. In the American republic, government is based on the wise principle
ol the separation of powers. Accordingly legislation can be formulated, con-
sidered, and ultimately enacted only by the legislative branch. Alter its enact-
ment, the legislature has no further concern with a law except for the possibility
of subsequent amendment or repeal. On passage, a law is referred to the executive
branch of government for its administration and enforcement. However, the con-
stitutionality of the law and the manner of its enforcement are subject to review
at any time on the initiative ol the citizenry by the third or judicial branch of
government which is manifest by the actions ol the courts. It is the duty of the
courts to pass upon the constitutionality of laws, to interpret them in the interest
of justice and the public good, and to determine their validity whenever con-
troversies related to them are brought before the court in the proper manner.

The jurisdiction of the court may be either original or appellate. That is
to say, it may be a place where the merits ol a controversy are originally passed
upon, or it may be a place to which an unsuccessful and dissatisfied litigant may
appeal for a review of the action taken by a court of original jurisdiction. Using
the judicial system of the states as a point of departure, their courts may be di-
vided into three categories. At the top are the superior courts including the state
supreme court, the superior court, court of appeal, or court of civil appeals.
Such courts usually have five to nine justices who hear appeal cases from the
lower courts of the state and who have, in some instances, varying amounts of
original jurisdiction. Appeals may be taken from here to the Supreme Court
of the United States if the case at hand involves the Federal Constitution, Federal
laws, or treaties. Below the state superior courts are the intermediate courts in-
cluding the circuit courts, district courts, county courts, and common pleas courts,
the terminology differing in different states. These are courts of original jurisdic-
tion and the first two in some states hear appeals [rom lower courts. In other states
these functions are separated. It is to be noted that a county court, although
locally elected and locally responsible for the administration of its verdicts, is
LEGAL CONSIDERATIONS 203

 

actually part of the state judicial system. On the lowest or most local level are
the locally elected justices of the peace who in effect individually constitute the
lowest rung on the state judicial ladder.

In addition to the above, a state may set up certain special courts to deal
with particular social problems such as juvenile delinquency, domestic relations,
industrial relations, and so forth. On the municipal level of government, by
virtue of a charter granted by a state government, an urban community may have
the privilege of setting up certain courts ol its own to administer justice in cases
involving problems of concern limited to the municipality itself. Thus, there
are police courts with original jurisdiction in minor matters, and municipal
courts with original jurisdiction in more important cases and also serving as a
place of appeal from the police court.

On the Federal level there exists, of course, the Supreme Court of the United
States, consisting of a chiel justice and eight associates, to which cases may be
appealed from the lower Federal courts and state supreme courts in instances
where the Federal Constitution, laws, or treaties are considered to be involved. In
addition, it has some original jurisdiction in interstate, maritime, and some other
matters. (See Article 3, Section 2, and Amendment 11 of the Constitution.) To
expedite the Federal judicial system a number of intermediate courts have been
established. Thus, there are ten Federal circuit courts with appellate jurisdiction
and, below them, over ninety Federal district courts, which are the principal
Federal courts of original jurisdiction. There are, in addition, Federal courts
for special purposes such as the Customs Courts and the Federal Court of Claims.
There might also be mentioned the increasing number of Federal administrative
boards, such as the National Labor Relations Board, which have a certain amount
of delegated original jurisdiction.

Sources of Public Health Law. Public health law may be defined as that
body of statutes, regulations, and precedents that have for their purpose the
protection and promotion of individual and community health. While the term
“public health” was not entirely unknown to contemporaries of the authors of
the American Constitution, its present-day sense and significance were undreamed
of. After all, there was no public health profession in existence and science was
not to enter the golden era of bacteriology until about one hundred years later.
Three-quarters of a century were to pass before the need for the establishment
of the first state health department was to be felt. Still forty years more were
to go by before the formation of the first county health department. The found-
ers of our country cannot be censured, therefore, for not considering public
health functions specifically in their organization of the new government. They
were so remarkably astute and far-seeing, however, as to provide for future de-
velopments in many fields by the use of certain broad and general phrases which
in subsequent periods were to make possible broad interpretation of the Consti-
tution, thereby allowing the introduction and inclusion of certain public health
activities in the functions of the Federal government.

By far the most important of these broad phrases is that occurring in the
Preamble to the Constitution which includes among the fundamental purposes
of the government the intent to “promote the general welfare.” This recurs again
204 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

in Section 8 ol Article I which, dealing with the [unctions ol Congress, gives it
“power to lay and collect taxes . . . to... provide for the common delense and
general welfare . . . .” It is the generous interpretation of this by the Supreme
Court which has made possible the activity of the Children’s Bureau in maternal
and child health and the subsidization, by means ol Federal grants-in-aid, of
state and local health programs by the United States Public Health Service. In
fact these Federal agencies owe their very existence in large part to the intent
which has been read into the “general welfare” phrase.

In addition, the varied and widespread activities ol the Federal government
in fields relating to health have as their legal basis the manner in which numer-
ous other clauses of the Constitution have been interpreted. Thus the direction
to Congress “to regulate commerce with foreign nations, and among the several
states, and with the Indian tribes” has been construed to include such matters as
international and interstate quarantine, sanitary supervision and vital statistics,
and direct responsibility for the health ol the American Indians. The provision
for the establishment ol “post offices and post roads” has led to the right of
Federal government to bar from the mails material deleterious to the public
health. The power “to raise and support armies” and to “provide and maintain
a navy” logically placed responsibility for the health of the armed forces, in
recent years a not inconsiderable [raction ol the population, in the hands ol
Federal agencies. Complete and exclusive jurisdiction over the inhabitants ol
the seat of the national government (the District of Columbia) is also specified.

The reader may be reminded at this point that the United States, [ar from
being one nation, is in a very true sense a federation of fifty separate nations
called states, each with its own history, economic and social problems, and still
somewhat jealously guarded intrastate interests. It will be recalled that the mem-
bers of the Constitutional Convention carelully guarded the rights ol their
respective states, jointly turning over to the newly formed Federal government
only such powers and activities as they felt desirable and necessary for the com-
mon welfare and survival of all. Matters they could adequately handle as in-
dividual states were retained by the states. Therelore, the Federal government
truly was and is a creature of jointly concurred action ol the several states. Since
the beginning, it has been inferred that all matters not specifically mentioned
in the Constitution and its subsequent Amendments were questions to be dealt
with primarily by the states. It is for this reason that we find the more complete
and coordinated organization ol public health activities on the state and local
levels. Each state has developed its own characteristic body ol legislation and
judicial interpretation as well as its own characteristic type of organization for
the implementation ol its public health laws, being in a position to do very
much as it wishes within the limitations ol interstate and international conflict.
Although we have these fifty differing sets of public health laws and organiza-
tions, certain fundamental legal principles, however, are involved in all. It
is to a brief discussion of some ofl these fundamentals that we must now turn
for the further discussion of sources ol public health powers.

Eminent Domain. The first ol the basic powers ol a state is that of eminent
domain, which is sometimes referred to as the power of condemnation. This is
LEGAL CONSIDERATIONS 205

the power or right of a sovereign state to summarily appropriate an individual's
property or to limit his use of it, il the best interest of the community makes such
action desirable. In so doing, however, the state must provide an equitable com-
pensation. In effect the state has the right to demand the sale or limitation of use
of private property. The distinction between the exercise of the power ol eminent
domain and actions upon which legislatures may insist without compensation
is not clear cut at any given time and varies [rom time to time. The history of
zoning measures to control the height ol buildings has been cited as a good
example of this. At first the state attempted to control the height ol buildings by
purchasing from individuals their primary right to build on their own property
above the height which was considered most desirable [rom the community stand-
point. This action being upheld in the courts was resorted to by more and more
people in more and more communities until it got to the point where as one
writer aptly stated it resembled the economy ol the mythical village of Bally-
cannon where everyone made their living by taking in their next door neighbor's
washing.'® In other words, when resorted to on a wide scale, use of the power
of eminent domain amounts to individuals as taxpayers purchasing the exercise
of a right from themselves as private citizens. Inevitably, such a procedure be-
comes ineffective as a measure of control. Recognizing this, the public through
its legislatures may finally say, “We shall forbid this particular action or use
by the individual,” and the courts more often than not uphold the action.

In a certain sense, the procedure followed by some health departments in
the past ol paying an allotment to chronic carriers of typhoid bacilli in order to
make sure of their refraining from engaging in [ood-handling occupations repre-
sented the purchase by the state ol an individual's primary right. Here again the
states, in most instances, finally simply forbade such activity by these persons.

As pointed out by Ascher,' it is interesting to note that those who were
attempting to bring about a form of building control which eliminated the
necessity of compensation deliberately avoided a test case lor about ten years.
Finally, when the Ambler Realty Company protested the restriction of its use
ol its land by the village ol Euclid," the United States Supreme Court upheld
this arbitrary use of the police power in a sweeping opinion which had as one
ol its basic contentions that over nine hundred cities already were subject to
zoning and about one hall of the urban dwellers of the nation lived under the
benefits ol zoning procedures. This is perhaps another way of saying that within
a relatively short period ol time the social concept of zoning had become part
of the custom ol American communities and that its requirement could be con-
sidered as having become part of the common law.

Laws of Nuisances (noscitur ad sociis). Long before our nation and its gov-
ernment were conceived, the concept was developed by medieval legal theorists
that while “a man’s home is his castle,” an individual's use of his private property
could be detrimental to others. The use of private property is unrestricted onty
so long as it does not injure another’s person or property. If this occurred, a
nuisance was considered to exist and the individual whose person or property
was injured could seek assistance [rom the courts. Innumerable examples of
this exist in the field of public health, especially with regard to the salubrity of
200 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

the physical environment. For example, an individual property owner has the
right to dispose of his sewage in any manner that he may see fit provided that
it cannot actually or potentially affect another. If he allows raw sewage to flow
onto the land of another, a social injustice has obviously occurred and the health
and well-being of others have been placed in jeopardy. Legal relief against
nuisances may be obtained in the courts by means of (a) a suit of law for dam-
ages resulting or (b) a suit in equity to forbid or abate the nuisance.

It is perhaps unfortunate that a large proportion ol public health officials
still consider the use of the law of nuisances as one of their most important if
not their chief legal recourse. The pursuit of this point of view eventually leads
to many difficulties and dissatisfactions since the law of nuisances is subject to
increasing limitations. Some of these limitations are discussed below.

In the first place, there are many things or uses of things that do not in-
trinsically constitute a nuisance but are merely in the wrong place. An example
of this is provided by the case of Benton et al. v. Pittard, Health Commissioner?
in which the plaintiff protested the establishment and operation by a health
department ol a venereal disease clinic in a residential district. The complaints
were that the diseases of the patients who would congregate in the neighborhood
“were not only communicable but were offensive, obnoxious and disgusting; that
the clinic operation would be offensive to the petitioners and that their sensibility
would be injured; and that their dwelling would be rendered less valuable as a
home and place of residence.” The defending health officer and county com-
missioner filed an answer and a general demurrer, a form ol pleading which,
while admitting all the facts, challenged their legal sufficiency to constitute a
cause of action. The judge, after hearing both sides, denied the plaintifl’s request
for an injunction and sustained the demurrer. On being appealed, however, the
State Supreme Court stated that the fact that the clinic was to be operated as a
public institution would not alone prevent it from becoming a nuisance il located
in a residential section and that the statutory provision requiring the care of
venereally infected persons did not imply the right to perform such care in any
location. “In other words, a nuisance may consist merely of the right thing in the
wrong place regardless of other circumstances.” On this basis the judgment of the
original trial court was reversed.

Another factor tending to limit the value of the law ol nuisances is that a
great many of the legal doctrines and decisions dealing with nuisances and their
abatement were developed belore the germ theory ol disease became accepted
scientific fact. During most of its development, there existed no obvious [actual
or scientific data on which to base conclusions, and those appearing in court in
such cases were merely pitting their opinions against the opinions of others.
This left the court as its only final recourse the expression of its own opinion.
As a result there has been built up a mass of unsound and unscientific decisions
which as precedents continue to influence the public health problems posed by
present-day communities. This also explains in part why many supposedly modern
health departments are required to expend much time, energy, and funds in
activities such as garbage and refuse control which have little relationship to
public health.
LEGAL CONSIDERATIONS 207

 

Still another difficulty is caused by the fact that recourse to the law of
nuisances does not overcome one of the rules of law. Decision by a law court
that a nuisance exists may result in damages being paid to the plaintiff but does
not necessarily effect the solution or abatement of the noisome circumstances.
There is, of course, the possibility of resorting to a court of equity with the hope
of obtaining complete justice. However, here again it is found that a rule of
equity may provide a way out for the defendant in that if he can demonstrate
to the court's satisfaction his intention or, better yet, partial action to abate the
nuisance, the case in all probability will be dismissed from court. The thought
might arise that the situation could be improved by trying to bring about more
up-to-date judicial interpretations and judgments regarding nuisances. While
theoretically possible, the task involved in order to accomplish this would be
enormous. Furthermore, even il modern present-day standards could be made the
basis of definition, time would continue to pass and belore long these standards
and definitions might become outmoded.

Police Power.* There remains another means of legal recourse for the public
health official to consider, i.e., the police power which the sovereign state pos-
sesses. As a matter of fact, public health law owes its true origin and only real
effectiveness to this inherent right of the state. Police power originated in the
so-called law of overruling necessity which claims that in times of stress such as
fire, pestilence, and so forth, the private property of an individual might be
summarily appropriated, used, or even destroyed if the ultimate relief, protection,
or safety of the group indicated such action as necessary. Through time this
concept expanded to include even activities designed for the prevention of causes
of social stress. The United States Supreme Court has on numerous occasions not
only upheld the principle of the police powers of the state but also has defined
their scope in sweeping terms to include, as did Chief Justice Marshall, all types
of public health laws and to acknowledge the power of the states to provide for
the health of their citizens.t It should be noted however, as Mr. Justice Brown
stated, that “. . . its (legislature's) determination as to what is a proper exercise
of its police powers is not final or conclusive but is subject to the supervision of
the court.”

One of the best definitions of the police power was given in the case of Miami
County v. Dayton!” in which the court defined it as “that inherent sovereignty
which the government exercises whenever regulations are demanded by public
policy for the benefit of the society at large in order to guard its morals, safety,
health, order and the like in accordance with the needs of civilization.”

Although the possession of police power is fundamentally that of the sov-
ereign state, the legislature of the state may for practical purposes delegate it to
an administrative agency acting as its functional agent. The use of the police
power is not a matter of choice when it has been delegated to a governmental
agency. The agency has a definite and legal responsibility to use it and further

*For more detailed discussion see The Police Power by Freund.'®
Perhaps the best known case is Gibbons v. Ogden (1824), 9 Wheat. 1, 6 L.Ed. 23.
Lawton v. Steele, (1893) 152 U.S. 133.
208 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

is accountable for the manner in which it is used. When the means for action
are made available to him, the public officer responsible may be compelled to
exercise the police power delegated to him il the public interest indicates such
action. Failure to do so makes the public official guilty of malfeasance ol office.
However, although application of the police power may be indicated and de-
manded, the manner in which it is employed is usually left to the discretion olf
the administrative officer. That is to say, the public officer may select his own
methods of enforcement, formulating rules, regulations, and standards as he
deems necessary, unless the statutes which made him responsible specifically
prescribed the method of procedure.

The position ol a public health officer in this regard, as related to the sum-
mary abatement ol a nuisance, was well stated by the Iowa Supreme Court in a
case! involving such action by a health department in enforcing an ordinance
dealing with the improper and indiscriminate dumping of garbage. In uphold-
ing the action of the board of health the court stated that while nothing in the
statute granted to the officers immunity [rom the consequences ol unfair or
oppressive acts, “the particular form ol procedure prescribed may vary from the
customary procedure, but essential rights are not violated by granting to the board
the right, in an emergency, to proceed in the abatement of a nuisance detrimental
to public health, and it is safe to say that most cases calling [or action on the part
of boards of health are matters requiring immediate action.” Of perhaps greater
significance, the court went on to say that while the courts had not been uniform
in their holdings, it believed that the weight of authority, as well as reason and
necessity, prescribed that in cases involving the public health, where prompt
and eflicient action was necessary, the State and its officers should not be subjected
to the inevitable delays incident to a complete hearing belore action could be
taken.

The right of a legislature to delegate rule-making power to an administrative
agency has been questioned many times, but only in one instance has such power
been denied to a state or local board of health. This occurred in Wisconsin!?
where it was held that the State Board of Health was simply an administrative
agency and that no rule-making powers could constitutionally be delegated to
it. On the other hand, the Ohio State Supreme Court stated “that the legislature
in the exercise ol its constitutional authority may lawlully confer on boards of
health the power to enact sanitary ordinances having the force of law within the
district over which their jurisdiction extends, is not an open question.”* The
question was more or less settled by the United States Supreme Court which held
(I) that a State may, consistently with the Federal Constitution, delegate to a mu-

nicipality authority to determine under what conditions health shall become op-
erative;

(2) that the muncipality may vest in its efficiency, broad discretion in matters affecting
the applicability and enforcement of a health law;

(3) that in the exercise of the police power reasonable classification may be freely
applied and that regulation is not violative of the equal protection clause merely
because it is not all embracing.7

*Ex parte Co. 106 0.8. 50.

i/Zucht v. King (1922) 260 U.S. 174, 43 S. Ct. 24.
LEGAL CONSIDERATIONS 209

It is obvious and logical that a municipality or an administrative agency in
dealing, [or example, with questions concerning the public health can act only
when it has been given specific authority for such actions, and that the ordinances
adopted by the legislative body of the municipality must not only be limited to
the subject matter of the power delegated but also must not conflict with or at-
tempt to set aside any provision of the Constitution, of the state law, or of any
other sanitary regulations ol the state. The same conditions apply to regulations
adopted by local boards ol health. They can apply only where the subject matter
has been placed by law under the jurisdiction of the local board of health.

Police Power, Administrative Law, and Judicial Presumption. The delega-
tion to administrative agencies and officers of the right and power to formulate
rules, regulations, and standards in order to implement the intent of legislation
has given rise to a relatively new and increasingly important branch of law and
source ol enforcement powers. It is unfortunate that in the public health pro-
fession there are still many who do not adequately realize the great administra-
tive possibilities presented by sound administrative law.* There are many com-
munities which, although sometimes possessing adequate enabling legislation for
various public health activities, have only limited control because of the [ailure
ol their health officials to make the rules, regulations, and standards necessary
for the proper and adequate implementation of the statutes. By flailing to form
a solid background based as much as possible on sound scientific criteria, the
public health official by his own neglect places himself, his department, and the
community at an unnecessary and unwarranted disadvantage. Mentioned in the
discussion of the law of nuisances was the undesirable possibility of the public
health official being in the position of pitting his mere opinion against that of
the defendant. The court's only alternative in such a situation would be to express
its own opinion regarding the desirability ol the action rather than its legality.
Ideally it is only the latter with which the courts are essentially concerned, and
as much as possible it is preferable that they not have to make decisions regard-
ing the sense or desirability ol an action. When a scientist, a health officer, or
another expert is in a position to provide the court with definite regulations and
standards based on scientific criteria or group judgment, especially if they have
been drawn up with the idea of administering legal advice, the judge of the court
is no longer in the somewhat embarrassing position ol having to balance what
amounts to the personal opinion of the plaintiff against that ol the defendant and
then being himsell forced to make a decision by expressing his own personal
opinion. The very existence of sound rules, regulations, and standards serves to
pass the burden of proof from the administrative agent to the defendant in the
case so that the judge can avoid conflict and save time and face by saying, for
example, that the defendant has not presented evidence to show that the health
officer did not fairly apply the rules, regulations, or standards which, by virtue
of their development, are more or less accepted without question. Thus, there has
been established what is termed a judicial presumption in favor of the findings,
conclusions, and recommendations of the enforcing administrative official.

¥For more detailed discussion see Administrative Law—Cases and Comments by Gellhorn.®
210 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

In order to obtain the maximum amount of judicial presumption, certain
conditions are desirable and should be borne in mind. First of all, laws and
ordinances should contain only broad principles with delegation of authority to
the enforcing or administrative agency for the development of the necessary de-
tails. Second, such rules, regulations, and standards, as may be indicated by the
law or ordinance should be carefully formulated. Third, as much as possible, they
should be based on accepted scientific facts or authoritative group judgments.
Fourth, it is desirable that they be written with the aid of an administrative
lawyer. Fifth, advantage should be taken of the opportunity presented in the
process of making the rules, regulations, and standards to lay the foundation
for their ready acceptance by the public and the courts of the community. This is
meant to imply that the process presents an important opportunity for education
and persuasion as well as democratic participation. If those who are to be affected
are consulted in the writing of a regulation, they will develop in the process
an understanding which is a first step toward voluntary cooperation, acceptance,
and self-enforcement. At the same time, the public health administrator is pro-
vided an invaluable opportunity to determine in advance how far the commu-
nity is willing to go.

Licensing. A related method of legal enforcement and control is found in
the technique of licensing. The legality of the principle of licensing as a method
of control and enforcement as well as a source of revenue to meet the cost of
the administration of a law has been well established and accepted for a long
while. However, intent and methods of licensing are constantly subject to ques-
tioning in the courts as are all other methods of enforcement. Licenses may be
granted or revoked under conditions imposed by public health authorities pro-
vided that there is a statutory basis for the licensing and there is no oppressive,
discriminatory, or arbitrary action involved in their application.

An example?! that might be given to illustrate the latter is that of a city
board of health which voted that, after a certain date, no more milk distributor
licenses would be granted to persons who were not residents of the city. The
plaintiff operated a well-qualified dairy six miles beyond the city limits and
brought suit to compel the issuance of a license, charging that the regulation
was discriminatory. The state law said that “boards of health may grant licenses
to sell milk to properly qualified persons.” The court held that the word “may”
in the state law should be construed as meaning “shall” so that a local board of
health, existing by virtue of state law, would have no alternative but to issue a
license to any person who satisfied the sanitary requirements. More pertinent
to the question at hand, it further held that the limitation on nonresidents was
unreasonable and arbitrary and that if it had been included in a law instead of
a resolution it would have been ruled unconstitutional.

On several occasions, licensing has been found useful by health authorities in
accomplishing a certain amount of indirect control and prevention of problems
not obvious from the primary purpose of the licensing. Several communities,
for instance, have found it necessary to institute the licensing ol individuals en-
gaged in certain personal service occupations such as masseurs and beauty parlor
operators in an attempt to stop advertising by prostitutes operating under the
LEGAL CONSIDERATIONS 211

 

guise of these occupations. This particular use has caused no difficulty since the
right of health departments to maintain sanitary control over individuals en-
gaged in personal services in order to prevent the spread of communicable dis-
eases has been well established.

However, when an ordinance requiring permits or licenses can be shown to
have no public health basis it will probably be considered an infringement of
personal rights by the court and declared invalid. This is illustrated by the case
of a city board of health which passed a regulation providing that no person
should engage in the business of undertaking unless he had been duly licensed
as an embalmer by the board of health. The State Supreme Court held the regu-
lation unconstitutional and invalid, saying, “We can see no such connection
between requiring all undertakers to be licensed embalmers and the promotion
of the public health as to bring the making of this regulation by the board of
registration in embalming or the refusal of a license by the board of health on
account of the regulation within the exercise of the police power of the state.”

Basic Public Health Laws Necessary. In a DeLamar lecture given in 1920,
Dr. Allen W. Freeman,* who was at that time Commissioner of Health of Ohio,
said, “Every thoughtful sanitarian has in his mind the picture of that ideal system
of health administration which would be founded on scientific principles, or-
ganized on the basis of administrative efficiency, and manned by a staff of trained
workers filled with the spirit of public service. This ideal organization would
have behind it a volume of law which, while fully recognizing the principles of
individual liberty, would permit no man to offend against the health of his
neighbor.”* Although Dr. Freeman subsequently added with considerable justi-
fication, “However thoughtfully a proposed measure may be prepared by its
framers, it has by the time it is enacted into law usually been so altered by ill-
considered, hasty or prejudiced amendment as to have lost all semblance of its
original form,” there may be considered to advantage some of the fields of public
health activity in which fundamental legislation is desirable or necessary. The
first of these is concerned with the registration or reporting of births and deaths.
It is conceded by all to be well-nigh impossible to carry out a public health
program in the absence of basic information concerning the circumstances sur-
rounding nativity and death. In most parts of this country, it is the public health
agency which is charged with the responsibility for assuring the collection of
this information. In order to achieve this, it is necessary that each state have the
necessary legislation and administrative machinery dealing with mandatory re-
porting of these biological events by those in the best positions to submit such
reports, the attendants at births and deaths. Related to this is the need for legis-
lation requiring the reporting and control of cases of certain types of illnesses,
especially those of a communicable nature. To accomplish this adequately re-
quires careful and exact definition of certain terms such as cases, communicable,
isolation, and so forth, and the listing of the morbid conditions to be included.
In accord with what has been said elsewhere, such defining and listing is best

*Freeman, Allen W.: Public Health Administration in Ohio, De Lamar Lectures, Johns
Hopkins University School of Hygene & Public Health, Baltimore, 1921, Williams & Wilkins Co.
212 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

accomplished by inclusion in the rules and regulations drawn up by the adminis-
trative agency rather than in the body of the statute, which should limit its con-
cern to broad principles, responsibilities, and penalties. The desirability of this
is particularly evident on considering the spectacular changes that have occurred
in recent years in the areas ol diagnosis, treatment, and social management
ol many ol the communicable diseases. II details ol reporting and control appear
in the law, further scientific advances are certain to result either in the necessity
ol changing the law or allowing it to become hopelessly out ol date.

In the field of food and milk control, an enormous, confusing, and very often
contradictory mass of legislation and regulation exists. Undesirable as this situa-
tion undoubtedly is, all will agree that certain types of legal control are neces
sary. It is obviously important for a community to exercise some control over
those who produce and handle its food and milk supplies.* This has been re-
peatedly upheld in the courts. With reference to milk, the Connecticut State
Supreme Court explained in an opinion, “The State may determine the standard
ol quality, prohibit the production, sale, or distribution ofl milk not within the
standard, divide it into classes, and regulate the manner of their use, so long as
these standards, classes, and regulatory provisions be neither unreasonable nor
oppressive. The many recorded instances in which the courts have sustained this
power of regulation bear witness to the liberality of their viewpoint where the
public health and safety are concerned.”f Judicial prejudice, in lavor ol rules,
regulations, and standards dealing with the sanitary quality ol food and milk
supplies, has been extended lar beyond the actual product itself. It has long been
accepted as proper lor the responsible health authority to formulate rules, regu-
lations, and standards dealing with the source ol food and milk and the health and
sanitation practices of all who come in contact with them, the sanitary lacilities
provided such persons, and the sanitary nature ol all machinery, instruments, or
utensils involved in their transfer from the source to the ultimate consumer.

In the field of general sanitation, including the sanitary problems involved
in housing and industry as well as the supervision ol water supplies, sewage dis-
posal and the like, basic legislation is necessary in order to place responsibility in
the hands of the public health agency and to give it such powers as are needed
in order to activate the intent of the law. Licensing ol certain trades and occupa-
tions has been mentioned briefly. It is obvious that before such a procedure could
be put into effect the necessary legal justification should be brought into
existence.

Perhaps the most fundamental of all is enabling legislation for the establish-
ment and development of local work. It should go without saying that a local area
being ultimately subject to the state must be granted the legal right to estab-
lish official activity dealing with the public health. The rapid expansion in
recent years ol local health work, especially on the county level, has developed
increasing interest in the proper formulation of such enabling acs. In the first
national conference on local health units held on Sept. 9-13, 1916, Dr. Harry S.

¥See Legal Aspects of Milk Control by Tobey* and The Legal Phases of Milk Control*
Shelton v. City of Shelton (1930), 111 Connecticut, 433.
LEGAL CONSIDERATIONS 213

Mustard?¢ summarized the essentials that should be included in enabling legis-
lation for local health work. These essentials are included here for their concise-
ness and inclusiveness. Speaking ol such legislation, he urged:

I. That this volume of law should provide assurance that there is a proper balance
between local autonomy and state supervision.

2. That this volume of law should provide insurance that where a local unit of gov-
ernment is too small for effective public health administration, combinations of local
jurisdictions may be made.

3. Insurance that health work locally wili not be scattered among different elements of
the local government.

4. Insurance that budgets for local health units be sufficient to meet at least a mini-
mum in terms of funds, and to meet standards as to personnel.

5. No local jurisdiction will remain in want of health service, merely because of un-
favorable financial position locally.

6. Supplementary to this insurance that even the poor arcas will be included, there

should be insurance that there will be adequate state aid.

Insurance that the whole state system of local health units will not be jeopardized

by local option.*

A valuable summary ol recent state legal practice in this regard is available
as a result of a study in 1952 by the Public Health Service.*?

Writing and Passage of Laws and Regulations. In completing a discussion
ol court actions Tobey?" states, “These cases also demonstrate that the actions of
public health authorities must be conducted in a strictly legal manner, with due
guarantee ol the constitutional rights of individual citizens and the people as a
whole. If regulations or procedures are defective, the courts have no choice but to
uphold the law as it should be, and this they will do despite their willingness to
support all reasonable public health measures. Public health officials must bear in
mind that prevention applies to law as well as to sanitary science, and they should
sce to it that legislation and law enforcement comply with adjudicated standards
and modern jurisprudence.”

In accord with this, it might be well to consider briefly a few practical con-
siderations with regard to the proper formulation of laws and regulations. Before
doing so, it is worth repeating at least two important legislative handicaps to
effective administration.* The first of these is that legislatures in the formulation
and passage of statutes often attempt to do too much by writing into the law
itsell too much detail with regard to administrative responsibilities, organization,
itemized appropriations, and procedure. In at least one state, for example, the
salaries of the state health officer and others are specifically limited in the state
constitution, ignoring economic changes, competition for good administrative
personnel, and progress in general. As a result, this particular state, during a
period of high living costs and generally increased salaries, finds itself unable
to obtain or hold qualified personnel for the administration of its public health

*Mustard, Harry S.: Legal Aspects of Planning for Local Units, Am. J. Pub. Health
(supp.) 37:20, Jan. 1947.

Tobey, J. A: Recent Court Decisions on Milk Control, 1933, Reprint 1955, United States
Public Health Service.

See New Horizons in Public Administration by White
214 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

program. The thought comes to mind that in the sound administration of a
private corporation, the board of directors, being somewhat analogous to a legis-
lature, does not attempt to decide on details of procedure, operation, and the like.

The second legislative handicap is the sacrificing of long-term considerations
to immediate, local, or personal advantage. It is possible to find many examples
of this in the field of public health. In more than one place legislation and ap-
propriation have been passed supposedly for the control of tuberculosis or syph-
ilis, but have emphasized the care of the chronic cases and ignored the all-
important factor of early case finding and control of the early infectious case. The
logical solution of these handicaps may be found in the passage of legislation
which considers general policy and leaves the details of procedure and operation
up to whatever administrative agency the legislature may see fit to hold respon-
sible. This requires, of course, that administrative agencies assume their full
responsibility in carrying out the intent of the statutes by adequately and ef-
fectively formulating and enforcing whatever rules, regulations, and standards
are indicated.

It is customary in this country for responsibility for the public health to be
vested in a board of health which is directed to employ as its agent a health of-
ficer and whatever other personnel is needed in order to carry out its policies. It
is much better that rules, regulations, and standards be passed by someone other
than the enforcement officer. The public then feels that it is being treated more
fairly and that the enforcement officer is not grinding his own axe. In turn the
health officer is relieved of the onus of enforcing his own regulations and the risk
of repeated personal liability. This alone presents an important justification for
the interposing of boards of health between the legislative body and the [unction-
ing agency. With these words of introduction, the following few suggestions are
made concerning the formulation of rules and regulations by public health
agencies:

1. First is the necessity that they be promulgated by a board of health or whatever other
administrative agency in which this authority and responsibility is vested. Furthermore, the
agency must have been properly created and legally existing in the eyes of the legislature. If
any of its members have been improperly chosen, elected, or appointed, the entire board does not
legally exist and all of its actions are considered invalid.

2. The actions of the board must arise by virtue of power and responsibility which has
been expressly or impliedly delegated to it by the state legislature.

3. The pronouncements of the board must relate and be limited to its legal jurisdiction and
not infringe upon the jurisdiction of another agency or another governmental entity.

4. The rules and regulations must not conflict with the Constitution and laws of the
United States or with the Constitution and laws of the state of which the agency is a part.

5. The rules and regulations must be reasonable and no more drastic than is necessary.

6. All rules, regulations, and standards must be adopted by a legally constituted board
of health, legally convened in an official session. No individual member of a board has power
to enact a regulation any more than an individual Congressman has power to enact a statute.
Final enactment can result only by a vote at a properly called meeting of the board, notice of
which has been given to each of the members of the board and at which a quorum is presented.
To attempt to act on a regulation by means of telephoning or visting the office or home of each
member individually does not constitute action by a legally convened meeting of the board.

7. Since a board of health regulation is in effect a law, it follows that the same care should
be exercised in its formulation as is exercised in drawing up a state or Federal statute. The first
LEGAL CONSIDERATIONS 215

 

consideration in this regard is proper form, including a title and enacting clause, a series of con-
secutively numbered articles each related to one subject, a statement concerning the time when
the regulation is to become effective, and a statement of penalties involved in instances of proved
infraction.

8. The ordinance or regulation must be precise, definite, and certain in its expression and
meaning. Complicated high-sounding phrases should be avoided, punctuation used sparingly
and parenthesis almost never. Foreign or technical terms should be avoided if possible. It has been
said often that there can be a lawsuit for every extraneous or ill-chosen word and for every ill-
advised punctuation.

9. If the legislature prescribes the manner in which regulations and ordinances should be
passed, such prescription should be exactly adhered to. If, for example, it is specified in the state
law that a proposed ordinance be read and voted upon favorably at three successive meetings of
a legally constituted and convened board, this cannot be fulfilled as has been sometimes at-
tempted by having the clerk stand and read the ordinance and call for a vote three times during
the same meeting.

10. The ordinance or regulation must be enacted in good faith and in the public interest
alone and designed to enable the board of health to carry out its legal responsibilities. It should,
therefore, be impartial and nondiscriminatory, applying to all members of the community.

11. In some states it is necessary that actions of boards of health be approved by the at-
torney general of the state.

12. On legal passage the final step is proper and adequate publication of the rule or or-
dinance in order that those who are to be affected by it shall have ample opportunity to be in-
formed concerning it.” This is usually carried out by means of publishing in the local
newspapers.

Concerning this last requisite Gellhorn makes the following comment:
“Regarding publication of administrative legislation the situation, especially in
the states, is confusing almost to the extreme and eventual reform is certain to be
demanded as a result of this disregard of the public interest in knowing what
rules and orders they are subject to. Such lack of adequate publication has un-
doubtedly led to judicial hostility toward delegated legislation and authority.”*

A final caution might be given concerning frequent practice ol adoption or
incorporation of rules and regulations by reference. This procedure has the en-
ticement of being convenient and easy but may give rise to legal difficulties in
that only existing things can be legally incorporated by reference. Therefore,
each time the original regulation or law is changed, it is necessary to reincor-
porate by reference. Furthermore, it is legally impossible, although it is some-
times attempted, to adopt or incorporate a subject by reference on a blanket basis
through time because such action amounts to committing the public to regula-
tions which are not yet in existence and is comparable to asking the public to
sign a blank check.

This is not meant to condemn entirely the technique of reference, since its
convenience amply justifies its use. However, it should be used with full knowl-
edge of its limitations and potential disadvantages, some of which are illustrated
by the case?! of a board of health which adopted a regulation dealing with the
sale of milk and milk products in accordance with the unabridged form of the
1939 edition of the United States Public Health Service Milk Ordinance. The
publication of the new regulation did not contain the ordinance but stated that

¥Gellhorn, W.: Administrative Law—Cases and Comments. Chicago, 1940, The Foundation
Press, p. 263.
210 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

a certified copy was on file in the office of the board of health. The State Supreme
Court in ruling on the case of a defendant charged with violating the regulation
stated, “The effectiveness of legislation by reference has been so generally rec-
ognized . . . that no very specific declaration appears in the reported cases,”
adding, however, that “no by-law or ordinance, or section thereof, shall be re-
vived or amended unless the new by-law or ordinance contains the entire by-law
or ordinance, or section revived or amended, and the by-law or ordinance, section
or sections so amended shall be repealed.” So long as there was no violation of
this section, the court said that it saw no objection to the incorporation by refer-
ence in a regulation of a district board ol health of a duly enacted statute or a
duly enacted ordinance which had been theretolore properly published. However,
the Supreme Court was ol the view that the publication of a board of health
regulation, which omitted the rules ol conduct to be observed and merely re-
[erred those who might be affected to a copy ol the terms on file in the office of
the board ol health, did not constitute proper publication as meant by the law
and, that until proper publication had been made, any such regulation was not
effective.

Liability and Agency.* In order to accomplish a desired purpose such as the
completion of a contract or the rendering ol a public service, practicality usually
makes it necessary that the one (the principal) who is legally responsible for ful-
filling the contract or for rendering the public service obtain an agent or agents
to carry out the details involved. This relationship between a principal and his
agents gives rise to an additional series ol legal complications especially in terms
ol those things for which the principal is liable and those for which the agent
is liable. In public health work the citizens ol a community as represented by
their legally designated board ol health may be considered the principal, whereas
the health officer acts as the agent ol the people and is responsible to the board.

This view has been held repeatedly by the courts, as illustrated by two
cases®® in which the courts observed that the authority for the appointment ol a
city health commissioner was precisely the same as or the appointment ol nurses
and other employees and that the health commissioner was not a public officer but
an employee under the direction, supervision, and control of the board ol health.

The fundamental rule governing the relationship ol principal to agent is
that the principal is liable lor contractual agreements or other acts of an agent
provided that the agent has acted within the real or apparent scope of his au-
thority. It should be noted [rom this that the principal is not vested with a
blanket liability for all contracts or all acts that might be carried out in his name
but is liable only for those acts for which the agent has been given power by him.
The most important and difficult problem is to define or determine the meaning
and extent of the agent's real and apparent authority and power.

The powers ol an agent have been divided into real and apparent. An agent's
real power consists of the authority which has been expressly or impliedly dele-
gated to him by the principal. Expressed powers are given usually in the form of

*For more detailed discussion sce Public Health Law, 111 Liability, p- 279-327, by Tobey.
LEGAL CONSIDERATIONS 217

 

actual and explicit instructions. Thus a board ol health may instruct a health
officer to control the spread through the community ol a communicable disease.

Added to this expressed authority, the agent also has certain implied powers
in order to find it possible to do whatever is reasonably necessary to carry out the
instructions given. The health officer, therefore, on being instructed to control
the spread of communicable disease may correctly assume the implied power and
authority to include whatever administrative procedures are reasonably indicated,
such as quarantine, contact examination, etc., in order to accomplish the respon-
sibility given him in relation to the expressed powers.

Over and above his real authority, expressed or implied, the agent has cer-
tain so-called apparent powers. In the use of these, the agent really exceeds his
actual power and he would be considered liable in many instances were it not
for the concept that other persons under certain circumstances are correct in be-
lieving that the agent has power to act. The use ol apparent power is involved
in major part in the solution of individual problems each with its own peculiar
circumstances, and the test of its correct use is the determination of whether or
not a reasonably prudent person in similar circumstances would have been justi-
fied in acting as did the agent on the behall of his principal. This may be illus-
trated by the case of the health officer who in the face of a smallpox outbreak
hospitalized an individual erroneously considered to have smallpox with the
result that the patient became infected with smallpox while in the isolation hos-
pital. The erroneous diagnosis having been made in good faith by the attending
private physician and similarly confirmed by the health department diagnostician
alter exercising due and customary care and judgment, neither the private phy-
sician nor the community through its authorized public health agents were held
liable. As the court stated, “T'o hold otherwise would not only invite indifference
at the expense of society, but the fear ol liability would well-nigh destroy the
efforts of officials to protect the public health.”

This emphasizes that an agent owes to his principal the exercise of a degree
of care and skill which a reasonably qualified and prudent person in terms of the
community involved at the time would be expected to exercise under similar cir-
cumstances. Therefore, the professional agent, in terms ol our particular interest
a health officer, owes to his principal (the community) the exercise of a reasonable
degree of care and skill as judged by the time and place. It should be noted that,
except where a contract exists to the contrary, there is involved no guarantee that
a certain result will be effected. All that is required by the law is the exercise
of that degree of skill, knowledge, and care usually displayed by similar members
ol the profession under similar circumstances.

In the absence of malice or corruption, or a statutory provision imposing
the liability, health officers generally are not liable for errors or mistakes in
judgment in the performance of acts within the scope of their authority where
they are empowered to exercise judgment and discretion.* Personal liability,
therefore, depends on proof of bad faith which “may be shown by evidence that
the official action was so arbitrary and unreasonable that it could not have been

*1 Dillon’s Municipal Corporations 771 as quoted in Public Health Law, p. 294, by Tobey.*
218 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

taken in good faith.”3* While obviously difficult to ascertain, “bad faith” has been
demonstrated to the satisfaction of the courts as in the case? ol a smallpox
patient who was forcibly transferred [rom her home to a dirty, insanitary cabin,
for which action a health officer was understandably held liable.

It logically follows, however, that il reasonable and legal instructions have
been given to an agent by his principal it is the agent's duty to obey them even
though he may disagree with them or think that he knows a better way in which
to accomplish the purpose desired. In such an instance, should the agent willfully
disobey the principals instructions or laws, and injury or any other undesirable
result follow, the agent is liable for whatever damages have been sustained as a
result of his disobedience.

With regard to liability of the principal il it is a government, it should first
be re-emphasized that the state is sovereign and as such cannot be sued or held
liable by its individual citizens except where it grants permission. Since county
governments are essentially local administrative and political units of the sov-
ereign state, the same rule tends to be applied to them. However, there is an in-
creasing tendency on the part of states to allow counties to be sued and to hold
them liable whenever there is question or doubt. Municipalities are somewhat
different in that they are corporations carrying on various [unctions and services.
Some ol these functions, such as the operation ol a transportation system or a
water works, are considered private and the city may be sued concerning them.
However, other [unctions and services such as the maintenance ol police and fire
departments are public functions and concerning these the city cannot be readily
sued. Public health activities fall into this category. Some states have been very
specific in this regard as evidence by a Michigan court which said “. . . the mat-
ter of public health is not local; it concerns the State. In matters relating to
public health the city acts as an arm of the State, and the property whose use
is devoted to the public health is used in the discharge of a governmental
function.” *

Extent of Use of Law in Public Health. Seen in its proper relationship, legal
enforcement represents only one of several ways by which an administrator acting
as an agent of the community may bring about desirable results and effect con-
formity to the socially desired standards of the community. In effect, the admin-
istrator has three main tools or methods of approach at his disposal—education,
persuasion, and coercion—and the extent to which he successfully blends and
balances them is one of the best measures of true administrative ability. As Tobey
has stated, “A health officer who is constantly involved in court actions, either as
plaintiff or prosecutor or as defendant, would hardly be classed as an efficient
public officer since he should be able to administer the public health of his com-
munity or State and enforce the public health laws in the great majority ol cases
by means of persuasion and education and by suitable action before the board
of health.” The efficient and reasonable health officer must be ready to recognize
sincere and honest attempts to meet the standards set up by society when such

*Michigan Supreme Court; Curry v. City of Highland Park et al. (1928) 219 N. W. 745.
t+Tobey, J. A.: Public Health Law, ed. 3, New York, 1947, Commonwealth Fund, p. 349.
LEGAL CONSIDERATIONS 219
attempts are within the range ol social tolerance, and he must be able to explain
the tolerance point to the average citizen, the legislature, and the courts.

. the reader should not infer that (legal and regulatory) restrictions are the basis
of all public health activities. Such a conclusion would be unfortunate, although it might
represent the philosophy of a group of health officers that is now rapidly disappearing.
Many of the most important achievements of public health have had the support of laws
and ordinances requiring conformity to specified sanitary standards. Without this sup-
port movements for the extension of public health work would have evolved more
slowly and would still be far from their present stage of development. Informed public
opinion would have brought about great improvement, but more slowly. The coercive
power must, therefore, be considered a powerful factor in the development of effective
public health work, but it has definite limitations. *

The carly history of public health in America might be characterized by
almost complete dependence on legislation and its enforcement.

During the past generation the student of public health has witnessed a rapid shift
in emphasis away from the doctrine of direct control toward that of education. This
change has been due in no sense to the failure of the regulatory theory but rather to
the broadening scope of public health that now includes problems of personal hygiene.
.. . Even the exercise of the regulatory authority must rest on education, for an unin-
formed legislative body will not enact proper laws or appropriate funds for their en-
forcement, and an uninformed public will not tolerate regulations it does not under-

stand or appreciate.

In many il not most instances, social legislation is framed by persons who
are somewhat more advanced in their social thinking than is the average citizen.
Only relatively recently has the realization come about that legislation dealing
with social concepts which are too [ar ahead of the citizenry as a whole is almost
inevitably doomed to failure. Many tragic examples of this nature may be found
in the history of public health. One of the best known is the first general board ol
health of England established in 1848, which failed as a result of overenthusiasm
due to Edwin Chadwick's social thinking and planning which was too far ahead
ol the people of England at the time. At least one local health officer in America
was literally tarred and feathered because ol his persistent attempts to institute
complete pasteurization of milk when the strongly opinionated citizens of his
area were not intellectually prepared or ready for it.

As a result of the relatively recent realization that social progress of all types
must be based on an understanding and acceptance by the majority of those in-
volved, leaders in the field of public health administration have turned to the
more practical procedure ol concerted educational and persuasive action, mini-
mizing the legal and enforcement approach. Boyd,*7 has pointed out that permis-
sive legislation [or the establishment ol local health units in Illinois has existed
for twenty-five years, but as a result of the legislation alone only six county health
departments came into being. As a result of recent public educational methods,
however, the citizens in most parts ol the state have by vote expressed their

*Anderson, G. W.: In Graham, G. A., and Reining, H. (editors): Regulatory Administration,
New York, 1943, John Wiley & Sons, Inc., p. 86.

Anderson, G. W.: In Graham, G. A,, and Reining, H. (editors): Regulatory Administration,
New York. 1943. John Wiley & Sons, Inc., p. 89.
220 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

desire for local health departments with practically no opposition. The place of
legal enforcement in present-day public health activity has been well stated by
Lade?® in discussing the control of venereal disease:
Now compulsion is not the only recourse in these cases—not even the first recourse.
A substantial number of contacts resistant to examination and patients delinquent
from treatment will respond to information, reassurance, persuasion, or assistance when
unable to pay for examination or treatment. Indeed, the extent to which these measures
are successful is to a degree a measure of the efficiency of a health department, and a
demonstration of the superiority of our democratic government over a dictatorship. But
there will always be a residue of cases resistant to all of these measures who are the
kernel of the venercal disease problem. Here a show of force is frequently all that is
necessary. Nevertheless, behind the facade there must be a solid structure of duly con-
stituted authority, lest we have government by the whim of officialdom. Hence, law is
necessary as an expression of sound medicolegal thinking in a problem which concerns
all the people.*

Court Procedure. Since despite all wishes to the contrary every active health
officer will sooner or later find himsell in court, it may be well to include a few
words concerning court procedure. When court action appears to be necessary,
all other efforts for the conformance to social standards and for the enforcement
ofl a law or ordinance relating to them having failed, the first step is to bring
charges against the offender. The party who initiates the action is called in law
the plaintiff and in equity the complainant. The individual against whom action
is brought is known as the defendant in both law and equity. In bringing charges
against the defendant the first step is to determine which court has jurisdiction.
The same action may be interpreted as constituting any one of several different
criminal acts depending on the intent, the circumstances, the existing laws, and
the consequences. Thus to give a dangerous contaminated material to a single
individual is considered an assault, to make it available to the public at large
results in a criminal nuisance, and if sent through the mails it is a breach of the
postal regulations. The first two offenses are crimes under the common law or
statutes of a state, the third a crime under the acts of the Congress of the United
States. As pointed out previously, violations ol public health laws or regulations
usually are considered misdemeanors. In any case, infractions of these laws
constitute a criminal act so the case is within the jurisdiction of a criminal
court such as a police court.

The plaintiff then files with the court a complaint (sometimes referred to as
a declaration, information, petition, bill, or statement of claim) which he has
drawn up himsell or preferably with the aid of a municipal, county, or state
attorney. This should consist of a detailed statement by, let us say, the health
officer, of the facts and circumstances leading up to the controversy and includ-
ing the terms of any regulation or ordinance violated, the plaintiff expecting to
prove the facts and circumstances beyond reasonable doubt in court with the aid
of creditable witnesses in order to obtain a favorable judgment. The magistrate
of the court then issues a summons ordering the defendant to appear in the par-

*Lade, James H.: The Legal Basis for Venerecal Disease Control, Am. J. Pub. Health 35:1041,
Oct. 1945.
LEGAL CONSIDERATIONS 221

 

ticular court on a certain stated day and hour, and the summons is served in per-
son to the defendant by an officer of the court. The purpose of the summons is
to give actual written notice to the defendant that legal action has been instituted
against him. Its personal service is essential since a court is powerless to render
a judgment against a defendant who has not been so notified. Every individual
is entitled to his day in court in order to give him the opportunity to bring out
whatever defense he may find possible. The defendant now has a choice of six
procedures.

I. He may ignore the proceedings, placing himself in default and inviting
judgment against himsell.

2. He may conless to the accusation of the plaintiff and again invite a judg-
ment against himself.

3. He may enter a Plea in Abatement, questioning whether the court had
power or jurisdiction to act against him and whether proper procedure
had been followed.

4. He may file a demurrer stating in effect that while he admits the truth
of what the plaintiff states, as a matter of law, the facts do not entitle him
to recover.

5. He may file an answer or a plea consisting of a denial of the facts s*ntcd
in the plaintiff's declaration.

6. Again the defendant may admit the facts brought out by plaintiff but
bring out still other lacts in avoidance or in excuse of those alleged by
the plaintiff. Pleading continues until one side denies the facts claimed by
the other, thereby raising an issue calling for a decision and the case is
then ready to go to trial.

Most public health legal controversies do not take place before a jury, al-
though either side is entitled to a trial by jury if it so wishes. The first step in
such instances is the impaneling of a jury, consisting of the calling of prospective
jurors Irom an approved list and questioning them individually concerning
prejudices for or against either litigant. The function of the jury is to decide
questions of fact, in contrast to the judge's function of deciding questions of law.
When the court proceeding gets under way, counsel for each side may make an
opening statement explaining briefly what they expect to prove. Following this,
each side introduces its evidence.

All offenses consist of two factors, i.e., the criminal act and the criminal in-
tent, and both must be proved beyond reasonable doubt in order to demonstrate
the commission of a crime. A criminal act is an action or omission which the law
forbids. To be considered criminal, the act must be defined by a law or regula-
tion forbidding its commission. The rule of law is strictly interpreted in favor
of the accused so that the act is not considered criminal unless it corresponds
exactly with the definition contained in the law. The criminal intent is the state
of mind of the accused at the time when the criminal act was committed. It in-
volves a conscious recognition of the unlawful nature of the act followed by a
determination to perform the act. The courts presume the existence of criminal
intent on the basis of the actual commission of the act and it is usually unneces-
222 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
sary to produce evidence of criminal intent unless the accused attempts to prove
that at the time the criminal act was committed he was incapable of determining
or understanding its nature and unlawfulness or that the act was involuntary.
Such proof must be based on (a) infancy, (b) insanity, (c) mistake of fact, (d)
accident, (e) necessity, or (f) compulsion. II he is able to do so to the satisfaction
of the court, while the commission of a criminal act is recognized, the proved
lack of criminal intent causes the court to consider that he did not perpetrate
a crime and he will be declared innocent.

When all evidence has been brought forth, the judge instructs the jury con-
cerning the law involved in the issues raised and the jury then retires to decide
upon a verdict. When the jury renders its verdict but before the court pronounces
judgment, the losing party may make a motion for a new trial. This may be
granted if the court feels that there has been made an erroneous ruling concern-
ing the admission or rejection ofl evidence, if an erroneous instruction has been
given to the jury, or il the verdict is obviously contrary to the weight of the evi-
dence given. If the motion for a new trial is refused, the court renders its judg-
ment. If the losing party still feels that there was a substantial error in the con-
duct of the trial, he may thereupon take the case on appeal to a superior court of
appeal, in which case he is termed the appellant and the other side is the appellee.
The court of review or appeal is exactly what its name implies since it does not
conduct a new trial. Rather it simply considers the record of the proceeding
which took place before the inferior trial court, the exceptions taken to ruling
of the trial judge with regard to procedure, pleading, admission of evidence, in-
structions, etc. If the court of review or appeals decides that a substantial error
prejudicial to the losing side was made by the lower trial court, the judgment of
the lower court is reversed and the case is remanded for a new trial.

Expert Witness. Occasionally the public health worker takes part in a court
proceeding not as a plaintiff or defendant but as an expert witness for either side
or for the court itself. Whereas ordinary witnesses are restricted in their testi-
mony to exact statement of facts, expert witnesses are called upon to give
opinion testimony. Before being considered an expert witness, evidence of com-
petency must be presented to the satisfaction of both sides. In general, any li-
censed physician is considered to qualify as an expert witness in controversies
dealing with any medical questions. Specialization is not necessary and the expert
witness may give an opinion even if he never before saw either litigant and even
if he never before observed a similar case. Expert witnesses are customarily com-
pensated for their services, but compensation can never be contingent on the
winning of the suit by the side for whom the individual appears as a witness.

Courts in general tend to be suspicious of any opinion or expert testimony
and its acceptance by the court depends largely on the manner in which it is
given. With this in mind the expert witness should prepare himself well for what-
ever questions he might anticipate will be presented to him. He should be serious
and unassuming and present an attitude of wanting to assist an intelligent jury
in their rendering of a verdict by offering whatever special knowledge he may
possess. The expert witness should be free of partiality and bias, frankly and
LEGAL CONSIDERATIONS 223

honestly admitting a fact even il it injures the side which employed him as a wit-
ness, and honestly admitting lack of knowledge on a particular item il he does not
have it. He should listen carefully to all questions, answer clearly, directly and
concisely in language understandable to the jury and by a simple yes or no
whenever possible. The wise witness never volunteers information when on the
stand, assuming that, il significant, counsel will bring it out. Finally, perhaps
the most fatal mistake that might be made by an expert witness, or any witness
for that matter, is to allow himself to be successfully prodded into losing his
temper.

REFERENCES

1. Gray, J. C.: The Nature and Sources of Law, New York, 1909, Columbia University Press.
2. Cardoza, B. N.: The Nature of the Judicial Process, New Haven, 1921, Yale University Press.
3. Blackstone, William: Commentaries (Lewis, editor), Philadelphia, 1897, Rees, Welsh & Co.
4. Wilson, W.: The State, Elements of Historical and Practical Politics, Boston, 1918, D. C.
Heath & Co.
5. Gurvitch, G.: Sociology of Law, New York, 1942, Alliance Book Corporation.
6. Cardoza, B. N.: The Growth of Law, New Haven, 1942, Yale University Press.
7. Seagle, William: The Quest for Law, New York, 1941, Alfred A. Knopf, Inc.
8. Holmes, O. W.: The Common Law, Boston, 1881, Little, Brown & Co.
9. Kent's Commentaries, Lecture 21.
10. Wisconsin Supreme Court; State ex rel, F. W. Woolworth Co. v. State Board of Health et al.
(1941) 298 N.W. 183.
11. Pennsylvania Superior Court; Fisher v. Sweet and McClain et al. (1944) 35 A 2nd 756.
12. Missouri v. Illinois (1901) 180 U.S. 208, 21 S. Ct. 331, 45 L. Ed. 497.
13. Ascher, Charles S.: The Regulation of Housing, Am. J. Pub. Health 37:507, May 1947.
14. Village of Euclid v. Ambler Realty Co., 272 U.S. 365 (1926).
15. Georgia Supreme Court; Benton et al. v. Pittard, Health Commission, et al. 31 S.E. 2d 6.
16. Freund, E.: The Police Power, Chicago, 1904, Callahan.
17. Miami County v. Dayton, 92 O. S. 215.
18. Towa Supreme Court; State v. Strayer (1941) 299 N.W. 912.
19. State v. Burdge (1897) 95, Wisconsin 390, 70 N.W. 347.
20. Gellhorn, W.: Administrative Law—Cases and Comments, Chicago, 1940, Foundation Press
Inc.
21. Whitney v. Watson (1931) 85 N.H. 238, 157, A. 78.
22. Wyeth v. Cambridge Board of Health (1909), 200 Mass. 474, 86 N.E. 925.
23. Freeman, Allen W.: Public Health Administration in Ohio, DeLamar Lectures, Johns Hop-
kins University School of Hygiene and Public Health, Baltimore, 1921, Williams &
Wilkins Co.
24. Tobey, J. A.: Legal Aspects of Milk Control, Reprint 939, United States Public Health Serv-
ice, 1924,
25. The Legal Phases of Milk Control, Reprint 1343, United States Public Health Service, 1929.
26. Mustard, Harry S.: Legal Aspects of Planning for Local Health Units, Am. J. Pub. Health
(supp.) 37:20, Jan. 1947.
27. State Laws Governing Local Health Departments, Washington, 1953, Public Health Service
Publ. No. 299.
28. Tobey, J. A.: Recent Court Decisions on Milk Control, 1933, Reprint 1555, United States
Public Health Service.
29. White, L. D.: New Horizons in Public Administration, 1945, University of Alabama Press.
30. Joffey, L. A.: Publication of Administrative Rules and Orders (1938) 24 ABA]. 393, 397.
31. Ohio Supreme Court; State v. Waller (1944) 55 N.E. 2nd 654.
32. Tobey, J. A.: Public Health Law, ed. 3, New York, 1947, Commonwealth Fund.
224

ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

33.
34.
35.
36.
37.

38.

Ohio Supreme Court; Scofield v. Strain, Mayor, et al., State ex rel, Reilly v. Hamrock,
Mayor, et al., (1943) 51 N. E. 2nd 1012.

Kirk v. Aiken Board of Health (1909) 83 S.C. 372.

Moody v. Wickersham (1922) 111 Kan. 770.

Anderson, G. W.: In Graham, G. A., and Reining, H. (editors): Regulatory Administration,
New York, 1943, John Wiley & Sons, Inc.

Boyd, Richard F.: Legal Aspects (of Local Health Units) From Viewpoint of a State Health
Department, Am. J. Pub. Health (supp.) 37:31, Jan. 1947.

Lade, James H.: The Legal Basis for Venerecal Disease Control, Am. J. Pub. Health 35:1041,
Oct. 1945.
chapter 9

Organizational considerations

in public health

 

Introduction. A department of health is a public agency created to perform
several different types ol public tasks. As in the cases ol most other public
agencies, its functions may be categorized as: (a) service, e.g., the operation of a
tuberculosis clinic or of a laboratory; (b) control of certain human activities,
e.g., isolation for communicable disease control or the supervision of food and
industrial establishments; (c) education ol the public toward the goal of health-
{ul behaviorial patterns regarding immunization, diet, the care of infants, and
the like; and (d) guardianship, e.g., the collection and saleguarding as well as
the use of certain public records, especially those relating to birth, illness, and
death.

In order to perform these functions, the efforts of a variable number of dif-
ferent types ol individuals are needed. This immediately plunges those respon-
sible for the success of the program deep into problems of public administra-
tion in all of its phases. Gulick! has compounded the word “posdcorb” to indi-
cate the component functions or activities involved in administration. The mean-
ing ol this word may be explained in the following manner:

Planning the things that need to be done.

Organizing the formal structure of the agency.

Stathng the agency.

Directing the work ol the agency and making decisions relating thereto.

Coordinating all staff activities.

Reporting to the executive and through him to those to whom he is re-

sponsible.

Budgeting and all other aspects of fiscal management and control.

It is of interest to note the considerable progress that has been made in all
of these phases ol administration during the past quarter of a century and the
extent to which public health organizations have been involved and have taken
part in these changes. In this relatively short period ol time, there has developed
a considerable amount of long range planning in public health, exemplified by

225
220 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
the White House Conferences on Child Health, the Emerson Report on Local
Health Units for the Nation,? The Arden House Conference, and the recent
National and World Health Assemblies. With regard to structural organization,
there has occurred a great deal of consolidation of public health agencies and
integration of internal administrative responsibility which has brought about a
new interpretation of the function of the executive personnel of health depart-
ments. In the field of agency staffing, there have been developed techniques of
job classification and examination of prospective employees, an increasing adop-
tion of merit systems, and preservice and inservice training programs. These have
resulted in a notable decline in patronage appointment and an increasing em-
ployment of professionally qualified individuals for executive as well as technical
positions.

The internal organization ol many agencies has undergone constant ex-
perimental change, and administrative analysts, functioning first as consultants,
and later as employees of health agencies, have accelerated the development and
acceptance of greatly improved procedures. These changes have also brought
about better coordination of staff activities within organizations and in addition
have resulted in markedly expanded interagency coordination. This, incidentally,
has been one of the many factors involved in the expansion ol national adminis-
trative power and influence at the expense of the states, and of the states at the
expense of the local governmental units. During this same period there has come
about a more practical attitude toward the establishment and use of budgetary
procedures. Administrative and service [functions of health departments have
expanded greatly. In this category are included responsibility for hospital con-
struction, and standards for and operation of facilities for maternal and child
care, tuberculosis, and venereal disease treatment. There has been a steady shift
away from law enforcement by court action to law enforcement by administrative
regulation with a further concurrent shift away from the use of laws and regu-
lations for health promotion to the more basically sound educational approach.
Each of these many factors has placed increasing burdens upon public health
officials and has forced them to adopt a broader view ol their responsibilities
and functions. This in turn inevitably affects the type of preparation that must
be obtained for successful public health leadership.

Purposes of Organization. Administration as a general field may be divided
into two constituent areas: administrative organization, which deals with the in-
ternal structure and arrangement of the personnel ol the agency, and adminis-
trative management, which is concerned with the direction of the personnel,
fiscal control, and other techniques related to operation. It is the former with
which we are concerned at this point. Subsequent chapters will take up the vari-
ous phases of administrative management. A certain amount of overlapping,
however, is unavoidable. The aim of organization is to arrange people into work-
ing groups, associating those with similar functions or purposes, in order more
efficiently to obtain a desired result from their group action. Gaus, White, and
Dimock* state this in more detail as follows: “Organization is the arrangement of
personnel for facilitating the accomplishment of some agreed upon purpose
through the allocation of function and responsibilities. It is the relating of the
ORGANIZATIONAL CONSIDERATIONS 227

efforts and capacities of individuals and groups engaged upon a common task in
such a way as to secure the desired objective with the least friction and with
the most satisfaction for those for whom the task is done and those engaged in
the enterprise.”* While indicating the difference between organization and man-
agement, this definition also points out the relationship between the two, indi-
cating that organization consists of more than the placement of groups of per-
sonnel as if they were building blocks. The process of organization, by virtue of
the nature of those involved, is forced to consider personalities to a not incon-
siderable degree. However, the practical extent to which personnel is considered
in the arrangement of the organizational structure should best be limited as
much as possible. It should be remembered that in the long run the organiza-
tion is expected to outlast any individual in it, and, accordingly, it is better to fit
the personnel to a sound structure rather than to sacrifice sound structure to in-
dividual whims of personality.

General Principles of Organization. In launching an organization, there are
certain basic questions that must be asked by the person who finds himself in
the responsible executive position: What is expected of him? In what direction
are he and the organization to be headed? What is the logical order of initiating
activities? There is apt to be great temptation to try to develop simultaneously on
all fronts. To avoid this requires self-control, careful and continuous analysis, a
sense of timing and strategy, patience and deliberateness. Unless this is done,
the executive soon finds himself and his organization involved in a confusing,
meaningless series of uncoordinated moves.

The steps involved in the development of an organization or a program have
been well and succinctly described by Dimock?:

First you must know what the job of your agency is—if in business what the product
and the market are to be; if in government, what the statutory authority and the execu-
tive mandate indicate. Second you must select and appoint at least two or three key
men to your staff so that the organization may begin to unfold. You can now formulate
your plans somewhat more in detail because you have additional principle power on
which to draw. Third, recognizing the size of the task you interpret your plans into
financial terms which means budget and work planning. You can now begin to fill in the
gaps in your organization with the necessary personnel, thus continuing the biological
process of cell division already started when you picked your right hand man. And
finally, you must prepare to expand, to gear your enterprise in such a way that you can
take on new functions, new activities and emphasis without losing your stride.t

Many executives of new organizations feel themselves torn between two ex-
tremes: a wish, referred to above, to start immediately on all fronts regardless
of the inadequacy of preparation, personnel, or facilities with which to do so,
and a wish to defer any action on a program until all desirable, adequate per-
sonnel and facilities are available. Both approaches, of course, are unwise. Every
organization, including the new ones, must function, must produce to some
extent, in some direction even at the start. However, it is far better to engage in

*Gaus, J. M., White, L. D., and Dimock, M. E.: The Frontiers of Public Administration,
Chicago, 1936, University of Chicago Press, pp. 66-67.
iDimock, M. E.: The Executive in Action, New York, 1945, Harper & Brothers, pp. 19-20.
228 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
one or a few activities which offer a reasonable chance ol acceptance and success
than to move off inadequately in all directions ol the unknown at once. Careful
study ol any community will reveal certain problems that are “touchy” and others
that are noncontroversial. Thus an attempt by a new health department or execu-
tive to push an effective industrial hygiene program in a mining community
may bring about disastrous consequences. Both labor and management may re-
gard the activity with suspicion and do everything possible to prevent its accept-
ance and success. Under ordinary circumstances neither faction will have any
objection to a maternal and child health program or efforts to secure protection
against disease. In the long run it may be advisable for the public health agency
to establish a foothold and to gain community acceptance and support by be-
ginning along these lines with the hope ol subsequently moving on to other
fields. In other words, the planning and organization ol the public health pro-
gram may often best be done on a gradual pick-and-choose basis even when this
involves the sacrifice of immediate benefits for long-range progress. Both the new
and the already established organization must continually move and grow. Stasis
actually represents retrogression, and an organization allowed to come to a stand-
still has already begun to decay and die.
«

There are certain well-established principles of organization that are ap-
plicable equally to public and to private enterprise. In the final analysis, they
consist essentially of the application of common sense to the management ol a
group ol people working toward a common goal: the maintenance of a balance
between responsibility and authority, consideration of the limits of human cap-
ability, the relationship between ultimate productive action and the supple-
mentary needs related to it. The outstanding principles may be summarized in
the following adaptation of an outline by Pfiffner.

1. An organization should have an hierarchy, sometimes referred to as the “scalar process,”
wherein lines of authority and responsibility run upward and downward through several
levels with a broad functional base at the bottom and a single executive head at the apex.

2. Every unit and person in the organization without exception should be answerable ultimately
to the chief executive officer who occupies the supreme position in the hierarchy.

3. The principal subdivisions on the level immediately under the chief executive officer ordi-
narily should consist of activities grouped into divisions or burcaus on the basis of function
or general purpose.

4. The number of these departments should be small enough to permit the chief executive to
have an effective “span of control,” yet large enough to provide effective contact with all olf
the major functions of the organization.

5. Each of these departments should be self-contained in so far as this does not interfere with
the necessity of integration and coordination.

6. Provisions should be made for staff services, both general and auxiliary in nature, to facili-
tate over-all management of the organization as a whole and coordination and function of
its component divisions.

7. In organizations large enough to warrant it, certain auxiliary activities, such as personnel
and finances, should be directly under the chief executive officer and should work closely
with similar units in cach of the line departments.

8. The distinction between staff and line activities and personnel should be recognized as an
operating principle and be made clearly understood to all concerned.
ORGANIZATIONAL CONSIDERATIONS 229

 

Levels of Organization, Policy Making. From the standpoint of organiza-
tion, public agencies such as those dealing with public health may be divided
into three distinct levels, i.e., policy making, administrative, and functional.
Policy making is primarily a function of legislative bodies which are concerned
essentially with the over-all or broad aspects of public responsibilities and pro-
grams. Thus, the legislative branch of government determines the areas in which
a public agency must act and the boundaries which limit that action. The details
ol policy are usually left or delegated to boards, the members ol which are usually
appointed rather than elected. Thus, it is customary in the United States for the
public health law to be promulgated by the legislature and for the detailed rules
and regulations necessary for the practical implementation of the mandate of the
law to be stated by a board of health. The actions of both the legislature and the
board are ol course subject to adjudication by the courts.

Boards. Boards of health ideally consist of an odd number ol members
neither too many nor too few (usually five or seven) appointed by the executive
head of the government, the mayor or governor, [or overlapping terms. Thus,
members ol a committee of five may serve for five years each, with one appoint-
ment expiring each year. In practice, there is considerable variation in the
manner of appointment of board members, in their characteristics, and in their
constitutent number. Using state boards of health as an example, the number
of members appointed varies from three in several instances to fourteen in one
state. With but a few exceptions, members of state boards of health are appointed
by the governor, whose selections are subject to senate approval in about a dozen
states. In several states the appointment must be made from a list of nominees
submitted to the governor by the state medical association, and in one state mem-
bers actually are appointed directly by the state medical association. In another
state, it is specified that the “Medical Association together with the Comptroller
General shall be known as the State Board of Health.” In this case the executive
committee of the state board of health (seven members of the medical associa-
tion) performs the functions usually delegated to state boards of health. The
period of service varies from two to seven years, with six years being the most
common. In about three fourths of the states the terms of the members of the
state board of health are overlapping.

It is desirable that there be represented on a board of health the interests
and points of view of certain key groups in the community. The most important
ol these but the most commonly overlooked is the public itsell. Again referring
[or descriptive purposes to state boards ol health, but few states specificially
require lay representation. The majority of states stipulate that a certain num-
ber, and in a lew instances all, of the members shall be physicians. Other desig-
nations encountered include a dentist, a civil or sanitary engineer, a pharmacist,
an attorney, a veterinarian, an osteopath, and a woman. In one state, the board
of health consists ol three ex officio members, the governor, the attorney general,
and the superintendent of health, who in this instance is appointed by the
governor.

It is appropriate here to point out certain objections to the policy of having
boards consist of ex officio members. Not infrequently, this procedure is resorted
230 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
to as a means of reducing or avoiding administrative costs. While it is true, as
claimed by some, that ex officio membership provides for contact and understand-
ing between several agencies of government and government officials, such mem-
bers are appointed to the board without any consideration of their ability to be
of service. Furthermore, this added responsibility, if taken seriously, consumes
either much personal time or time that may better be devoted to the duties of
the individual's primary office. Not infrequently the health officer is added as an
ex officio member of the board of health. To a considerable degree this defeats
some of the basic purposes of the board which will be discussed later. No objec-
tion is raised, however, to the health officer meeting with the board as a non-
voting participant and perhaps acting as its secretary.

Generally speaking, it is considered that boards of health should be more
equitably representative than ordinarily found. There are many advantages to
this. Policies will be developed with [ull understanding of the opinions and
preferences of those most directly concerned and affected, and of the probable
effects of a particular policy upon them. Policies are thereby more apt to be
realistic and acceptable and therefore more easily enforced. When the primary
groups affected are represented on the board, there is provided an opportunity
for them to be educated and to understand the viewpoints of others in the com-
munity and of the responsible public authority. Opinions that tend to be hidden
or overlooked are brought out into the open and given a fair opportunity to be
heard. Finally, the determination of policy by a truly representative board is a
much more democratic procedure than administrative dictation by either an
elected or appointed official.

A legally established board has still other advantages for the health officer
and his department. It provides for a nonpolitical method of appointment and
removal of the executive health officer, who should be a professionally trained
career person and protected from the sources of political interference. By virtue
of its delegated responsibility, a board also protects the health officer from many
legal involvements. Finally, if provision is made for overlapping terms, the board
provides for continuity of community public health thought, direction, and action
from one political administration to another, or when a change of health officers
occurs.

It is only fair to state that under certain circumstances boards may have dis-
advantages which arise in either or both of two ways: conflict among the mem-
bers of the board itself, or conflict between the board and its executive officer.
While it is generally desirable for boards to be representative of the constituency
they serve, and ol outstanding interested parties and groups therein, conflict
within boards is more apt to occur where the membership has representation
of many diverse groups. Not infrequently board members may, in effect, “choose
up sides” with the result that no agreement can be reached and as a consequence
effective administrative action by the executive officer is weakened or paralyzed.
The actions of the board in instances such as this may consist of a series of ma-
jority or minority decisions and bitter charges that one side or the other is trying
to steam-roll policies through or capture impartial members. In such situations,
what real progress may be made depends largely upon the joint action of any
ORGANIZATIONAL CONSIDERATIONS 231

 

impartial board members and a wise executive officer. Working together for
common-sense mediation, they may sometimes bring about conciliation or at
least effective compromise.

Conflict between the board members and the executive officer may develop
in several ways. The executive officer, either because of dogmatic personal force-
fulness or preoccupation with his daily work, may ignore his board, fail to con-
sult it or give it work to do, or disregard its recommendations. If the board and
its traditions are weak, he may get away with it. Not infrequently, on the other
hand, there may be one or more particularly active and forceful board members
who, because of overenthusiasm or a wish to express power and influence, may
step beyond their prerogatives and attempt to enter the field of operations. In
doing this, they encroach upon the functions and responsibilities of the executive
personnel. In addition to these situations, there is the type of executive who,
because of personal weakness or of particular confidence in his board, may try
to pass his responsibilities to it. Fortunately, this is observed relatively infre-
quently. From the foregoing, it is seen that the ideal relationship between an ex-
ecutive officer and his board is a delicate one wherein each party must be con-
stantly alert to his own responsibilities and prerogatives and those of the other
party. Board members must always bear in mind that the field of operation be-
longs to the administrative or executive officer who in turn must respect the func-
tions and responsibilities of the board by keeping them informed, asking their
advice, and bringing them along with him in his professional plans.

Boards have certain specified responsibilites and functions. In the final
analysis, the board ol health is the legal representative of the community's public
health program and agency. As such it has certain semilegislative powers, par-
ticularly with regard to the promulgation of rules and regulations that may be
deemed advisable for the community. Related to the semilegislative powers are
certain limited semijudicial powers, in that a board of health may hold hearings
on some matters relating to the public health. Perhaps the most important ad-
ministrative responsibility of a board of health is its customary power to appoint
the executive health officer and, il necessary, to dismiss him. Boards of health
sometimes have responsibilities relating to the determination of general admin-
istrative and program policy, the approval of major appointments, and budget
review and approval. Except in very unusual circumstances, such involvement in
the details ol operation are generally considered undesirable. It is desirable that
a board of health meet at regular intervals, usually once each month, at the
request of the health officer, and at times ol emergency. Board members should
be [ree to advise the executive officer either on his request or on their own
initiative. They are entitled to be kept informed, should have access to all health
department records, and when their suggestions and recommendations are not
followed they are entitled to an explanation.

It cannot be denied that an organizational pattern which includes a board
may sometimes appear to be less efficient and slower in action than one operated
along more dogmatic, bureaucratic, or dictatorial lines. The design of an organ.
ization is necessarily of great importance in the search for an efficient instrument
of action. In a democratic society, however, the organizational mechanism must
232 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

correspond, at least in its fundamental form, to a pattern which is acceptable to
the people who are to be served. It is often necessary to sacrifice some measure
ol efficiency in deference to the public wish for freedom ol action and even to
their prejudices and lack of understanding. A realization of this serves to em-
phasize the basic importance of public education in the public health program
which in the final analysis bears the most satislying and lasting fruits.

Advisory Committees. A [ew comments should be made with regard to ad-
visory committees. Because of the numbers involved, complete interest repre-
sentation is impossible of achievement on the policy-making board of health.
To offset this, many public health agencies have formed advisory councils or
committees as an additional means of obtaining broader community contact
and participation. Many times the existence ol advisory committees enables civic-
minded individuals and citizens with specialized knowledge or interest to render
services of incalculable value to the community.

Advisory committees are of two general types—constituent and technical.
Members of constituent advisory committees may be chosen for their personal
qualifications or because they represent social, professional, or other groups in
the community. The chiel advantage and use of constituent advisory committees
is to act as a channel through which the community on the one hand and the
health department on the other are kept aware of each other’s thoughts, plans,
and action. They are ol considerable value in the health education program as
well as occasionally serving as a line of defense for the functional public health
agency. Technical advisory committees, on the other hand, are designed to assist
the administrative officers of the public health agency in the formulation of plans
and in the development and application ol various techniques of value in the
public health program. Naturally, the larger and more complex the community,
the greater the number ol technical advisory committees that might be indicated.
Thus, a large city or state health department may have advisory committees deal-
ing with problems ol pediatrics, maternity, engineering, law, and the like. Ad-
visory committees should, of course, have no powers, and the executive officer
must be constantly on guard to thwart the assumption ol power by overenthusi-
astic advisory committee members. A mitigating technique in this regard is for
advisory committees to be established on a temporary basis, the need to be de-
termined by the executive officer ol the health department. This is generally
considered to be good practice since it is pointless to have a permanent committee
for needs which arise only occasionally.

Administrative Level. On the executive or administrative level ol organiza-
tion, there is found what is often relerred to as the hierarchy, built upon a
scalar plan. At the apex ofl the pyramid is the chiel executive who, for our
purposes, is the health officer or health commissioner. Although an employee,
he is in a somewhat different position Irom the rest ol the employed personnel
ol the agency. It is he who is responsible for the over-all management of the
agency and for the planning and implementation of its program. Whereas the
remainder of the personnel may be subject to civil service or merit system status,
he usually is not. The activities of the chief executive are usually defined and
limited by the terms of the corporate charter or state law. He has the privileges
ORGANIZATIONAL CONSIDERATIONS 233

ol what has been called an economic royalist, which means that he has been
entrusted with a considerable sum of other people's money and he is expected
to find ways to put it to as profitable use as the law allows and his board approves.
His position differs [rom that of a private executive or administrator in that,
while the latter may do anything except what the law forbids, the public ad-
ministrator may do only those things which the law specifically allows.

The functions of a chiel executive are threefold: political leadership, admin-
istrative management, and ceremonial representation. It is with the second ol
these that we are chiefly concerned. In fulfilling his managerial duties, the health
officer should first acquaint himself thoroughly with the most minute details of
certain aspects of his position. The first of these are his rights, prerogatives, and
responsibilities. This involves a careful study and analysis ol the public health
law and sanitary code under which he is to operate. Next he must familiarize
himself with the facilities actually and potentially available to him, including
finances, personnel, and material. In order to exercise his rights, meet his respon-
sibilities, and properly use his [acilities, the health officer must next perform
a careful and thoroughgoing analysis ol all ol his evident and potential problems.
These problems are not necessarily restricted to matters requiring professional
or technical knowledge. Many ol them may be in the realm ol personnel man-
agement, public relations, or finances.

Beyond this initial stocktaking, which of course should be Irequently re-
peated, the public health administrator has a number of duties ol a managerial
nature. Some of these are imposed by charter, constitution, or statute, some are
defined in executive orders, while others may be merely customary or attributable
to the administrator's personal wishes and interests. The most important of these
is the determination ol the basic administrative policy ol the agency. It is the
health officer’s right and duty to decide in what direction the program should
move, when each move should be made, and the manner in which progression
is best achieved. Next he must issue the necessary oral or written orders, directions,
and commands to his subordinates in order to put his administrative policy into
cffect. This necessitates that he work out the details of organization of the agency,
its internal structure, subordinate leadership and responsibilties, and whatever
committees are needed to solve controversies, adjust relationships, or establish
policies and techniques to meet emergencies. ‘This leads to the need for coordinat-
ing the activities ol the subdivisions of the agency. Most ol this is best accom-
plished at lower levels, but the chiel executive has a definite responsibility for
over-all coordination. He must arbitrate claims of conflicting action and over-
lapping jurisdictions. Within the agency, he serves as the court ol last resort.

In the financial field, he must develop a fiscal program for the agency, pre-
pare and submit a budget, and supervise the expenditure ol the appropriations.
He should have direct responsibility for the appointment, supervision, and dis-
charge of all personnel in the level immediately below him, usually consisting
ol division and bureau heads, and certain staff and auxiliary personnel. Discharge,
however, should be subject to review and approval of a merit system. While in
large agencies, choice and supervision of line personnel should be a prerogative
of the appropriate division or bureau chiel, decisions should be subject to the
234 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH oo
approval of the chief executive. The executive health officer by virtue ol his posi-
tion bears the ultimate responsibility for the supervision, facilitation, and control
of administrative operations. He is not expected to perform all or even part of
the many jobs or services of the agency, but it is his responsibility to see that they
are done properly and effectively. This means that in order to be effective he must
pass down or delegate some of his authority and responsibility. This frequently
ignored fact will be discussed in more detail further on. A final duty of the chiel
executive relates to public relations, which is the subject of Chapter 12.

It may be appropriate to devote a few lines to the consideration of what
makes an effective chief executive officer. Perhaps the most comprehensive general
statement that could be made is to the effect that the characteristics that go to
make up a good administrative officer are in many ways similar to those required
for good parenthood. A primary function of the executive health officer is to
provide leadership. His usual problem is how to lead his organization in the face
of the limitations and obstacles ordinarily found in most situations. There is
no standard answer to the question. Solution depends to a considerable degree
upon the individual and his personality rather than upon his technical knowl-
edge. This explains why capable technicians are so often abject, unhappy failures
when placed in administrative positions. The answer to the question varies by
place and time. The problems encountered in a new organization are quite differ-
ent from those of an old established agency. It should be further recognized that
different organizations have different backgrounds of development which condi-
tion the rate and manner in which they move. Executive manner and action are
certain, of course, to differ under emergency conditions in contrast with normal
circumstances.

Perhaps the most important philosophy for the executive to adopt is that
the end results are the products of the organization and not of any one individual
even himself. In the long run, any effect he has is due to his influence and not to
his command. Whether he wants to or not, he has to rely upon his subordinate
staff in order to accomplish the purposes of the agency. Even if this were not
true, the executive should not attempt to take over the tasks of those on lower
levels. To do so invariably confuses and antagonizes the personnel in general and
the division and bureau heads in particular. The executive health officer’s posi-
tion is that of a catalyst dealing with people, assimilating their ideas, evaluating
them, determining lines of action and seeing that action is taken. He should do
everything possible to conserve his time and energy for these higher level admin-
istrative functions, adopting the policy of Andrew Carnegie who never did any-
thing he could hire someone else to do for him. The executive health officer
should approach his position with a long-range view, recognizing that most
administrative changes and advances take a long time. This means that he must
balance his type or method of action to fit particular situations, slackening the line
at this point and at this time, and reeling in or striking out at other places and
at other times.

One final word about executive behavior. The popular picture exists of an
executive austerely established behind a shiny desk, in a comfortable office, grant-
ing a series of interviews to a parade of subordinates and others who appeal for
ORGANIZATIONAL CONSIDERATIONS 235

 

advice and guidance. It is felt that this presents a rather false view of sound ad-
ministrative practice. The chief executive in public health as in any other field
is neither the ultimate fountainhead of all knowledge nor physically capable of
personally directing the activities of a large number of individuals. The numbers
of those within his agency with whom he has intimate working relationships
should be limited, otherwise he misses the forest for the trees. This is not meant
to imply that the executive should confine his contacts or relationships to those
who voluntarily come to him. Rather he should actively seek out those who need
his help and who can be of assistance to him.

Functional Level, Delegation. An organization functions most effectively
when a capable executive officer, rather than attempting to control and supervise
intimately each of the various activities which make up the total program, is
able to delegate control and supervision to responsible subordinates. This is un-
questionably the most important single factor in successful administrative prac-
tice. The executive has to decide what part of his responsibilities and authority
he will entrust to those immediately below him and what he will withhold for
himself. Each of these key subordinate executives should be allowed to pick
those who will work under him or he cannot fairly be held responsible for results.
The subordinate executives in turn delegate to those next in rank such parts
of their own specified responsibilties as they may choose, and so on down the
line. As Dimock? has described it, the executive in effect says to his department
heads, “You know our objective. You know the plans. You know the policy. Now
the job is to see that this part of the work is done. I am holding you responsible
for it. It is up to you to get results.”

This type of leadership almost certainly pays dividends since it gives com-
petent men pride in their work and encourages initiative, self-confidence, and
ability. The opposite and usually unsuccessful approach is that of the executive
who insists that all actions and decisions originate with him, and that everything
go in or out over his desk. Inevitably this causes division heads either to leave
the organization for more reasonable and stimulating fields, or to lose interest
and initiative, thereby becoming intimidated “yes men” of little real value to
the organization. If the latter, while they may appear to be obedient, they
gravitate into a sullen rut, secretly delighting in the event of administrative errors.
Equally inevitable in such cases is the puzzlement of the executive over the ap-
parent lack of cooperation, understanding, and support from his subordinates.

It is not to be inferred that the job of the executive is merely to find capable
subordinates, to delegate authority to them, and then to sit back in ease and
watch the wheels go round. Rather, the real test of sound leadership involves the
ability, alter delegating authority, to step in unobstrusively at appropriate times
to give suggestions or directions on the basis of greater knowledge and a more
complete understanding of over-all strategy. Pfiffner® has listed certain rules and
prerequisites for the successful delegation of authority and responsibility. The
first, most important, and most frequently overlooked of these is simply that the
executive must honestly want to delegate. If responsibility is to be delegated,
subordinates must be carefully chosen, who are capable of shouldering that
responsibility. The responsibility must be defined for them and they must be
trained to carry it. Furthermore, il responsibility is delegated, there must also
be delegated with it the appropriate type and amount of authority. Failure to do
so is the second most common error. If subordinates are good enough to employ
in the first place and to assume responsibility, they are good enough to trust.
In addition, general policies must be established and disseminated throughout
the structure ol the organization. Management planning must be carried on
continually and must include job analyses, organizational studies, budget plan-
ning, work-flow studies, and, in so lar as possible, standardization ol systems, tech-
niques, and procedures. Internal checks must be established that will automati-
cally show danger signals when responsibilities are not met or when authority
is overstepped. Finally, provision must be made to assure this flow of manage-
ment up, down, and across the hierarchy of the organization.

While the foregoing rules are sound and based upon the experiences of many,
one of the easiest organizational mistakes that can be made is to assume that a
position or function can be established according to hard and fast specifications
and that any one of a number of people can be found to fill it satisfactorily and
equally well. Human beings are not made to fit into precise patterns. To again
quote Pfiffner,® “the functions delegated to each man can be performed only
within the limits of his individual capabilities. The best procedure for preparing
an outline ol responsibilities is first to dralt an ideal organizational chart, then
to sit down with the individuals whose names appear on the chart, discuss specific
responsibilities with them at length and with infinite patience, and then to
allocate responsibilities wherever common agreement dictates.” *

The Scalar Principle. The term scalar principle has been referred to in the
preceding discussion of the hierarchy and the executive officer. It consists of the
administrative arrangement ol the [functional groups or units in steps as in a
scale. (Fig. 3.)

This involves the three considerations of leadership, delegation, and func-
tional definition. There must be a single supreme leader ol the organization,
but, as has been discussed, in order to exercise his leadership effectively it is
necessary that he delegate both authority and responsibility to subleaders on the
various subordinate steps in the organization. Each of the primary steps, usually
referred to as divisions or scctions, are determined on the basis ol secondary
constitutent purpose or function, such as water control, food control, or milk
control. The looseness of and resulting confusion [rom different terminologies
are somewhat unfortunate; department, division, bureau, service, and office often
being used interchangeably il not haphazardly in the structural plans of many
organizations. Actually it matters relatively little how the terms are used, so
long as they are used in a consistent manner and not mixed up.

The fundamental concept of the scalar principle is unity of command, with
lines of authority and responsibility going both up and down so that every in-
dividual in the organization is directly responsible to only one superior and
through him ultimately answerable to the head ofl the organization. These lines
are sometimes referred to as organization lines or channels. All interagency com-

*Pfiffner, J. McD. Public Administration, New York, 1946, The Ronald Press Co., p- 81.
ORGANIZATIONAL CONSIDERATIONS 237

 

munication and action must follow these lines and should never cross or short-
circuit them. Lines should never be considered permanent, since good organiza-
tion depends partly on the skills and personalities of the individuals involved
and partly on the nature of the functions to be performed. An organization, in
other words, is a living thing which continually grows and changes, and its
structure accordingly must be adaptable. The administrator must set up the best
structure possible but should never hesitate to change it for a good reason. The
units to be headed by subleaders should be established or differentiated on the
basis of functional definition. The trend has been to provide a small number of
relatively large major divisions, each with a single major purpose or function,
and each further subdivided into bureaus, il necessary, on the basis ol sub-
functions.

 

<« TOP ADMINISTRATOR

 

 

 

 

 

 

 

 

| «+ DIVISIONS

 

 

 

 

 

 

1 I EE
4+BUREAUS
UNITS
SERVICES

 

 

 

Fig. 3. The scalar process.

While theoretically ideal, this is often more easily said than accomplished
since many instances arise in which two or even more departments or other
organizational units are involved and appear to have valid claims. Should the
industrial hygiene program be placed in a state health department or in a state
labor and industry department? If the former is decided upon, should responsi-
bility for the program be delegated to the division of environmental health, the
division of medical services, or should it be set up as a entity in itself? Should the
school health program be in the department of health or in the department of
education? Whether assigned to the one or the other, the school health program
involves salety, sanitation, medical services, and education, cach ol which overlaps
into other fields. With these problems in mind, White" asks the question, “When
is a function of sufficient major importance to warrant organization as a division
rather than as a bureau with other related [unctions in a broader unit? Decisions
on such cases usually flow from other considerations than abstract plan; the
pressure of interest groups; the capacity ol those who possess to resist change;
bureaucratic and political bargaining. The concept of [unction itself is not en-
tirely precise although it is a genuine guide. The very [act that no division can
 

be functionally self-sufficient and must inevitably have frontier problems with its
neighbors is itself a further guide to the necessity for general staff and strong
overhead management.” *

While it is best for each individual division or bureau to be concerned with
a particular function, they should each contribute to an over-all major purpose
of the department as a whole and not have been allocated to the department
as a result of a search for a roosting place. At least one department on the Federal
level, the Department of the Interior, has been referred to as a federation of
unrelated bureaus rather than a department. Occasionally it is found expeditious
and practical to form administrative units on bases other than functional. Thus,
they may be determined by geographic area such as the Tennessee Valley Author-
ity, or by type of clientele such as the Department of Public Welfare or the
Children’s Bureau.

The question frequently arises, in relation to public service organizations
such as health departments, as to whether the unit of organization should con-
form geographically to already existing boundaries, such as corporate limits and
county lines, or whether altogether new boundaries should be established based
entirely on the nature of the problem to be met or the distribution of the public
to be served. Theoretically, at least, there is much that may be said in favor of the
latter type of administrative district. The size and limits of an administrative
district, being divorced if necessary from political boundaries, may be determined
on the basis of like groups of population, trading or economic areas, topograph-
ical considerations, and with the convenience of officials and citizens in mind.
They are relatively easy to readjust with little or no friction, in contrast with
service areas whose boundaries conform to those of established political units.
The effect of the latter is commonly seen when attempts are made for purposes
of efficiency to expand the jurisdictions of local health departments either by
combining a city with its surrounding county or by combining two or more
counties for health services purposes. Vested political interests are disturbed.
Conflict arises between city and suburb and between village and farm.

Nevertheless, the firstmentioned type of administrative district has but
limited governmental status, no independent existence, and usually no power to
raise revenue in its own right and by its own action. Hence, public health units
in the United States are based on well-established politically defined units of
government: municipalities, counties, combinations of counties or of counties
and municipalities, and states. The characteristics of such units of government
have been outlined by Anderson® in the following manner:

1. The unit has its own separate continuing governmental organization, either a

board or a council, or in some cases a single elective or appointive official.

2. This governing body has the power year after year to provide some governmental
service, or some quasi-governmental service like a public utility on its own respon-
sibility and subject to its own control.

3. This governing body is independent of other local governments and is not a mere

board handling some function on behalf of, or as a department of, another local
corporation.

*White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co., pp. 86-87.
ORGANIZATIONAL CONSIDERATIONS 239

 

4. The area covered by a unit of local government may or may not coincide with the
area of some other local government. If the areas coincide, the test is whether the
corporate existence is separate for the two or more units occupying the same area.
There can be separate public corporations in the same area, of course, if they are
organized for different purposes.

5. Among the important powers for any unit of local government the power to raise
revenue by taxation, or by special assessment, or by fixing rates for service rendered
must be considered one of the most important. When other tests fail, this test may
decide the case*

 

county BOARD OF SUPERVISORS |

 

BOARD OF HEALTH
HEALTH OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

[PH. ENGINEER] | SUPLRV. NURSE | [OFFICE MANAGER| [OTHERS
1 [— 1
SANITARIAN| [SANITARIAN]| [STAFF [oraer FILE STENO
NURS E|| [NURSE CLERK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STAFF CLERK
NURSE TYPIST

Fig. 4. Example of county health department organization.

 

 

Returning for a moment to the internal structure of the organization, it is
not possible to make a single rule concerning the number of subdivisions or
bureaus that should be established. The decision varies with individuals, time,
place, and circumstances. Some agencies, such as health departments, with many
professional types (engineers, physicians, nurses, veterinarians, health educators,
etc.), may have to have a larger number of divisions and bureaus than an agency
with a more or less homogeneous personnel such as a fire department. Further-
more, some executives feel that they must have, and are capable of maintaining,
more effective and frequent contact with the workers of their organization through
many division chiefs.

The smaller the organization, the greater the tendency and reason for the
chief executive to have personal contact with all phases of activities. This is
most completely seen in the small county health unit where the small personnel
precludes the necessity for breaking down the organization into smaller sub-
divisions. The typical result is a structure such as illustrated in Figure 4.

* Anderson, William: The Units of Government in the United States, Public Administration
Service, No. 42, 1934, p. 2.
 

 

 

Governor of State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Division of
Tuberculosis Control
1934

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I
Advisory le momen J State Board of Health Lome ee Advisory | _____________ een memo
Laboratory Comm. 1885 Hospital Council
I |
Secretary ond Executive Officer |
1885 T (
Division of Veterinary Public Health Sertrol Adminisirelion Division of Mental Hygiene
1947 Health Education Services 1946
1936
|
Assistont Secretary and Director |
Dwision of Local Health Administration) |
1940 |
Public Health |
Nursing Services |
1943
Division of Public Division of Division of | Division of Vital Division of Division of Maternal Division of Venereal
Health Laboratories Food ond Drugs Sanitation | [Statistics and Records Epidemiology ond Child Health Disease Control
1886 1907 1907 ' 1911 1912 1918 1918
!
i
Division of Division of ' Division of Personnel Division of Division of Hospita!
Dental Sygiene Industrial Hygiene ' and Finance Cancer Control Focilities (created by f======c==-d
19 1942 ' 1943 1946 Legislature - 1947)
|
pmmccmnan -—ammeema- BD En +
1 1 1
Counties with with Full-time Counties with Port-time |
Public Health Nurses Local Health Units Heolth Officers |

 

 

 

 

 

 

 

Fig. 5. Organization of State A health department.

HLIV3H JI11gnd NI SNOILVHIAISNOD IAILVHLISINIWAY

ote
ORGANIZATIONAL CONSIDERATIONS 241

 

In this situation, the health officer, in addition to performing the medical
activities of the agency, personally carries out all of the staff and auxiliary func-
tions and directly supervises the rest of the personnel except in the case of staft
nurses who, when sufficient in number, are supervised directly by a chiel nurse
and indirectly by the health officer.

Organizational Structure. The problem of structural organization is an
important one because upon its solution depends whether or not the chief execu-
tive is actually in command of or at the mercy ol his organization. The more
widely dispersed his direct organizational contact, the further away he gets from
the functions of top administration. Generally speaking, a small number of divi-
sions is desirable, giving a quantitatively limited but qualitatively strong span of
control. Too fine a structural breakdown tends to bring about a number of un-
desirable effects. The number of fields or directions in which even the most cap-
able human being can effectively focus attention is decidedly limited and has
been estimated to be not more than six to eight. The unfortunate type of structure
found so frequently in large health departments with a dozen or more divisions
strung out across the line makes it impossible for the administrative health officer
to grasp and to hold in his span of attention and control all phases of the pro-
gram. He finds it difficult to see the activity ol each division in relation to all the
others, and this results in unbalanced decisions and a field day for pressure
groups or a few forceful division chiels.

An example of this horizontal type ol administration is shown in Figure 5,
which presents the structure of the health department of a moderate-sized state
with a relatively small and homogeneous, predominantly rural population. In-
terpreting the organization chart literally, it appears as if seventeen division di-
rectors report directly to the chiel executive officer. That an arrangement of this
nature could actually function as depicted is improbable. In practice, in most
instances of this type, there is usually some division of responsibility and authority
between the state health officer and his one or several deputies.

Figure 6, which presents the plan of organization followed for many years
by the health department of State B, illustrates a particularly poor structure. The
Commissioner had a dual responsibility to the Governor and to the Public Health
Council, the members ol which were also appointed by the Governor. Directly
responsible to the Commissioner in turn were the directors of nine separate divi-
sions, a number considered somewhat excessive [or effective span of control.
Attention should be called further to a number of incongruities within the line
structure. Altogether there were four separate laboratories, not counting those
which, for good reason, were located in and served the hospitals. The laboratory
designed to serve the Division ol Sanitary Engineering was itself set up as a divi-
sional entity. While the Cancer Section was within the Division of Adult Hygiene,
the Cancer Hospital was placed in the Division of Tuberculosis. Public Health
Education was effectively provincialized in the Division of Child Hygiene. A final
point of wonder was the placement of responsibility for Health Districts in the
Division of Communicable Diseases. Interestingly enough, this particular State
Health Department has a long and honorable record of effective service, perhaps,
one might say, despite its form of organization. Recently it has been reorganized
242 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

 

into five sections: general services, preventive medical services, hospital and medi-
cal services, environmental sanitation, and local health service. Each contains a
reasonable number of logically related divisions, the directors of which are
responsible to a deputy of the Commissioner. Since reorganization it has operated
even more effectively, as well as with greater coordination and smoothness.

A particularly satisfactory and workable arrangement is presented in Figure
7, which shows the structure of the health department of one of the largest and
most complex states. In this organization, the span of control for the chief execu-
tive and for each of those directly responsible to him has been limited to a reason-
able practical number. Furthermore, services and functions have been combined
in as logical a manner as possible. Lines of direct responsibility and reciprocal
relationships are clearly indicated.

 

Governor

 

  

Public Health Council

 
 

Cormissioner of Public Health J

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[ L I I I 1 I 1
Division of |[Division of | [Division of | [Division of Division of Divisioq | Division Division ivision
Sanitary Communi = iological [Tuberculosis Central of Chil of Water of Food of Adult
Engineering || cable Labaratories Administration Hygiene || and Sewage||and Drugs ygiene

Di Laborator=-
ies
1/7 — —Tr—/—
[path | Diagnos~| [Venereal Sanatoria [Clinics | [Cancer Public Food and Cancer
Districts | |tic Lab-| [Disease [Sanatorid (lintes] Hospital J Health Drug Lab=- Section
oratory| (Control Education oratory

 

 

 

 

 

 

 

 

 

 

Fig. 6. Former organization of State B health department.

There are three types of organization charts: skeleton, personnel, and func-
tional. Skeleton charts, of which the foregoing are examples, merely present the
major units of the organization. Personnel charts show in addition the major posi-
tions and often the names of those persons occupying them. Functional charts
not only depict the major units, but also describe briefly the functions, purposes,
duties, and activities of each.

A small number of divisions does not necessarily [ree the chiel executive
from details since there may easily develop several layers ol administration which
block him off from the rest of the organization, as illustrated in Figure 8.

A final warning with regard to number and type of divisions or bureaus
relates to the danger of statutory definition of an organization’s internal structure
and the functions of each division or bureau. When this is done, as has occurred
in a number of instances in public health, there invariably develops a group of
inflexible and unmanageable principalities.

The bureau is the basic functional unit of the department. Generally speak-
ing, it has a homogeneous structure intended to perform a particular task or a
series of closely related tasks in contrast with the division, the function of which
COVERNOR

DEPARTMENT OF PUBLIC HEALTH

 

 

 

 

1
STATE BOARD OF HEALTH
DIRECTOR OF PUBLIC HEALTH = >t...... DIRECTOR AND SEVEN i

 

CONSULTANT IN PUBLIC HEALTH PUT JRECTOR OF PUBLIC HEALY
Hi
ADMINISTRATION AND TRAINING DEPUTY DIRE oF PUBL LTH

 

 

EDUCAT RE

AL

 

TICS

 

 

 

 

 

 

 

T
i

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIRECT RESPONSIBILITY
LOCAL HEALTH DEPARTMENTS

DIVISION OF
IRONMENTAL | SANITATI DIVISION OF PREVENTIVE MEDICAL SERVICES DIVISION OF LABORATORIES 0
BUREAUS OF ASST DIVISION CHIEF 2
SERyICES OF n
VECTOR [saniTARY [FOOD Q
CONTROL |[ENGINEER- | AND uy "le >
ING DRUGS Division Foto Lf 312 | Z
> ©
ola a 2 lg |< =
clog | wl 8 ES

<|°2| eo < IN

32 z% 4 | 2
Elo z |p| 2 |< >
9lz le | a -
Zz |w c vw = —_

ze w [5% a | ®
NERE AL| CHRONIC ijgelk (2583 0
DISEASES S333 [52 |¢2 Z
ROL $
r
8
4 4
0
DIVISION OF LOCAL HEALTH SERVICES | =
o
CONSULTATION - ADVISORY FIELD STAFF | m
A
2
Z
wn

cree RECIPROCAL RELATIONSHIP

Fig. 7. Organization of State C health department showing lines of responsibility and relationship.

cre
244 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

is coordination, the maintenance of effective working contact between the [unc-
tional bureaus, and the channel through which the basic functional units com-
municate with the chiel executive. Ordinarily the bureau is a very stable unit of
organization. It may be moved within or even without the total organization into
new relationships with others of its kind, but it is seldom torn apart or abolished.
While the direction of a bureau involves some problems of general management,
the outstanding problems are usually technical in nature, dealing with the most
effective manner in which to perform the specific task at hand. Work is assigned
to divisions and bureaus, usually on the basis ol the character of the work itself.

 

EXECUTIVE HEALTH oF F1cER

 

5

 

[DIVISION OF LOCAL HEALTH SERVICES |

 

4

[BUREAU OF ENVIRONMENTAL HEALTH |

 

3

[WATER & sewace section]

 

2

 

[WATER CONTROL OFFICE]
|

STREAM POLLUTION CONTROL OFFICE

 

 

 

 

Fig. 8. Undesirable organization stratification.

Not infrequently, however, other circumstances, such as an unfilled supervisory
position or the personality of a particular bureau chiel, may affect the distribution
ol activities. A particularly aggressive bureau or division chiel wishing to become
a minor empire builder may extend his jurisdiction in as many directions as
possible, usually along the lines ol least resistance. The units of organization
supervised by less [orceful persons, thereby tend to lose their functions and in the
long run may pass into oblivion.

Even within the functional bureau, the workers are grouped unofhcially
if not officially. Interestingly enough, even il management should fail to do so,
the workers will eventually arrange themselves into the ultimate functional units
of activity. Naturally, it is best for all concerned il such arrangements are a
matter of organizational policy and planning. In order that this may be so, each
employee in each position should be characterized [rom several points ol view.
Gulick suggests that proper grouping must be based on a consideration ol five
factors which for our purposes may be illustrated as follows:

1. The major purpose or service, such as milk control, operating a treatment clinic, or education.
2. The process used, such as laboratory analysis, the administration of therapy, or home visits.
ORGANIZATIONAL CONSIDERATIONS 245

 

 

3. The persons ov things dealt with or served, such as expectant mothers, tuberculosis patients,
or restaurants.

4. The place where service is rendered, such as the Eastern Health District, Macomb County, or
Central High School.

5. Knowledge, skill, and facilities available, and procedural convenience.

Staff Services. Until relatively recently almost all bureaus and divisions of
public agencies were more or less sell-contained units performing all of the
activities and functions necessary [or their operation and maintenance. Beginning
about 1900, with the expansion ol public service and its increased specialization,
there developed the trend of splitting off from the various functional units of
organization all operations ol a staff or housckeeping nature. Activities of this
type were then brought together to form what are referred to as staff and auxiliary
services. They are usually aligned structurally in very close relationship with the
chiel executive officer of the organization. Still more recent has been the tendency
to develop these stall agencies into a combination of service and control units.

Stall agencies do much more than study, plan, and advise. Their ultimate
purpose is to lacilitate the work of administration. They frequently are called
upon to assist the line or functional units by working with them but without
infringing on their authority or responsibility. The executive staff agency is not
in the direct line of the administrative hierarchy. Lines of authority, command,
and responsibility should not pass through them. Instead, they are situated some-
what apart, on the side lines so to speak, as adjuncts to the office of the chief
executive. Because of this rather special status, their purpose and value often
tend to be misunderstood. Occasionally the staff person may have a certain
amount of specially delegated authority, but when this is so it must be made clear
to all concerned that the authority has been delegated and that it is definitely
limited as to time and extent.

Staff agencies are of three types, i.e., administrative, service or auxiliary, and
technical. General or administrative stall functions are usually concerned with
problems of over-all management, such as budgeting, program planning, per-
sonnel management, and questions of structural organization. They are designed
to assist the chiel executive in handling important management matters without
his becoming entangled in a mass ol details. This is accomplished through per-
sonal secretaries and in larger organizations through administrative assistants
and economic advisors. The [unctions of administrative staff personnel vary
considerably. The stall officers, in most instances, receive reports and investigate
the efficiency and administration of the units making up the organization, look
for duplication ol work, formulate and suggest plans for the coordination of
the units, and handle the routine work of the executive. In collecting documents
and information and in planning a course ol action, they advise the chief execu-
tive with reference to problems and proposals, and, when a decision is made,
they may transmit and explain the orders to the line officers concerned and fol-
low up by observing and reporting the results. In theory, they have no inde-
pendent power or authority apart from the chief.

An administrative staff officer usually finds himself in the peculiar situation
ol having an interesting, important, and fruitful job but one in which his in-
2406 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
tentions are frequently misunderstood. He therefore must possess certain peculiar
characteristics in order to carry out his duties properly. First of all, he must have
negotiating ability rather than a highly developed capacity to command. This
requires great patience and persistence rather than a tendency to quick and fixed
decisions. He needs a broad range of practical knowledge rather than extensive
specialized or technical expertness in one or a few fields. He must be loyal to the
policies and views ol his superior rather than concerned with the promotion of
his own plans or recommendations. Finally, he must have an honest willingness
to remain more or less in the background rather than a wish for personal
prominence and publicity. As aptly stated in the report of the President’s Com-
mittee on Administrative Management, “He must be possessed of high compe-
tence, great physical vigor and a passion for anonymity.”

Service or auxiliary staff functions usually deal with the more strictly house-
keeping activities of the organization, including the facilitation of office services
such as the operation of a stenographic pool, statistical services, legal aid, central
purchasing and supplies, and accounting. While usually referred to in terms of
services, many of these activities relate, at least in part, to control ol line units.

One of the auxiliary services which sometimes gives rise to controversy is
that of central purchasing and supplies. While this office is intended to assist
the line or functional units in the most efficient and economical manner pos-
sible, there is implied a division of responsibility and authority between the unit
which uses and that which purchases. Theoretically, the procedure should operate
in about the following manner. The functional or line unit, perhaps a bureau or
a division, takes the first step. It decides upon the articles or material needed
and describes them on a standard form, specifying the quantity required, the
desired time and place of delivery, and any special considerations of the purchase
in question. This requisition may even include the names of preferred manu-
facturers when one commercial product is considered superior to those of other
companies. The requisition is sent to the central purchasing office, usually after
it has been examined by the comptroller or fiscal officer in order to be certain
that sufficient funds are available. Actual purchase may then be made by the
central purchasing officer, if possible on the basis of open competitive bids. The
authority to purchase is vested solely in him. Upon delivery, inspection and even
laboratory tests may be carried out to ascertain the proper quality and quantity
of the materials supplied.

The point of possible controversy revolves primarily around whether or not
the purchasing officer should have the right to modily a requisition, either
quantitatively or qualitatively. The extent to which he has this right depends
essentially upon the policy of the particular organization and occasionally upon
legally specified authority. Another objection concerns the delay encountered in
obtaining the materials. Functional units not infrequently complain that by the
time delivery is made, the need has passed. Many organizations have attempted
to solve this problem by allowing direct purchase of emergency material and
specialized equipment under specified circumstances.

Technical staff service, as the term implies, is primarily concerned with
methods, planning, and the technical aspects of operation. The technical per-
ORGANIZATIONAL CONSIDERATIONS 247

 

sonnel are functional specialists, such as found in technical field staffs of state
health departments and the skilled specialists loaned to states and localities by
the Public Health Service, the Children’s Bureau, or other similar agencies.
Whenever such technical specialists are loaned to work in line units, they should
be answerable to the director of those line units rather than to some technical
headquarters or to the top executive.

The relationship of the technical field staff to the functional line unit poses
a number of problems. The situation where they are perhaps most clearly seen
is in the functioning of a technical field staft of a division of local health service
in a state department of health. The objective, ol course, is to provide a smooth
effective channel along which the knowledge and facilities of the central organ-
ization may flow to and through local units without destroying the initiative of
the local personnel or impairing the authority which the director of the local
unit must possess if he is to administer his program successfully.

Complete autonomy of the local units tends to inhibit the flow of technical
service and advice from specialists in the central office to their counterparts on
the local level. On the other hand, for central office specialists to have directing
authority over corresponding specialists or technicians on the local level, inter-
feres with or destroys the proper coordination of the various activities of the local
organization. When this occurs, the director of the local unit is reduced to little
more than an administrative clerk. This is an unfortunate occurrence since the
local health officer is the only person with local personnel and facilities who is
in a position to know where, when, how, and to whom to render local service.?

As in the case of the administrative staff, care must be taken on the top level
to assure complete understanding, both on the state and on the local level, of
the purpose and function of the technical field staff. In turn, the members of the
field staff must do everything possible to deserve and gain the trust and con-
fidence of the local personnel. The first and perhaps most important step toward
this goal is for the top executive of the state or central agency to choose the mem-
bers of the field staff as much on a personality basis as for their technical knowl-
edge and ability.

Much depends on the organizational arrangement by which the aid of the
technical experts of the central agency is channeled to the local unit. A mistake
that has been made occasionally is to follow the pattern illustrated in Figure 9.
Here, each functional division of the state agency independently sends its expert
consultant directly to the personnel of the local agency. Even if this pattern is
improved to the extent of channeling all of the state technical field consultants
through the county health officer, only confusion and annoyance will still result.
Coordination of the policies, activities, and methods of approach is exceedingly
difficult, if not impossible, to attain. A given worker on the local level is apt to
have several consultants from the state agency on his hands during the same
period. In fact, the meeting of the state consultants in the field may be quite un-
expected to them. The waste and inefficiency inherent in this situation is obvious.

Experience has indicated that a much better approach to the problem is
that illustrated in Figure 10. By this pattern, all technical field consultants who
go into the local units originate from a single coordinating division or head-
248 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

[STATE HEALTH OFFICER]

 

 

|

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIV. OF DIV. ENVT. || DIV OF MED. DIV. OF PH. DIV. OF P.H.
STATISTICS| | SANITATION|| SERVICES NURSING EDUCATION
T [ 1
| | | |
| | TB COMM. || VD
| ois |, I
| 3 75 ! to / \ I
| | JN TO |
lo Ly TIN
| | A SN
| county HEALTH OF FICER Oo
| | => So
Y T Y | ' \ h Ta
OFFICE ENGINEER OR PH. HEALTH
CLERK SANITARIAN NURSES EDUCATOR
Fig. 9. Unsatisfactory organization of technical field staff.
[STATE HEALTH OFFICER]
[ ETC.
DIV. OF STATISTICS] [DIV. OF ENVT. DIV. OF PH. DIV. OF MED.
SANITATION EDUCATION SERVICES
~ » ¥ —v
~ Sa yd —
SL DIV. LOCAL _—
~«a| HEALTH SERVICE | o—
1
|
1
| COUNTY HEALTH OFFICER]
OFFICE ENGINEER OR PH. HEALTH
CLERK SANITARIAN NURSE S EDUCATION

 

 

 

 

 

 

 

 

 

 

 

administrative responsibility
—-—— functional relationship

Fig. 10. Satisfactory organization of technical field staff.
ORGANIZATIONAL CONSIDERATIONS 249
quarters. Duplication ol efforts and multiplicity ol visitors are avoided. All re-
quests or plans [or field consultation channel through the director of the local
unit, on the one hand, and the director ol the division ol local health service, on
the other, the latter usually designated as Deputy State Health Officer.

One ofl the potential dangers involved in the use of stall agencies is that the
chiel executive may become overenthusiastic or impatient with his [functional
subordinates and direct a staff assistant in whom he may have personal confidence
to take a line situation in hand and straighten it out. Invariably, this results in
divided responsibility, with the personnel in general not knowing exactly whose
orders they are expected to follow. Very naturally this tends to cause resentment
on the part ol the division or bureau head. Furthermore, the personnel of the
unit frequently adopts an interesting protective attitude toward their division
or bureau chiel even il they know him to be weak or to have other faults. The
staff officer more than anyone else then finds himself in the uneviable middle
position between the chiel executive on the one hand and the functional per-
sonnel on the other. Operating units are understandably jealous of their integrity
and authority and resist any interference by an outside person whom they may
consider an administrative spy, stooge, or snoop. In any case, they can easily
thwart the work ol a staff officer by following a policy ol noncooperation and
passive resistance of a degree short of insubordination. The staff officer in such
cases must move warily, taking the time to win over not only the director of the
operating division but also his personnel, demonstrating that he is there to assist
rather than to criticize or undermine. The most desirable approach is to study
the situation in cooperation with the division and with its assistance to seek a
remedy. New findings or recommendations should be reported to the chief execu-
tive, preferably in company with the head of the operating unit involved, to
whom should fall the responsibility for issuing whatever orders or taking what-
ever steps are considered necessary for correction or improvement of the particular
situation.

Decentralization. A problem, somewhat similar to the relationships between
a county health department and the technical field staff of a state department of
health, exists when an urban agency attempts to decentralize its operations for
purposes of greater efficiency and service. As has been said elsewhere, one of the
chief characteristics ol public health work is that it deals essentially with people
rather than with things. Even in the sanitary control ol inanimate material such
as food, milk, or water, it is the attitude, understanding, and cooperation of the
producer, the handler, and the purveyor which are the important factors. Most
of a health department's budget is devoted to the salaries ol professional workers
who work with or serve the public or groups thereof. Nothing is manufactured.
Practically speaking, the sole product is interpersonal relationships. This being
the case, it is only good sense to attempt the delivery of these personal services
and interpersonal relationships as close to and as convenient [or the consumer
as possible.

In a very real sense, no one really lives in a city, state, or nation. As far as
actual living is concerned, it is done in neighborhoods. This is particularly true
of large cities wherein only a relatively few blocks are meaningful in the daily
250 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

 

life of the average individual, i.e., the area around the home, the school, the
church, the shopping and recreational centers and, for the breadwinner, the area
around the place of employment. Certainly a city hall or a state capital building
is relatively meaningless to the average person, and, if he has any feeling for
them at all, the chances are that they are not particularly warm. Attempts have
been made in some places to carry out public health programs from city halls or
state capitals. None have really succeeded. Increasingly, therefore, attention has
been given to the decentralization of personnel, activities and services to the
maximum extent practical and possible.

In such situations, large cities for example, it is customary to divide the
total area into districts each with a population of from 100,000 to 200,000 per-
sons. In defining the district boundaries, attention should be given to factors
which may limit movement, such as streams, ridges, or railroad tracks, to con-
centrations of industries, to socioeconomic concentrations, to public transporta-
tion facilities, to boundaries of other departments and agencies, and to numerous
other considerations. A district health center is usually established in each district
with perhaps a number of satellite clinic facilities serviced from the district health
centers. The latter serve as the headquarters of the district health staffs and as
the location of the more important activities of the district health program.

Mere physical decentralization alone, however, does not result in a decen-
tralized program. It must be recognized and accepted that the public health
personnel who work in a particular district are in the best position to be familiar
with the problems, needs, and resources within that district. Therefore, insofar
as that district is concerned, the district personnel should have the responsibility
and the authority for determining and carrying out the details of the daily
operations and activities, consistent, of course, with the over-all policies and goals
of the organization as a whole. Furthermore, in order to assure a well-coordinated
district program, all personnel assigned to a district should work under the ad-
ministrative or operational direction of a district health officer. Some measure
of administrative authority and responsibility must also be decentralized, else
the intent will be defeated by red tape and delayed communications or starved by
bureaucratic anemia. An important consideration, therefore, is to obtain capable
individuals for the positions of administrative leadership in the decentralized
units, and to allow them, organizationally and functionally, to determine and
carry out their local programs to the maximum extent feasible. To enable them
to do so, of course, provision must be made for obtaining and dispensing funds,
personnel, and materiel. Also a communications system must exist among the
decentralized units and between them and the central offices. These are manage-
ment functions which can only be carried out centrally. In addition, the central
administration’s program divisions must be concerned with the establishment
of standards and qualifications, and performance or quality control, as well as
with the professional and technical aspects of program conception, planning,
supervision, and evaluation.

It would appear, therefore, that except in very small agencies, organizational
activities and responsibilities divide themselves naturally into three functional
areas, i.e., management, field operations, and professional or technical direction.
ORGANIZATIONAL CONSIDERATIONS 251

 

One of the most difficult administrative problems is to bring about a method ol
organization and a degree of personnel understanding that will allow each of
these three functional areas to perform adequately and satisfactorily both unto
itself and in relation to the other two. Figure 11 illustrates an example of this
type of organization which has proved to be successful.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIRECTOR
of
PUBLIC HEALTH
Management District Health Professional
Services Operations Direction
Professional Professional
Services Programs
Fiscal Public Health Nursing Environmental Health
Personnel Public Health Education Mental Health
Communications, ——Public Health Laboratory Dental Health
Maintenance (Public Health Statistics Health Promotion
and Supplies L-Social Sciences Epidemiology
HEALTH DISTRICTS
District
Health
Officer,

 

 

 

operational supervisory staff
operational field staff

Fig. 11. Example of a decentralized city health organization.

Coordination and Control Measures. To devise a sound organizational struc-
ture and to staff that structure with qualified personnel under a capable chief
executive does not necessarily guarantee continued successful function. There
must be put into operation and constantly maintained certain measures and
techniques in order to make sure that the principles and policies set down are
adhered to, that the plan which has been adopted is followed, that the responsi-
bility that has been delegated has been met, and that the orders or work that
have been assigned have been fulfilled. The general purposes of these measures
are to keep the activities of the total organization and each of its component
parts in line with established policies, to maintain a proper balance among the
various divisions and bureaus of the organization, to maintain efficient work
standards and performance, to assure consistency of action, and to prevent the
development ofl personnel stresses and strains through the promotion of har-
monious and satisfactory work relationships.

The tendency for certain aggressive subexecutives to magnify the importance
of their work and to become “empire builders” has been referred to. Usually
every unit in an organization is imbued with the essential value ol its work and
can present arguments to justify its expansion in terms of jurisdiction, appropria-
tions, and personnel. However, the resources available to the total organization
252 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

are limited and must be carefully and logically distributed among all of the
functional units on a basis determined by the over-all purpose and program of
the organization. To accomplish this successfully involves continuous efforts for
the coordination of all parts of the organization.

Coordination has been spoken ol as the dynamics of organization. It is a
broad term which includes a wide variety ol activities, the aim ol which is to have
related workers or groups of workers function harmoniously and effectively to-
gether where and when they are needed to avoid duplication and conflict. Pfiffner®
has presented an excellent example ol automatic administrative coordination
in terms ol what occurs when a fire alarm is sounded. When the police and firemen
answer the call, “upon their arrival they are likely to meet repair crews from the
telephone company, the gas company, and the electrical company. The high pres-
sure pumps of the water company are already in action. All of these coordinated
activities have been set in motion through the alarm system.” In public health
work, this type ofl situation can be observed perhaps most dramatically in the
teamwork of a well-trained epidemiological stall working to control an outbreak
ol a communicable disease. Diagnosis and control of the problem requires the
smooth, well-coordinated interaction of many types of personnel. Medical and
nursing personnel provide care for those already afflicted in order to speed their
recovery and to prevent the further spread of disease from them. Field investi-
gators obtain personal histories and make whatever other inquiries and examina-
tions are necessary in order to trace the original source ol the epidemic. Here
the sanitarian and the engineer may play a most important role. Working with
them may be a staff of laboratory workers. Meanwhile the cooperation of the
public and the professions is solicited through the efforts of health educators.

There are many techniques that may be used to assure elfective control of
the activities and program of an organization. Much could be written about each,
and the following is intended as merely a briel outline. The most elementary
step that can be taken is the development ol an organization chart. Several aspects
of this have already been discussed and little more will be added at this point.
Suffice it to say that the very concept ol the use ol organization charts has been
a subject of controversy. Some authorities in administration have warned of
danger in their mere existence since there may easily develop a tendency to tie
the future of the program to the chart, thereby hampering growth and develop-
ment, rather than constantly to adjust the chart to the program. True as this
potentiality may be, it is felt that to attempt to administer a program and to
supervise an agency, of any but the smallest size, without some form ol organiza-
tion chart showing channels, responsibilities, and authority is like trying to
steer a ship blind without a chart showing passages, reels, and shoals on the one
hand and without established connections with the engine room on the other.

Once the structure is established, many methods ol over-all management
and control of the activities of the agency become possible. Various types of
manuals have been found to be of value even in small agencies. Worthy of
particular mention are administrative manuals which present the legal and other
policies to be followed, and technical or work manuals which describe in detail
the steps to be taken in the performance of particular functions. Standing orders
ORGANIZATIONAL CONSIDERATIONS 233

 

for the nursing personnel may be considered a special example of this category.
Manuals are especially useful for the “breaking in” of new personnel and are
indicated particularly in larger organizations. As is the case with many similar
types of materials, they must not be allowed to become stale and must constantly
be reviewed and brought up to date. Of a like nature are written executive and
administrative orders, information circulars, special instructions and directives.
These should be numbered, codified, indexed, and routinely channeled through-
out the organization.

One ol the chiel means ol administrative contact with, and therefore control
ol, the functional units of the organization is through written records and reports
that may be required to flow upward. Generally speaking, these are of two types:
financial and service. In the typical large health department, for example, the
staff nurses routinely submit daily or weekly reports of visits and services with
costs of transportation or mileage noted. These are summarized, first, for the
individual nurse's service and payment records, and second, for the monthly
and annual report of the nursing division. When correlated with salaries, over-
head, and transportation costs, the ingredients of service cost accounting become
available. Records and reports should not be relied upon entirely for contact
with the functional units. Those in executive positions do well to get out occa-
sionally to the level where the work is being done and the service is being
rendered.

It is important to review at least periodically the purpose of and need for
each record or report. Two examples in the experience of the writer may serve
to illustrate the point. In one large health department the request was made
for a review ol certain office procedures. It was found that one typist-clerk was
devoting her entire time to the compilation and typing ol a very detailed monthly
report referred to as Dr. X's report. When each report was completed, it was
sent to another office where it was immediately and permanently filed. Inquiry
brought out that while Dr. X had once asked for the information, he had left
the organization about eight years before. A similar instance was discovered
in the progress of a community health survey. Here a certain record flowed
through a small office with a single typist who carefully made a copy ol each
record before sending it on its way. The copy was filed by her with equal care
but in response to questioning she stated that to her knowledge no one had ever
referred to her file of copies. The origin of this strange ritual was never dis-
covered.

To a considerable extent, the program and activities ol a health department
are implemented by means of correspondence. The handling and routing ol cor-
respondence, therefore, becomes important. One occasionally finds chiel execu-
tives, such as health commissioners ol even large cities and states, who for reasons
ol vanity, distrust, or uncertainty insist that all incoming and outgoing mail
pass through their hands. This procedure, ol course, is foolish and wasteful and
is indicative of questionable administrative ability. A practical screening pro-
cedure should be developed in order to conserve the time and energy of those in
the hierarchy ol the organization. Thus, bureau chiefs may read or scan most
or all of the dictated correspondence arising within their units and division chiefs
254 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

may read a great deal, whereas the chiel executive may limit himself to letters
involving complex issues, controversial cases, new policy, or important persons.

Before closing this discussion of the higher level of the organization, mention
should be made of staff conferences and special committees. Staff conferences serve
the dual purpose of administrative control and the promotion of good personnel
relations. They are best held at definitely stated intervals, neither too long nor
too short. Most health departments find it advantageous to have staff meetings
once a week. In times of emergency or when developing a special program, they
may, of course, be held more frequently. While the chief executive should preside
and steer the meetings, he should by no means monopolize the discussion. Each
division and bureau head should be provided with an opportunity to present his
problems or contributions. The designation of a staff secretary and the keeping of
minutes are sound policies to be strongly recommended. Pro tem staff committees
often serve important purposes. They may be formed for the purposes of in-
spection, survey, investigation, planning, coordination or technical study. Usually
they should include one or several from whatever unit or service may be in-
volved and should report back to the executive or to the staff.

Getting closer to the functional line employees, there are a number of
procedures that facilitate control. Important among those that might be men-
tioned are work-flow charts, cross-checks, job analyses, and descriptions and
standardization of methods and procedures. The use of internal cross-checks is
frequently possible. These are arrangements for checking the work of one em-
ployee, unit, or agency against another. Examples that may be cited in the field
of public health are the routine or spot check of reports of inspections against
related laboratory reports, and the check of supplies of biologicals furnished
against therapeutic or immunologic services rendered.

The classification of positions is important but merely as a first step. There
is great need at this time in the field of public health for extensive job analyses
and description. Not only would they make possible more logical employment
standards, qualifications, and placement policies, but could help to improve the
training curricula in schools of public health. The public health profession
has progressed considerably with regard to the establishment of standards, par-
ticularly so when the relatively brief existence of the field is considered. Stand-
ards have been formulated for both the quality and quantity of various profes-
sional types of personnel, for basic or minimum programs, for utimate goals, and
for many technical procedures. This has been the result largely of committees
of the American Public Health Association, particularly those concerned with
laboratory methods and administrative practice. Out of them have come widely
accepted and used reports on Standard Methods of Water and Milk Analysis,
the Control of Communicable Diseases, and the Evaluation of Health Practices.

The Evaluation Schedule For Use in the Study and Appraisal of Community
Health Programs? developed over many years by The American Public Health
Association, is deserving of particular mention since it provides an admirable and
convenient tool for administrative control and coordination as well as for
appraisal. Referring to it, Pfiffner has said:
Un
on

ORGANIZATIONAL CONSIDERATIONS 2

Probably no administrative field has gone further than public health in developing
criteria to judge the effectiveness of its work. Since public health administration in its
present form is so young, this fact becomes especially significant. The standards and
measurement referred to are the results of experiences growing out of a number of
public health surveys covering a period of years. . . . The criteria are so objective that
little is left to the opinion of the appraiser. . . . Indeed, it has been shown quite con-
clusively that there is a very direct relation between the amount that is spent for public
health administration, score achieved, and the health of the community as shown by
the mortality and morbidity rates.*

Rating is based upon performance rather than results. In other words, the
schedule takes cognizance of the administrative organization, and facilities of
the health administration rather than sickness and death statistics.

Every public health worker should become thoroughly familiar with the
Evaluation Schedule. It considers in separate detail the following sixteen phases
ol the public health program:

Personnel, facilities, and services
Public health problems

Community health education and staff training
Communicable disease control
Tuberculosis control

Venereal disease control

Maternal health

Infant and preschool health

School health

10. Adult health

11. Accident prevention

12. Water supplies and excreta disposal

13. Food control

14. Milk control

15. Housing

16. Financial support for local health work

nN —

EI EE

©

The American Public Health Association has also published a document
entitled Health Practice Indices, which consists of an extensive series of line
charts relating to the particularly significant items in the Evaluation Schedule.
Each chart presents the reported experience of a large number of communities
(1947 edition—276 communities covering approximately 26 million people).
Their value in allowing a health officer to insert the position of his community
is obvious. Concurrently the Association published a summary scoring sheet which
made it possible to obtain an over-all view of the strengths, weaknesses, balance,
and coordination of the program of a public health agency. Certain items were
graphically emphasized, being considered to be of such great importance that a
poor score for them outweighed any benefits that might result from other ac-
tivities. Thus, an approved water supply, a satisfactory sewage disposal system,
and pasteurization of milk were considered fundamental to the health of a com-
munity regardless of whatever other accomplishments were achieved.

*Pfiffner, J. McD.: Public Administration, New York, 1946, The Ronald Press Co., p. 220.
256 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

The use ol administrative control tools such as these is of great importance

in measuring success and progress toward the goals and objectives which should
always consciously exist. Generally speaking, once the administrator determines
the needs, goals, obstacles, facilities, and abilities, [ailure to reach the goals can
be due only to poor administration and inattention to duty.

More recently, the Association has developed Guide to a Community Health

Study for use by community organizations and agencies in studying and improv-
ing all aspects of their community’s health structure and program, both official
and nonofhcial.

REFERENCES

Gulick, Luther: Notes on the Theory of Organization, In Gulick, L., and Urwick, L. (editors):
Papers on the Science of Administration, New York, 1937, Institute of Public Adminis-
tration.

Emerson, Haven: Local Health Units for the Nation, New York, 1945, Commonwealth Fund.

Report of the American Public Health Association Task Force, Arden House Conference, Oct.
12-16, 1956, Am. J. Pub. Health 47:218, Feb. 1957.

Gaus, J. M., White, L. D., and Dimock, M. E.: The Frontiers of Public Administration,
Chicago, 1936, University of Chicago Press.

Dimock, M. E.: The Executive in Action, New York, 1945, Harper & Brothers.

Pfliffner, J. McD.: Public Administration, New York, 1946, The Ronald Press Co.

White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co.

Anderson, William: The Units of Government in the United States, Public Administration
Service, No. 42, 1934.

Editorial: Vertical Versus Horizontal Administration, Am. J. Pub. Health 32:86, Jan. 1942.

Evaluation Schedule For Use in the Study and Appraisal of Community Health Programs,
New York, 1937 (reprinted), American Public Health Association.

Guide to a Community Health Study, New York, 1955, American Public Health Association.
chapter 1 0

Personnel factors in public health

 

Introduction. Parran,! while Surgeon General of the United States Public
Health Service, once stated: “The tripod upon which the public health structure
of any country rests is (1) a force of well trained personnel, (2) the appointment,
promotion and retention of personnel on a merit basis, and (3) adequate finan-
cial support, evidencing public understanding of the problems involved.” It is
noteworthy that of these factors not only do the first two deal directly with ques-
tions of personnel but even the third is partly so concerned, since financial sup-
port of public health programs is manifest chiefly in the payment of salaries.
These considerations, plus the lact that the management of personnel and their
problems is one of the health officers first, continuing, and biggest jobs, indicate
the necessity of devoting attention to some of the personnel factors in public
health work.

In order to discuss the subject intelligently, certain phases of the background
of public health in America must be considered. It should be realized first that
despite historically earlier activity, public health work in the modern sense is of
relatively recent origin. When it is recalled that the establishment of the first
state health department (Massachusetts, 1869) postdated the American Civil
War and that the first continuing full-time county health departments were only
recently organized (Jefferson County, Kentucky, in 1908, and Guilford County,
North Carolina, and Yakima County, Washington, in 1911), one should be
neither surprised nor discouraged by present difficulties relating to public health
personnel.

Another historical fact influencing the problem is that the foundations ot
public health in America were laid by a group of unusually sincere, energetic,
and socially minded individuals [rom many walks of life. In our influential back-
ground have labored a medley of educators, physicians, engineers, and laymen,
including for example one of the most influential, the book dealer Lemuel Shat-
tuck. Such was their sincerity, vision, and energy that one sometimes has cause
to wonder if the pace they set might have been in some instances a little too rapid
for the citizenry as a whole. That disaster did not result from this is, in a very real
sense, testimony to the practicality and the soundness of the principle of citizen
participation.

257
258 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

A third characteristic of the public health movement which must be con-
sidered in discussing matters ol personnel is the relatively early decision that,
to be most effective, most activities should be done primarily by agencies within
the framework of government. This at once necessitates [rank recognition of
some of the traditional but fortunately waning American attitudes toward public
service, such as acceptance if not support of the ideas of political patronage and
of the spoils system, a tendency to expect and to tolerate some degree of inefh-
ciency in public affairs, and a heritage of relatively low salaries. It should be
recognized, however, that the word politics often is misunderstood or misinter-
preted. What is meant most often is what might be termed pernicious partisan
politics. Furthermore, it should be realized that there are many forms of per-
nicious politics other than those stemming from political parties and that all of
them are deterrents to efficient service. The public health administrator, by virtue
of his contacts and activities, may find himself involved in personal politics,
fraternal politics, racial politics, religious politics, professional politics, labor
politics, economic and social politics, and politics of many other types. Politics,
good or bad, are not limited to government.

Public health work itself has certain characteristics which give rise to peculiar
personnel problems in contrast to most businesses and industries. It is a curious
mixture of public and social responsibility and service. It is notable in this
respect that, despite what was said in the preceding paragraph, public health as
a social movement has only recently been adopted by government, that much
public health work is still carried on by private voluntary organizations, and that
not infrequently the budgets ol official health agencies are still augmented by
funds from private sources. Thus, it is still in the process of organizational de-
velopment. In public health work the department is literally the personnel since
there is but little overhead expense for machinery, tools, and so forth. A complex
breadth of ability and function is required which necessitates the activity of
many different specialized types of personnel. In the same organization there
may be physicians, engineers, chemists, nurses, bacteriologists, educators, and
others, each with particular pride and interest in his professional specialty.

Not only are the activities of public health agencies ol many types but they
are continually undergoing a process of change, adaptation, and evolution so
that what is good and adequate practice today may be inadequate or outmoded
tomorrow. Furthermore, we are dealing with an expanding field, somewhat in
the nature of an exploding nebulus, having begun with the barest essentials of
sanitation and expanding from that narrow area into the fields of preventive and
promotive medicine and, in some instances, even into the realm of treatment.
In contrast to most other private and public businesses there are relatively few
activities in public health which are subject to formalization or formularization.
In most instances the product to be sold tends to be intangible and the consumers
are all the people with their varying degrees of pride, prejudice, reticence, and
intelligence. Often the selling literally involves a change in the habits, desires,
and customs of the people, so that a successful approach in one instance, time, or
location may be an abject failure in other circumstances.
PERSONNEL FACTORS 259

 

Because of the relative newness of public health work and the widely created
demand previously referred to, additional difficulties have arisen, perhaps the
majority of them involving personnel. For a considerable period there were no
special facilities for training individuals for this new field of endeavor. In the
absence of trained specialists it was considered satisfactory to employ a wide
variety of, generally speaking, unqualified individuals, including, all too often,
retired or unsuccessful practicing physicians and political appointees. Related to
this was the failure to attract and hold capable personnel because of insecurity of
tenure, low salaries, competition from other fields, and because the profession of
public health as a whole was not yet well known enough to be attractive. The
problem was summed up by Rosenau® who said:

The time has long since gone by when the physician can spend a few hours from his
busy day to look after the duties of the health office. The situation demands the entire
time and energy of those who consecrate their lives to the public welfare. In order
to attract capable men to the new profession it is important that the health officer
should have an assured tenure of office with adequate pay and freedom from politics. *

To complete the circle, due to the above inadequacies, there was a corresponding
lack of established, well-organized agencies in which at least practical field train-
ing and experience might be obtained.

As time went on, however, the public health profession undertook to solve
these problems on many fronts, literally lifting itself by its own bootstraps.
Through the effective efforts of those who were sincerely concerned with the
work as a career, there came about a fairly rapid maturing of the profession,
resulting in widespread public and professional acceptance, an accumulation of
sound experience, and the application of more scientific procedures. Gradually,
medical schools began to include preventive medicine and public health in their
curricula. The recency of this, however, is emphasized by a prophecy by Rosenau?
in an article dated 1915. “The modern practitioner of medicine is fast adding
prevention as one of the tools of his equipment. The future student of medicine
will make a study of health and how to maintain it, as well as a study of disease
and how to cure it.” Because of the rapidly evolving scope of public health, med-
ical training alone was soon recognized to be inadequate preparation for the
health officer, as well as not serving the needs of the nonmedical personnel in
public health work. In pleading for specialized training and degrees for public
health workers, Rosenau said:

Public health work is becoming, in fact, has already become, a separate profession.
It has split off from medicine just as medicine long ago split off from the priesthood.
Public health service, as a career, must be an end in itself. It is often difficult and some-
times impossible to bend the physician into a health officer. The ordinary medical train-
ing does not qualify a person to be a health officer.*

In 1912 there was established at the Massachusetts Institute of Technology,
in cooperation with Harvard University, a program providing basic training in

*Rosenau, M. J.: Courses and Degrees in Public Health Work, J.A.M.A. 64:794, March
6, 1915.
260 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

 

the biological sciences similar to the first two years in medical school followed by
courses in public health science instead of the usual clinical courses pursued by
medical students. In 1914 a conference of leaders of education, medicine, and
public health called by the General Education Board, recommended that public
health schools of high standards be established as scparate entities but affiliated
with universities and their schools of medicine. The first distinct school of this
nature was established in 1916 at The University of Pennsylvania. As time passed,
additional schools were founded.

But now an additional complication had arisen. Due to the acceptance of
the value of public health programs and the resulting demand for personnel, a
large number ol educational institutions of all grades ol quality began to grant
degrees in public health, more often than not on the basis of grossly inadequate
training. By the year 1939, a total of forty-five schools and universities were listed
as granting eighteen different kinds of degrees in public health.? The situation
became so undesirable and confusing that finally in 1941 there was established an
Association of Schools ol Public Health consisting of schools later accredited by
a system developed by the American Public Health Association.* As a result,
there are at the present time thirteen schools accredited for the granting of accep-
table professional degrees in this field.> These are the University of California,
Columbia University, Harvard University, Johns Hopkins University, University
of Michigan, University of Minnesota, University of Montreal, University of
North Carolina, University of Pittsburgh, University of Puerto Rico, University
of Toronto, Tulane University, and Yale University. *

In order to establish criteria for the accrediting of schools, it was logically
necessary first to determine qualifications and standards for prospective personnel
ol public health agencies. In other words, what was the final product of the
schools to be? Efforts toward this end were begun in the late 1930's by the Com-
mittee on Professional Education of the American Public Health Association,
with the result that educational qualifications have been established for the ma-
jority of the various kinds of professional personnel that might be employed by
an official or nonofficial public health agency.”

While each specialty is of necessity dealt with separately, those usually con-
sidered to represent the basic personnel of a health department, i.e., health
officers, public health engineers, and public health nurses, have certain requisites
in common. These may be summarized as follows:

1. Graduation from an approved school in their specialty (medicine, nurs-

ing, etc.).

2. At least one full academic year in an approved school of public health or
in the case of nurses in a school approved by the National League for
Nursing, leading to a degree.

3. A period ol practical supervised experience in a subordinate position in a
health department.

4. The customary desirable personal qualifications.

*For detailed analyses see Report on Schools of Public Health by Rosenfeld and others.’
PERSONNEL FACTORS 201

It was soon realized that just as an internship was necessary to round out the
academic training ol the medical graduate, so a period of practical field training
should supplement study at a school of public health. Therefore, a special Sub-
committee on Field Training analyzed the types ol field training desirable for
public health personnel, dividing them into the following five categories®:

1. Observation—duration: 1 day to 1 week. The individual takes no direct part in
the activities of the health department. It is best suited for a well-trained,
experienced person who simply desires to learn of new procedures or to discuss
new policy.

2. Orientation—duration: 1 to 2 months. This is training to prepare an individual
for a specific position in a specific place. It is intended to familiarize a skilled
person with the particular problems, laws, codes, customs, and procedures of
that area or state in which he is about to work.

3. Field Experience—duration: 3 to 6 months. This training is supplementary to a
theoretical, academic training in public health. It is comparable to an internship
which follows medical training. The training areas should be carefully selected
and require teaching personnel, in addition to standard personnel.

4. Apprenticeship—duration: 3 to 12 months. This training is given before the
candidate has had his academic year of work at a school of public health. It has
special advantages in the selection and training of medical health officers. The
individual is employed as an apprentice by the health department, and if he likes
the work and proves to be capable he is then given a period of academic train-
ing by the state and returns to his official sponsor at the completion of the
theoretical work.

ot

Inservice Training—This is simply a continuous educational program for all types
of personnel in the health department, in order to keep them abreast of the times.
It is a special function of the local health department, with aid from the state
health department.*

The next step taken was the development of accredited field-training areas
to supplement the academic training received in a school of public health. This
began in 1950 and has been carried forward under the tripartite aegis of the
Committee on Professional Education ol the American Public Health Associa-
tion, the Council on Medical Education and Hospitals ol the American Medical
Association, and the American Board of Preventive Medicine and Public Health.
By now, about one half of the states and through them a number of localities
have programs approved for residency training.”!* The program is analogous
to the approving of hospitals for internships and residencies. Still another step
was the establishment in 1949 of the specialty board, the American Board
ol Preventive Medicine and Public Health, by the Council on Medical Educa-
tion and Hospitals of the American Medical Association assisted by the American
Public Health Association in order “I. to encourage the study, improve the prac-
tice, elevate the standards, and advance the cause ol preventive medicine and
public health [and] 2. to grant and issue to physicians duly licensed by law to
practice medicine, certificates of special knowledge in preventive medicine and
public health.”1>

*Proposed Report on Field Training of Public Health Personnel, Am. J. Pub. Health 37:709,
June 1947.
2062 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

Since these activities relate only to physicians, several other professional
disciplines engaged in public health work, notably environmental health and
public health nursing, have also been in the process of developing plans and
programs for approved field training and accreditation.

Further trends tending to the solution of personnel problems in public
health are the increasing adoption of merit systems, in which the American
Public Health Association, the United States Public Health Service, and the
Children’s Bureau have taken leading roles,'61% and the gradual improvement
of salaries resulting from a number of circumstances including personnel demand
in relation to supply, improved training, and recognition of the value of public
health work. Related to the subjects of personnel shortage and training is the
interesting recent trend toward recognition that the problems are of national
scope rather than simply state or local. In recent years an increasing number
of fellowships for professional public health training have been made available
to the states through Federal grants,’ and in 1958 the National Congress passed
the first bill to subsidize accredited schools of public health to a modest extent
partly on the basis of their representing regional training centers for the nation.

By 1951, while the majority of physicians employed in public health agencies
had attended various short courses and institutes on specialized subjects, only
about one third had had formal training leading to a degree in public health.
About 36 per cent of stall nurses employed in state and local health agencies had
had one or more years’ study in public health or public health nursing. Of sanita-
tion officers, approximately one third had had no public health training.?® This
situation has improved somewhat since then, but there are still significant num-
bers of individuals in all categories working in public health with inadequate spe-
cialized-training backgrounds. An analysis of educational requirements of local
health officers has shown that by law or regulation, only twenty-six states spe-
cifically require training in public health. In nineteen others it is a commonly
accepted practice, while two states by regulation say it is not necessary and one
state actually prohibits the requirement.?!

The generally accepted minimum staffing requirements for proper basic
health services are as follows:

One public health physican for every 50,000 persons (or one for every local
health unit, whichever is less)

One public health nurse for every 5,000 persons, if bedside nursing not in-
cluded; otherwise, one per 2,500 persons

One sanitary engineer or sanitarian for every 15,000 persons

One clerk for every 15,000 persons

One of the most complete analyses ol the quantitative needs for public health
personnel was that presented by the Emerson report on local health units for
the nation.?? This report, based on data for the year 1942, indicated that during
that year 40,782 persons were employed in providing local public health services
under the auspices of the local, state, or Federal governments. Of these, 11,581
or over one fourth were part-time workers. Part-time health officers and clinic
physicians contributed about equally to account for 8,973 of the latter. At least
PERSONNEL FACTORS 203

 

 

23,000 additional trained individuals from the various specialties were needed
to provide the minimal public health services on the local level alone. The
greatest need was for public health nurses, with a discrepancy of 12,116, or almost
100 per cent, between the number employed and the suggested minimal number
of 26,390. While the suggested number of health officers appeared to be decreased
about four fifths from the 5,519 then engaged, the difference was accountable
largely by dropping the many decidedly part-time physicians and others who
serve in more or less nominal positions in village, town, and other minor civil
jurisdictions, usually in the absence of a properly organized health department.
The number of full-time health officers was essentially unchanged (1,202 existing
compared with 1,197 suggested). The 307 dentists employed needed to be multi-
plied by ten, as well as the 318 dental hygienists and the 44 health educators.
Three times as many laboratory workers were considered to be needed and the
number of office and clerical workers should be doubled.

The situation has not improved particularly since then. By the end of 1949
the number of full-time personnel employed by full-time official local health
agencies totaled 33,555. Fewer than hall of the local units had sufficient physicians
to meet minimum requirements. Approximately one fourth of all units reported
no physicians employed on a full-time basis. Shortages were much more pro-
nounced for nurses than for any other types of personnel. Only 6.5 per cent of
units had enough nurses to meet the minimum standard. With regard to en-
vironmental health personnel, i.e., sanitary engineers, sanitarians, and veterinar-
ians, nearly 63 per cent of cities but only about 31 per cent of counties met mini-
mum standards. About 50 per cent of units had adequate clerical and office staffs.
According to accepted requirements there were needed an additional 1,223
physicians, 11,826 nurses, 1,982 environmental health personnel, and 1,587
clerks.2?

For other specialties, approximately 20 per cent of budgeted positions for
health educators, public health dentists and medical social workers were vacant
at that time. For nutritionists the figure was 16 per cent, for laboratory workers
about 10 per cent, for veterinarians 10 per cent, and for statisticians and analysts
15 per cent.*

By 1957 the situation appeared on the surface to have continued to improve
somewhat with a total of 38,949 full-time workers of different categories reported
employed by local health departments. This represented a 16 per cent increase
since 1919. However, certain groups had actually decreased in numbers. Thus,
full-time public health physicians dropped from 1,609 in 1949 to 1,431 in 1957,
and laboratory personnel from 1,391 in 1949 to 1,290 in 1957. The greatest gains
made over this period were in environmental health personnel (from 6,531 to
7,315), in medical and psychiatric social workers (from 111 to 284), and in
public health nurses (from 11,251 to 12,956). Despite this, when the increase
in population during the eight years is taken into consideration, it is found that
with the exception of social workers and dentists, no net gains were achieved
and some significant decreases in relative numbers had occurred.?® It is interest-
ing but not surprising to note that while in absolute numbers the need is greatest
in the larger and more populated communities, the proportionate need is greatest
204 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
in the smaller, less populated areas. Undoubtedly this is attributable to the many
attractions of work and life in urban as against essentially rural or small-town
circumstances.

In summary it might be stated that the consensus at the present time is that
two intimately related [actors are contributing the most to retarding the develop-
ment and expansion ol public health work; these are (1) inadequate salaries and
(2) inadequate personnel, both quantitatively and qualitatively.

Personnel Management. It has been stated that one of the health adminis-
trator’s chief responsibilities is the direction and supervision of the function and
activity of the other members of the health department staff. This is important
in any organization but its relative importance is perhaps accentuated in public
health practice because, to an unusual degree, the personnel is literally the health
department and, furthermore, because the successful function and behavior of
the members of the health department’s staff determine in the last analysis the
acceptance and success of the organization’s work. This is true because acceptance
and success depend on the reaction of the public and it is through personal con-
tacts of the departments staff with the public that the health program operates.

In view of this, it is tragic to see how frequently health officers ignore the
personnel aspects of their programs. Too often the health officer looks upon
himself as the source of medical activity in the department, having merely a
nominal appointment as the representative head ol the agency, perhaps by virtue
ol age, length of education, or community prestige. Common as is this attitude,
it is certainly not good practice and is naive from the viewpoint of legal and
executive responsibility. The capable administrator, in public health work as
elsewhere, must assume an active interest and responsibility for every phase of
personnel management from recruitment and employment straight through to
dismissal if necessary.

Recruitment and Employment, Merit Systems. Recent years have seen the
development and wide acceptance of the merit system principle for the purpose
ol recruiting and selecting capable individuals to fill specific positions in the civil
service. It is curious to find occasionally among administrators of public health
programs a certain amount of resentment toward the civil service or merit system
idea and at the same time complaint against partisan political patronage as a
handicap to efficient service. This dissatisfaction may, perhaps, be attributed to
three things: lack of understanding by the executive of the essential purposes and
potentialities of the merit system; the unfortunate fact that some civil service
agencies are still forced to think of their original “fight the spoilsman” slogan,
and consider themselves more as policemen than as program facilitators; and lag
in the development of new personnel techniques to aid effective administration.
Despite these attitudes and difficulties, it is obvious that merit systems are here
to stay and, generally speaking, have already resulted in considerable improve-
ments in civil service.

By now the majority of governmental employees in the United States serve
under merit systems and each year sees more added to the list. White® has

pointed out that:
. . the basic conditions of government are such that the eventual triumph of the
merit system seems inevitable. The ever-increasing technological aspects of govern-
PERSONNEL FACTORS 205

 

mental operations; the greatly intesified social responsibility of government, making the
risk of administrative failure equivalent to the risk of social catastrophe; the emerging
professional point of view in many branches of administration; and the expansion of
civil service unions intent on protecting their own interests by the steady application of
the merit system, these and other circumstances forecast the certain destruction of
patronage in due course of time.*

Civil service systems and merit systems have had a long and slow history,
and only recently has there occurred accelerated adoption of the idea. Although
the first but unsuccessful measures were taken in the national government as
early as 1853, it was not until the assassination of President Garfield in 1881 by a
disappointed office seeker that increasing sentiment was crystallized. As a result
the Congress reluctantly approved the Pendleton Act, which serves as the basis
of civil service regulations in effect today. Originally the Pendleton Act included
only about 14,000 Federal positions, chiefly those in the postal and customs serv-
ices. Successive presidential orders have increased the number of Federal em-
ployees under the merit system to over 2 million, representing 86 per cent of
the total. Of particular effect has been the Ramspeck Act of 1940, which gave
the President wide authority to extend the scope of the civil service act and the
classification act. The first state civil service law was passed by New York in 1883.
Two years later Massachusetts [ollowed suit. Twenty years passed belore any
other states took action (Illinois and Wisconsin in 1905). More widespread
adoption continued slowly until the late 1930's. By 1937 only ten states had
adopted merit system legislation. When many states finally introduced the prin-
ciple, it was due largely to pressure from Federal agencies rather than to an
appreciation on the part of the states themselves of the value of civil service or
merit systems.

Concerning public health agencies, with but rare exceptions, states establish-
ing civil service or merit systems did so because of restrictions in the Federal laws
and regulations governing financial payments to the states for the much needed
“grants-in-aid” programs of the United States Public Health Service and the
Children’s Bureau under the Social Security Act. The effect of the Federal re-
quirements is dramatically indicated by the fact that in 1940 alone, the year
following their adoption, twelve states established merit systems affecting public
health personnel!

In the interests of promoting and maintaining sound personnel policies, Federal
administrative agencies are authorized to examine civil service or merit systems of states
and territories receiving “grants-in-aid” funds. Such systems when submitted by the
state and territories are considered by Federal agencies under two headings and approval
or disapproval is given either or both of these, The parts thus examined are: (1) the
basic law or rule, (2) the classification and compensation plan. The score by 1945 for

51 states and territories with the United States Public Health Service is:

Reviewed Approved
Law or rule... 50 45
Classification and compensation plans... 46 207

*White, I. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co. p. 287.

fMountin, J. W.: On Making Public Health Positions More Attractive, Am. J. Pub. Health
35:1150, Nov. 1945.
260 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

 

By the end of 1951, only 14.5 per cent of local public health workers were not
included in some type of merit system.28

The terms civil service system and merit system are often used interchange-
ably as if synonymous. There is a difference, although the distinction is slight
from a practical standpoint. Both are nothing more or less than organized meth-
ods of selecting and advancing employees on the basis of their qualifications in
relation to the aptitudes required by a particular job, together with relatively
assured permanency ol tenure, prescribed personnel benefits, and equal pay for
equal work. If the plan exists by virtue of a statute, it is usually referred to as a
civil service system. If it originates [rom an administrative ruling, it is called a
merit system. A merit system, therefore, might be considered a civil service sys-
tem without benefit of legislation. However, as this newer term gained in popu-
larity and generic use, it appeared also in legislated plans, so that one cannot
autoamtically infer the structure from the name. Neither term has yet been sup-
planted by the preference of personnel administrators to speak of public person-
nel programs in which the merit principle is assumed.

In order to accomplish the purposes outlined, a number of prerequisites
are indicated. In a civil service system, the first essential is the necessary enabling
legislation accompanied by adequate appropriation for the satisfactory operation
of the program. The legislation should provide the necessary authority to the
civil service agency so that its activities may not be circumvented or ignored. If
a number of agencies are involved, of which the health department is only one,
provision should be made for uniform policies and procedures inasmuch as pos-
sible. The law itself should give attention to the removal of the system from the
influences of local politics. This is desirably accomplished by providing for a
separate personnel agency administered by a career executive under a nonpartisan
advisory, regulatory, and appellate commission whose members serve for over-
lapping terms.

Of more recent origin is the trend toward professional personnel divisions
within large functional agencies such as health departments of states or large
cities. This unit reports to the agency administrator, assisting him in carrying out
his personnel responsibilities, and provides liaison with the civil service agency.
In order to provide for the selection and promotion of employees on the basis
of their qualifications or merit, a civil service agency is faced with the preliminary
problem of position analysis and classification. This is futher necessary in order
to make possible the desired uniformity of policy mentioned above and in order
to prevent a number of individuals, doing essentially the same type and amount
of work, from getting widely varying compensation. Needless to say, position
analysis and classification and the resulting qualifications for prospective person-
nel should be carried out jointly by the administration of the functional agencies
and the civil service agency, or a personnel department under the latter's control,
with an attitude of helpfulness. It should be revised periodically to reflect changes
occurring in the content of positions.

Once position classifications and personnel qualifications have been estab-
lished, the next step is to provide for the recruitment and examination of ap-
plicants. In the field of public health more recruiting activities are carried on
PERSONNEL FACTORS 207

 

by the public health agency itself than by the civil service agency, since in most
instances the health officer is in a better position to know the type of individual
he wants and where he might look for him, and candidates usually do not
abound. Examination may consist of one or all of the various approaches, includ-
ing substantiated records of training and experience, written examinations largely
for the purpose of determining technical knowledge, and personal interviews
chiefly to get an insight into the personality of the applicant. Since achievement
of a high grade is not invariably indicative of desirable personnel and since,
as will be discussed, an important phase of operation is the interplay between
the personalities of the executive officer and his subordinate personnel, it is only
reasonable to allow the executive officer a choice among the candidates who were
successful in the examination.

When circumstances result in a surplus of desirable applicants, it becomes
an added function of the civil service agency to maintain a register of qualified
personnel. Where retirement plans have been put into operation, responsibility
for them has often been given to the civil service agency. In addition, they
frequently serve as places of appeal and review in instances involving disciplinary
measures, dismissal, or overt employer-employee conflicts.

Compensation, Tenure, and Promotion. It was stated that one of the essential
purposes of a compensation plan based on position classification is equal pay for
similar work. In the absence of such a plan, the weak executive tends to be un-
concerned or ineffective in obtaining increases for his personnel in general. At
the other extreme is the executive with a strong and aggressive personality who
may tend to secure increases for favorite employees without consideration of the
absolute or comparative value of their services. Compensation in such instances
may then depend largely on political influence, friendships, favoritism, and nepo-
tism. Needless to say, the morale of the employees of either of these types of ad-
ministrators rapidly degenerates.

The position in an organization having been classified and a general policy
of compensation having been decided upon, the next step is the allocation of
pay rates to the various position class titles. Usually this is done by establishing
a range from the minimum rate to be paid to new employees up to a maximum
that may be paid to anyone in the particular position class. In setting this salary
scale, consideration should be given to numerous factors, among which are pay-
ment for comparable work elsewhere in the same locality, cost of living, wage
trends, the financial condition of the community and agency, legal restrictions
that may exist, and recognition of union rates. In many professional health
classes, the national mobility and recruitment of personnel cause salaries for
comparable work in agencies across the country to become a significant factor.
Once set, salary scales should be reviewed regularly to maintain currency.

It is usually desirable that the minimum rate of a position class should not
be less than the maximum rate of a lower class. Between the minimum and
maximum there should be one or more intermediate steps. A usual compensa-
tion policy is to start the new employee at the minimum of the range, granting
the first increase at the end of an introductory or probationary period, followed
by further increases annually thereafter until the maximum salary for the particu-
208 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
lar position class has been reached. It should be clearly understood, however,
that compensation advancement is not automatic but only follows demonstrated
and continued proficiency. Whenever possible, the decision concerning an in-
crease should be made by more than one person. For example, in larger organ-
izations the decision might involve the combined judgments of the executive
health officer, the immediate supervisor of the employee in question, and the
personnel officer.

Of considerable assistance in making decisions concerning compensation
increases is the use of efficiency and service ratings. It is reccommended that the
administrator periodically and systemically survey or study the efficiency of his
employees and that the results be made part ol a permanent personal history file
ol each employee. Inasmuch as possible, the evaluations should be based on fac-
tual data, measurable performance, and work records rather than on purely
personal judgments, although the latter should be included as auxiliary informa-
tion. An important personnel [function of the administrator, therefore, is an
attempt to develop practical and equitable standards of measurement or evalua-
tion. There should also be included in the employees personal history file memo-
randa concerning specific and noticeable changes in behavior, attitude, or effi-
ciency. Contrary to all too [requent practice, these memoranda should relate to
changes for the better as well as for the worse. Furthermore, they too should
consist of statements of fact rather than mere superivsory deductions, impres-
sions, or opinions which not infrequently are biased.

The factors involved in determining tenure and promotion are essentially
the same as those that determine the granting ol step increases in compensation.
It is customary and proper that an employee expect to hold a position so long
as he adequately fulfills its purpose and so long as his behavior is not detri-
mental to the interests of other employees or of the organization.

Vacancies in the organization may be filled in essentially two ways: by pro-
motion of an employee already working in the organization or by employment
of someone new from outside. If the position is other than the lowest in the scale
and if it is filled by promotion from within, the executive is faced with the pos-
sibility of having to carry out promotions all down the line, involving consider-
able reshuffling, readjustment, and retraining.

While on the surface this may appear to have the disadvantage of upsetting
the work of the organization to a considerable extent, it also has definite ad-
vantages. First, if it is wished that employees approach their work from the
point of view of possible careers in public service, promotion from within can
be considered a fundamental premise and is conductive to desirable organizational
morale and loyalty. It also develops a staff with wider interests and abilities than
is otherwise possible. Furthermore, to follow a policy of filling upper positions
from outside discourages the really capable individuals from remaining in the
organization, with the result that over a period of time there is built up a residue
of predominantly disappointed, disillusioned and mediocre employees. Once this
occurs, the responsible executive, or one so unfortunate as subsequently to take his
place, finds himself with no choice but to go outside for capable personnel.
Finally, if there is any reason for employees to suspect that an outsider has been
PERSONNEL FACTORS 209

 

brought in because of personal or partisan [avoritism, a disastrous lowering of
morale is sure to follow.

It must be realized, of course, that some positions must be filled from the
outside, especially during a period of organizational growth or when there is
no one within the agency truly capable ol filling the vacancy. Occasional problems
of intra-agency [rictions, favoritism, and cliques may be effectively solved only
by the reallocation ol certain of the existing employees and the introduction of
one or several new employees. In general, perhaps the best course to follow is
in the middle, filling positions from within as much as possible but always keep-
ing in mind the basic interests and purposes of the organization. Accordingly,
many capable administrators follow a policy of occasionally introducing a few
new, particularly well-qualified leaders in key positions made available by retire-
ment of older employees or by their reassignment to other duties, in conjunction
with the development as rapidly and as extensively as possible of a group of prom-
ising younger employees well trained from within.

Some ill-advised executives avoid the advancement of younger capable em-
ployees either [rom fear of their possibly presenting eventual competition to
themselves or [rom fear of losing them to another agency. Such an attitude is, of
course, absurd since the truly capable administrator need have no fears of compe-
tition from loyal staff members, and should his capable assistants advance into
other fields or agencies, that might be considered a measure of the successful
nature of the administrator's policies and leadership. In fact, the wise executive
should derive considerable satisfaction from seeing individuals trained by him
go out and spread his philosophy and viewpoint much farther than he could ever
hope to do by himself.

The Executive and His Personnel. Administrative management is essentially
a question of the organization ol man power, materials, resources, and strategy
for the accomplishment ol a desired goal. This is impossible unless the adminis-
trator has successfully organized himsell so as to intelligently understand the
causes of the problems he meets in his day-to-day work and the remedies for their
adequate solution. It requires, therefore, an intimate knowledge and understand-
ing of a great many factors, including people as well as materials, plus a great
deal of curiosity, imagination, determination, integrative ability, and good judg-
ment. In a field such as public health, there also is required a greater than usual
social consciousness and understanding. Accordingly, the work of the public
health administrator becomes much more than a matter of writing rules and reg-
ulations, issuing orders, or establishing clinics. In effect it involves the power and
ability to influence, if not to determine, the happiness, welfare, and even the lives
of a large number of people, beginning with the staff of the agency and extend-
ing out to include every member of the public. This is statesmanship in the
correct sense of the word in that the executive health officer, in keeping with
executives of other fields, plays an active and significant role in shaping the future
not only ol his organization but also of a community and of a society as a whole.
This represents a truly great responsibility.

In order to be successful, the executive officer must be well balanced. He
should possess the type of personality which marks him naturally for a position
270 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

of leadership and which inspires the confidence of others because of a mature
interest in them rather than using them for his own selfish purposes. He should
demonstrate a constant sense of fairness, giving his employees the assurance that
their individual and collective welfare and interests are sale in his hands and
that they will not be subjected to the undesirable influences of prejudice, favorit-
ism, or arbitrariness. The most effective administrator is the one who is not
specialized in any particular field, which would make him a technician and
would result almost certainly in an unbalanced program. He should, however,
gain enough knowledge and understanding of the various technical phases and
activities of the organization to enable him to coordinate them intelligently and
assist administratively in their development.

It follows, therefore, that the administrative health officer, like executives
in other fields, must establish his goals, make plans for their attainment, create a
sound organization providing for practical levels of authority and coordination,
recruit and manage good personnel, delegate responsibility and its concomitant
authority, establish whatever rules and regulations are needed for smooth opera-
tion, develop a sound financial policy and an efficient work plan, provide con-
tinued leadership, education, and inspiration, maintain good morale, secure co-
operation, and keep the plans and programs of the organization constantly in
tune with the social forces on which depends its success and survival. To accom-
plish all this he needs personal characteristics such as those summarized by
Dimock29:

The successful executive, therefore, is he who commands the best balance of
physique, mentality, personality, technical equipment, philosophical insight, knowledge
of human behavior, social adaptibility, judgment, ability to understand and to get
along with people, and a sense of social purpose and direction.*

This sounds as if some type of superman is required. However, this does
not necessarily follow, since, stripped to the essentials what is required is a de-
termination to carry out a certain few proved administrative principles, e.g., that
authority should equal responsibility or that functions should be defined, plus a
genuine liking and understanding of human nature. The administrator's function
is to maintain a sense of goals, strategy, and timing and to supply specific en-
couragement, instruction, and pressure at the right point and time. The executive
is most effective when, having delegated as much detail as possible to his subordi-
nates and their having contributed everything of which they are capable, he pro-
vides the extra 5 per cent of knowledge and leadership with which to turn out
a completed and workmanlike job.

The executive health officer should always bear in mind that he is placed in
a managerial position for a social purpose and not because of any personal interest
in him or his welfare. He is employed for more than routine management and
housekeeping. He is expected also to be a tactician and social philosopher, using
his wits, his ability as a leader, and his understanding of social forces to improve

*Dimock, Marshall E.: The Executive in Action, New York, 1945, Harper & Brothers,
pp- 10-11.
i PERSONNEL FACTORS 271
the state of society. Since society and the forces influencing it constantly fluctu-
ate, he never operates in a fixed environment. He must constantly adapt himself,
his program, and his organization to these environmental changes and further
must try to influence the environment in any way that might seem indicated for
the accomplishment of the ultimate purpose of the program.

With this in mind, there should be mentioned a not unfamiliar type of ad-
ministrator commonly referred to as a promotor, who, although possessing great
imagination, enthusiasm, and salesmanship, lacks the ability or momentum to
follow through. He finds it difficult to sustain an interest in any one thing for
long, dislikes routine, and is constantly searching for new worlds to conquer.
Accordingly, his interest and energy jump unpredictably from one thing to an-
other, with the result that his personnel never knows in what direction they are
going next or what their relative positions will be. Particular subordinates may
receive concentrated attention and support one day, only to be ignored and
forgotten the next. That this is conducive neither to a sound balanced program
nor to high morale is obvious.

There are others, however, who achieve a balance between promotional
ability and executive leadership. They, while never satisfied with the status
quo, realize nevertheless that “the show must go on,” that all parts of the pro-
gram must be continuously sustained. Possessing strong imagination, they are
ever on the alert to new problems and methods of attack, carrying a promotional
activity to the point where it has been established and accepted and may be
turned over to a capable subordinate for its complete development, without at
any time unbalancing or confusing the program as a whole. This is the difference
between the “will-o’-the-wisp” promoter and the executive with promotional
ability.

While the latter type of leadership is desirable in every organization at all
times, it is of particular importance in the initiation and development of a new
enterprise. Such circumstances require an unusual amount of imagination, cour-
age, exploration, self-confidence, and planning ability, plus a sense of good tim-
ing, and an ability to combine what is in the process of creation with what already
has been brought into existence. In this regard, it should again be realized that
public health work, being a rapidly expanding field, requires that the executive
health officer, to be effective, constantly face the problem of initiation and promo-
tion of new programs.

It is clear, therefore, that the health executive of a functioning agency must
be three things: a trouble shooter constantly expecting the unexpected and
always ready to deal with crises, a supervisor delegating everything he can to
those working under him, and a promoter of new programs to increase the use-
fulness and effectivness of his organization. As pointed out by Dimock,*® this
order is reversed in the formative stages of a new organization. Many executives
successfully carry out one or two of these, but the test of a truly competent ad-
ministrator is if all three can be accomplished.

Delegation. Delegation has been referred to as fundamentally necessary for
successful administrative management. In fact, administration might with con-
272 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

siderable truth be defined as getting things done through others. In present-day
public health organizations as well as other organizations, it is impossible for one
person to do the whole job. The head of an organization should not try to handle
all of the details himself; it is a physical and mental impossibility and it is not ex-
pected. Decisions should be made at the lowest possible pont in the organization's
line of command. Were this not true, there would be little use or justification for
creating an organization in the first place. The wise executive will employ as
subordinates individuals who are more capable than he is in each of the various
functions of the organization and will let them take care of the details. Far from
indicating weakness, it is a sign of a good administrator for subordinates to be
called upon to present detailed information to outsiders as well as to the execu-
tive himself. Furthermore, to do so boosts the ego, job interest, and loyalty of the
subordinate.

Probably the average executive does not adequately understand the basic
principles involved in delegation. Not uncommon is the pitiful spectacle of an
executive who, fecling that only he can do each job correctly, is trying to face all
points of the compass at once and has become a slave to nonadministrative
minutia with which others are better fitted to cope. He lets the job run him in-
stead of the preferred and intended reverse. Meanwhile his subordinates must
helplessly stand by, losing interest and initiative, merely nodding assent to the
wishes and actions ol their superior.

On the other hand are the many executives who, apparently lacking the
courage of their convictions, delegate responsibilities to a greater or lesser ex-
tent but avoid establishment of clear-cut lines of command and neglect to invest
the employee with the corresponding authority needed for adequately meeting
the added responsibility. They thereby tend to expect more from their subordi-
nates than they have a right to, expressing great surprise and disappointment
when their subordinates appear not to stand up fully to their responsibilities.
They appear not to realize that a subordinate under such circumstances, in ad-
dition to feeling a lack of recognition and trust, is in great danger of being left
out on a limb, caught between an employer who demands that he carry out a del-
egated responsibility and other employees who understandably question his right
to make requests or issue orders.

Failure to delegate, therefore, has many undesirable consequences. First,
and probably of least importance, is that the executive tends to drive himself
toward a physical or mental breakdown following never-ceasing “high pressure”
work days coping with annoying details and sleepless nights fed by bulging brief
cases. Inevitably the organization suffers because the executive himsell is the
chief bottleneck and the work is incompletely and inefficiently done. The agency
loses the benefit of whatever abilities exist in the rest of the personnel, capable
potential employees shy away from the uninspiring environment, and those
within the organization soon ask themselves either, “Why stay?” or “What's the
use of working or trying?”

All who have studied the problem agree that in practically all instances of
“one man shows” with the absence of delegation the essential difficulty is one of
psychological inadequacy on the part of the executive. This masquerades in
PERSONNEL FACTORS 273
many forms: conceit, boorishness, false pride, false interest, fussy perfectionism,
or obvious lack of self-confidence. As Dimock has said:

Show me the man who does not delegate and it will frequently be found that he
is a bundle of fears and misgivings. He is afraid to make mistakes. He is afraid that he
will be tricked or embarrassed. He is afraid that others would not do it his way.*

This gives a sadly accurate word picture of more than one executive officer in the
field of public health.

Certain few essentials are necessary for successful and effective delegation.
The first requisite is that the executive must truly and consciously want to do it.
It is never a subconscious action. The executive must look upon his function as
essentially that of a coordinator of the activities of many others, each of whom has
been entrusted with specific responsibilities and authority. He must consider his
position akin to that of the conductor of a symphony orchestra, through whose
coordinating activity inspiring music results where there might otherwise be
cacophony.

The organization must be set up with clear-cut and well-understood lines or
channels. In delegating, these lines must be respected, never making one person
responsible for a job only to give the job or the authority for it to someone else.
Perhaps the most important consideration involved is the realization that dele-
gation properly involves a multiple action. The key setting off the chain reaction
is the necessity of delegating work load or function. This infers a delegation of
responsibility. In turn, to make the fulfillment of the responsibility possible, dele-
gation of an appropriate additional amount of authority is necessary. In some
instances, a change in the title or rank of the employee is indicated as part of
the delegation of authority, in order to implement it.

In discussing the relationship between delegated responsibilty and authority
most writers speak in terms of equality. Actually what is called for is an even
more delicate adjustment. The good executive has a real interest in the develop-
ment of his subordinates as well as in getting the work done. Accordingly he
will grant to the responsible subordinate the amount of authority required by the
responsibilities, plus just enough in addition to allow expanded opportunity for
experience and improvement without risking marked difficulty and a sense of
failure.

It must always be understood that delegation is in effect a loan which is
never permanent and which can be recalled at any time. Delegation is most
effective in an atmosphere of mutual understanding and respect. The executive
has the right to expect that his trust will not be abused. He should, however, be
constantly alert to the possibility that his trust as manifest by delegation might
not be justified. Unfortunately he will occasionally find this to be the case. Such
instances are not always easy to handle, as Dimock well emphasizes:

The worst kind of a person to deal with in any organization is the slippery evasive
individual who gives the appearance of a good fellow and a square shooter, who pays

a sort of obsequious deference to the wishes of his superior, but who goes contrary to
known policies and abuses his authority to the extent where it cannot help but be

*¥Dimock, Marshall E.: The Executive in Action, New York, 1945, Harper & Brothers, p. 175.
274 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

noticed, but not quite to the point where the official is jusified in chopping off his
head. It is this kind of person more than any other who gives the executive pause
when it comes to delegation, and who is most likely to damage the morale of the
organization as a whole. The egoist is soon discovered and can be eliminated. The man
with an inferiority complex can be built up and restored to normalcy. The devious per-
son is the hardest to handle on all scores, but especially in any situation requiring a
delegation of authority. *

A few words about the “power relationships” of the head of an organization.
The successful leadership of an organization involves a constant struggle with
those in other organizations or groups who also possess power. The executive
health officer must recognize this and be ever ready and able to engage in a
struggle for proper power. This is vital if his organization is to survive and if he
is not to betray it, its employees, and those it serves. He should not allow himself
to be deluded or deterred in this by false modesty, weakness, or complaisance.
Of course a struggle for power should never be simply for the accumulation of
power for its own sake or for self-aggrandizement but should be engaged in in
order to assure that no important or essential part of the organization and its
program will be lacking or misplaced.

A most succinct summary of the approach to situations such as these has
been given by Upson3?:

As an executive, you must expect some people to disagree with you—some who are
smarter than you are and honestly object to both your methods and objectives; some
who are less smart than you are and out of that inadequacy damn what you are doing
in an effort to make themselves appear big; some, who dislike or misunderstand your
motives and who will fight everything you try to do simply because you are doing it.

Of these groups, respect the first, ignore the second, and fight the third—and fight

them without compromise, winner take all.¥

Morale and Discipline. In every organization some rules or regulations will
be necessary, but if they are to be effective they must be few, simple, readily under-
stood, and inflexible. Items that may be effectively included are limited largely
to such matters as the hours of work, the length of the lunch period, the hand-
ling of certain records and correspondence, holidays and leaves. The adminis-
trator’s real difficulties begin at the point where objective inflexibility ends. He
cannot hope to constantly police the work and behavior of all of his subordinates,
and even if he could it would preclude the possibility of good leadership. The
best he can hope for, and what is probably most desirable in the long run, is to
develop inasmuch as possible an almost subconscious self-discipline within the
group itself so that improper behavior of a particular employee is considered by
his fellows as an infraction against their self-developed and self-enforced code of
working ethics.

The executive and his supervisors should always bear in mind that while
most people are quite willing to be subordinate to good leadership, they are
not willing to be subservient. While the person in authority may have the legal or

*Dimock, Marshall E.: The Executive in Action, New York, 1945, Harper & Brothers, p. 197.
Upson, Lent D.: Letters on Public Administration From a Dean to His Graduates, Detroit,
1947, privately printed by the author, p. 11.
PERSONNEL FACTORS 275

 

financial power to demand obedience, the subordinate similarily has the power
to refuse to obey or, what is more practical from his standpoint, the power to cir-
cumvent orders while appearing to obey.

Individuals in an organization may often with relative ease find it possible
chronically to arrive late and leave carly or to spend considerable time visiting
with fellow workers. If promptness and attention to work has over a period of
time become part of the organization's code of working ethics, in most instances
the administrator will find it unnecessary to deal with the individual situation
himself. The other employees by virtue of their own interest in the matter will
handle it for him. They will take the attitude that the individual is trying to
get away with something which is contrary to the best interests and welfare of
the group. If, on the other hand, there is a tradition of slipshod management
and administration, the affairs of the organization will tend to assume the atmo-
sphere of a routinized semisocial event to the detriment of the program and the
morale of all concerned.

The question of attendance control is only one example of a great many
problems of administrative management [or which there is more than one answer.
Depending on the type of activity in which the organization is engaged, attempts
to obtain strict adherence to the scheduled hours of work may be a deterrent
to whole-hearted cooperation and high personnel morale. This probably applies
to most phases of public health work, where a reasonable degree of latitude al-
lowed by a good leader will in most instances result in greater loyalty to and
interest in the work than would otherwise be attained. An organization is recalled
where unusually high morale, evidenced by interest, willing overtime, and loyalty,
was definitely jeopardized by the installation of a time clock for the professional
personnel by an overenthusiastic “efficiency expert” from the mayor’s office.

In terms of what has been said, therefore, the goal for which the good ad-
ministrator will aim is a cooperative team, which is probably most successfully
achieved by the development of a logical organizational structure with well-
defined and understood lines of authority and responsibility and a well-estab-
lished tradition of good self-discipline. Good personnel management depends
partly on sound organization and partly on sound individual guidance, correc-
tion, reward, and punishment. It has been said that the administrator must
understand people and be a leader. There are two kinds of leadership, the first
demonstrated by a person with superior ability which people gladly follow, the
second consisting of mere possession of authority. Authority in itself is of limited
value. It is well to remember the adage, “You can lead a horse to water but you
can’t make him drink.”

The wise executive will understand the difference between a well-balanced
person and one who is emotionally disturbed, and he will be conscious of the
gap that may exist between ability and achievement. He will recognize that these
characteristics apply to himself as well as to his subordinates. He will realize that
an emotionally immature person will tend to measure accomplishments against
those of more gifted or more fortunate people or against some unreasonable
standard he has set for himself. Such a person remedies failure by daydreaming,
rebellion, self-pity, bullying, bragging, or even by deliberate failure which is a
276 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

form of overcompensation. The well-balanced person, on the other hand, will
measure his accomplishments against his honestly recognized aptitudes and
share of luck. His aim is to seek a cause worth serving, for which he has an
aptitude, and in which he can find mental and emotional satisfaction. In dealing
with personnel, therclore, the executive should be aware of the various types
of behavior defenses that may arise from a feeling of failure or dissatisfaction.
These are ol many types: “II I give in, you won't need to hurt me.” “If I am
humorous, you won't think to hurt me.” “If I flatter you, you will be deterred
from hurting me.” “If I am sick and unfortunate, you will be ashamed to
hurt me.” “If you love me, you won't want to hurt me.” “If I hurt you first, you
won't be able to hurt me.”

This leads to the question of discipline. As White has indicated:

In a healthy organization the staff possesses a high morale which relegates discipline
of any type to a position of secondary importance. For most persons the attitude and
morale of the group are a sufficient guide to conduct; and where effective leadership
and good supervision exist, problems of discipline largely disappear. The basic attack
on disciplinary problems is therefore an indirect one, rather than the search for new
forms of action or the imposition of heavier penalties. *

Practically every instance requiring discipline comes after a failure of
some kind on the part of management. This applies even to cases ol “born
troublemakers” since an effective personnel program would preclude their em-
ployment in the first place. It should always be realized that a disciplinary
act deals with much more than the immediate present and the individual di-
rectly involved. The case at hand merely concentrates in the present the results
ol the past and possible consequences of the future. Furthermore, literally every
other member of the organization is alert and watching for the outcome because
the solution will show them what to expect under similar circumstances. Magoun?!
has illustrated this point with the story ol the office boy who was disciplined for
absenting himsell [rom work to attend a family funeral after being refused by
the boss, who suspected that he went to a World Series baseball game. Needless to
say, such an employer would never be forgiven by those working under him for
his bad judgment and ill-considered disciplinary action.

While avoidance of conditions requiring discipline is much better than suc-
cessful discipline, failure to discipline when it is indicated is demoralizing to
the group. There are a number ol behavior patterns that require action ol some
sort on the part ol the administrator or supervisor. Among these are inattention
to duty, including chronic tardiness, laziness, carelessness, breakage or loss of
property, inefficiency, insubordination in the form of violation of an order, regu-
lation, or law, or disloyalty to the organization. Certain personal behavior such
as continued and overt intoxication, immorality and lack of integrity manifest
by violation of a recognized code of ethics, soliciting, accepting a bribe, or de-
liberately neglecting to enforce a law also require action.*?

*White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co., p. 388.
PERSONNEL FACTORS 277

 

A poor executive, in approaching disciplinary problems of this sort, will tend
to rely merely on his power to coerce and command. In so doing he is actually
attempting to reassure himself for his own [eeling ol inadequacy and weakness,
refusing to recognize that perhaps he and his lack of leadership had something
to do with the development of the problem at hand. The capable executive, on
the other hand, sees unbalanced behavior as a symptom of wrong conditions
either in the way the employee has been handled or in some external situation
such as the work, social, community, or home environment. He will recognize the
importance of the employee's stage of emotional development and even consider
the possible influence of [rustrations and insecurities of earlier origin along with
those developed in the recent past.

In dealing with an upset employee one should ask himsell a number of ques-
tions of a psychological nature. What accounts for the emotional insecurity
which resulted in the employee's decision to press the rebellion, to side-step
the basic difhculty, instead ol consciously and honestly recognizing his feelings
and responding to them in an intelligent manner? What opportunity can be
given him to gain self-assurance so the solution will be permanent rather than
temporary?

Some may consider an approach such as this, unwarranted, patronizing, and
out of place in business, industry, or public service. It might be pointed out,
however, that considerable attention is paid to inanimate machinery and, if
something goes wrong in its mechanism, we go to great lengths to discover the
seat of the trouble rather than to discard the whole machine or to rely on make-
shift repairs. It is high time that we realize that the animate mechanism, the
human employee, merits this and much more attention and consideration.

The actual approach to a disciplinary action should never be casual or
momentary. A series of steps should be taken. The executive officer should first
study himself to discover and eliminate personal bias as well as to discover any
personal responsibility [or the situation. He should make a many-sided approach
to the problem, looking at it through the eyes of the employee himself, his family,
his fellow employees, and his immediate supervisor. The entire situation should
be investigated, giving consideration to the condition ofl work at the time, the
employee's past record, the morale and behavior of the employees as a group, the
type and degree of infraction, the organization’s tradition in such cases, and
any outside conditions that may have influenced the employee. An attempt
should be made to discover whether the failure was due to misunderstanding, an
emotional upset, lack of experience, some irregularity in working conditions, or
poor leadership. Throughout the whole process, the executive should look upon
his function as that ol a counselor rather than that ol a judge and should be alert
to opportunities to solve the problem from the point of view of the welfare of
the organization while enabling the employee to save face.

Magoun, in teaching human engineering at the Massachusetts Institute of
Technology, used the case analysis method to considerable advantage.® The
approach to disciplinary situations which he suggests is outlined here in some
detail because of its value as an exercise in the solution of personnel problems.
278 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

Prepare
IL

II.

III.

IV.

Analyze

I.

11.

111.

IV.

Study the situation until you feel completely clear as to

. How your habits and emotions color what you see in it

. How the other people concerned are affected by it

. All the significant facts

Exactly what the problem is that requires solution (problems in

human relations are almost never what they seem to be on the sur-

face)

Write down the essential facts of the problem

A. Be sure to avoid any interpreting and include only accurate concise
statements of fact

B. Be sure to include material other people recognize as facts, even
though you may not

Write down the emotions involved in the problem

A. What desires created the situation?

B. What desires are maintaining the situation?

C. What long and short term goals are desired by you and others and
why?

Check by making believe you are each person involved, and see whether

you have made a valid presentation of his facts, problems, and desires

from his point of view

Cow

Separate the fundamental from the trivial (beware that your emotions

do not fool you in this)

What are the key logs in the jam?

A. Make a careful and exhaustive analysis of each person’s acts and re-
actions, step by step. Begin by finding out first, in detail, all the
consequences each person’s attitude has for him and what satisfac
tions it fulfills. Then be sure to get to the bottom of what actually
happened, and work out an exact explanation of why. Does it
make psychological sense? Common sense?

Write all of this out in its proper relationship

A. So that you can see the problem as a whole

B. So that you can see where the situation is going and how fast

Write out in significant detail the requirements for a total solution

A. What are the things it must accomplish—can accomplish? Why is any
given goal desirable? Why are there only certain ways of achieving it?

B. Check for the immediate and total satisfaction of each person in-
volved

C. Note conflicting desires that must be harmonized by a successful
solution

. Contrive a total solution

A. Write out every possible alternative showing how you derived it,
and choose the best one (usually the simplest) that offers the inter-
weaving of interests
PERSONNEL FACTORS 279

 

Handle

I. Once the goal has been determined, the means become the most im-
portant thing; now that you have decided what to do, plan to do it
A. With a minimum of self-assertion or disturbance to habit patterns
B. With careful consideration of time, place and individuals
C. With reference to the various possibilities that may arise
II. Write out your plan concretely, accurately, and in detail
III. Rehearse your plan as one would familiarize himself with a detailed map
A. Go through it step by step, with the help of someone else, looking
for flaws in your plan, flaws in your attitude, ways of bettering your
presentation in terms of the individual involved and places where
you might meet failures due to the unexpected
IV. Wait for the appropriate time and conditions. Then try out your plan
A. Be thoroughly sincere and keep voice, eyes, posture emotionally calm
B. Begin by getting the facts understood
C. Present your case in terms of his intelligence, viewpoint, and emo-
tional responses
D. Listen to his case so that you can express it to him better than he
did to you; then he knows you understand it; you may also catch
any new evidence that you overlooked
E. Together come to a decision based on the facts

Evaluate

I. Review the entire case
II. Write out its lessons
A. What almost failed and why?
B. What almost succeeded and why?
C. What did you do for yourself and others?
D. What did you do to yourself and others?

The types of disciplinary action that may be taken in specific situations can
be divided into several categories. First there is what might be termed the indirect
or informal approach. Here there is no specific or explicit reference made to dis-
satisfaction, and reliance is placed on inference by the employee as a result
ol a change in attitude in the executive officer or supervisor. There may be de-
veloped, for instance, a more or less obvious chilling of the atmosphere, closer
supervision of work, a failure to invite the employee to confer or consult with
reference to relevant matters, a rejection of proposals, or a reduction in estimates.
The employee might further experience some loss of privileges, a curtailing of
authority and responsibility, or actual reassignment to less desirable work. The
assumption of this approach is that the employee will be intelligent enough to
“get the point” and without further action spontaneously undertake a program
of self-improvement.

A more explicit approach may be the application of what are sometimes
referred to as direct or formal penalties of first degree. Usually these are imposed
and enforced by the head of an office or division on his own responsibility and
280 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

without review. They may take the [orm of formal notice and warning, repri-
mand, the loss of seniority, a delay in salary increment, or the requirement of
overtime. The use of the last two disciplinary actions are somewhat open to ques-
tion. The employee may with considerable justification and support object to
unpaid overtime as a means of getting some work done for nothing. With regard
to seniority, the supervisor or administrator may find himself involved in a con-
troversy, very often with the employee and the civil service agency on one side
and himself on the other, since for some reason it is not rare to find civil service
agencies considering as one of their functions the protection of the misunderstood
employee [rom an overbearing or malevolent supervisor or administrator.

The transfer of an employee might be considered a penalty of the first degree
and in many instances solves the difficulty to everyone's satisfaction. Not infre-
quently the problem employee may cease to be a problem il he is reassigned to
work under another supervisor, put in a new social or physical environment, or
assigned a different type of work. This is understandable considering that per-
sonnel problems involve much more than the employee, i.e., fellow employees,
the physical environment, the supervisor, the type of work, and many others.
The surly and careless file clerk may turn out to be an excellent receptionist.
The inefficient and unproductive field nurse may develop into an exceptional
clinic assistant. While often very effective, there is one objection to this approach
on the basis that it encourages some supervisors and executives to feel justified in
dodging personnel problems, to the development of which they have often con-
tributed, simply by transferring them to others. Much more than a transfer is
needed in every instance—a complete study of the circumstances of the problem
is indicated.

If more drastic disciplinary action is indicated, what have been referred to
as penalties ol the second degree may be applied. They usually require the action
ol the head ol the department or organization itself and sometimes the employee
has the right to appeal to a board, a civil service commission, or occasionally to
a court. The first penalty in this category is temporary suspension. It is question-
able il this is ever sound or justified. The [act that the employee is subjected to
enforced although temporary absence [rom work and therelore loss ol salary
inevitably results in his return to work in a more disgruntled, defensive, and
vengeful frame ol mind than when he left.

The same objection may be raised to the use ol demotion as a penalty. Oc-
casionally, however, il the employee has great intrinsic desirability for the organ-
ization, a temporary demotion, with the clear understanding that reinstatement
will readily follow demonstration ol good intentions, may be indicated. One
might well raise the question, however, whether some of the less drastic methods
ol approach would not be equally or more effective in such instances.

Dismissal or removal [or cause is, ol course, the extreme and final measure.
A word of caution is indicated here which applies to all types of disciplinary
action. When it first appears that an employee may be a problem, a detailed
documentary record should be made ol pertinent instances and facts for possible
reference and use in the event that subsequent disciplinary action may be ap-
pealed. It is a good policy to keep the employee in the case informed at every step
PERSONNEL FACTORS 281

concerning his status rather than to subject him, as too often happens, to a
sudden release of pent-up managerial objections. This always should be and can
be done with an atmosphere ol counseling, which shows a genuine concern for
the employee's welfare as well as for that of the organization. True, this often
takes much time, but in the long run it pays great dividends in the maintenance
ol high morale. In the past and to a considerable degree in the present, the
attitude of executives toward dismissal has been that it represents merely a dis-
agreeable experience for the employer involving simply the summary discharge
of the employee. If dismissal is necessary, the employee should be made to realize
that it is in his best interest as well as the organization's and, in effect, presents
an opportunity for his rehabilitation elsewhere.

One final word ol caution. Under no circumstances should a worker be sub-
jected to any active form of disciplinary action in the presence of his fellow
employees. While some of them may appear to enjoy it, they will all resent it.

Conditions of Work, Job Appeal. A high level ol employee morale has been
referred to repeatedly as a prime essential for the satisfactory and efficient opera-
tion of a public health program. Good morale is difficult if not impossible to
define. Perhaps like health, the best way to recognize it is when it is not present.
If the state of mind and the working relationships ol a group of people are
satisfactory, one seldom if ever finds himself even thinking about the problems in-
volved in the development and maintenance of good morale. In contrast, one
becomes acutely aware ol the problem if things are not what they should be.

The nature of high morale might be better understood by some of its symp-
toms, such as a pride ol the employees in being identified with the organization
and their pleasure in working for it. There are health departments, unfor-
tunately, the employees of which look upon their activity as merely a means of
earning a wage or salary. On the other hand, health organizations exist in which
everyone, including the office boy, the elevator operator, and the lowest clerical
worker on the staff, feels that the organization is their health department and
that they are contributing something essential to its activity; they thereby derive
considerable happiness and satisfaction [rom their daily work.

While morale is determined by a great many factors, unquestionably the
most important is the quality of leadership ol the “line officers,” i.e., the immedi-
ate supervisors of the workers and the amount ol inspiration and job interest
they can impart to the personnel. The concept that once prevailed with regard
to subordinates was, “If you don’t like the orders or the work, you can quit or be
fired.” The complete futility ol this approach is exemplified by the recent at-
tempt ol the Nazi conquerors to force the peoples of the countries they overran
into productive labor. The whole world knows the devastating and significant
effect of the “slow downs” to which these conquered workers resorted.

Now, instead of trying to prod or drive the employee into doing work, the
approach is based on good leadership, example and respect, job and employee
analysis, and employee training. From this is seen the great importance ol the
specific job in relation to the specific worker. Very often both an employee and
a job are individually desirable and important but simply may not mix. As
previously mentioned, an unsatisfactory file clerk may on reassignment turn out
282 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

to be an excellent receptionist. Very few situations in life work only in one direc-
tion. If an employee is expected to give his best effort to his job, the job should
be expected to give him something in return. The activity must appear to be
something more than busy work or dull routine. The worker must have the
opportunity to realize its significance and its contribution to the attainment of
the total goal.

An excellent example of this was found in the attitudes of the large numbers
of clerical workers who were engaged by state health departments during the
recent war to handle the routine paper work of the Emergency Maternity and
Infant Care Program for the wives and infants of servicemen. Unfortunately,
most state health departments simply employed clerks, assigned them to tables
and desks with pens or rubber stamps, and subjected them to a continuous rapid
flow of inanimate sheets of paper. This gave them no real understanding of the
significance of the program and the vital part they were playing in it. It was not
surprising that these organizations experienced considerable difficulty, not merely
in obtaining personnel but also in holding them. In fact in many instances per-
sonnel turnover was truly appalling and seriously hampered the effectiveness of
this important program. In a [ew states, however, some consideration was given
to the worker, his intelligence, the possible monotony of the job and the relation
of it to the employee's morale. It was refreshing to visit these lew state health
agencies and to notice the alert and satisfied expressions on the faces of the
workers. In discussing the work with them, the same interpretations were re-
peatedly encountered. They were not working with pieces of paper and rubber
stamps. Indeed, they were making it possible for a large number of women and
children to obtain necessary medical attention. They looked upon the bene-
ficiaries involved as “their mothers and their babies” and thereby received con-
siderable satisfaction from the work they were doing in helping them. As might
be expected, while these latter organizations had the same difficulty in obtaining
new personnel, having done so they kept them, and in a highly satisfactory state
of morale.

The administrator's responsibility for seeing that his staff is well informed
ol the agency's current goals, its progress toward them, and the importance of
every job in their achievement is too often overlooked or is exercised casually.
While free communication may be conducted best on an informal personal basis,
there must be planning to assure that it does occur. In large agencies, use of
mass communication techniques is often a necessary and desirable supplement
to building a staff that knows what is going on and feels that they are part of it.

Dimock,*” in the course of management studies, asked a number ol business-
men [or their views concerning [actors that determined employees’ activities. In
other words, for what reason do men and women put forth their best efforts?
The replies received were so consistent that he felt justified in suggesting the
incentive scale which is duplicated here. (Fig. 12.) Up to a point, the chiel in-
centive is increased income, in order to give a sense ol security. At some point
there is superimposed upon this financial urge, a desire [or power and position,
an opportunity to determine policy and to make one’s own work. In turn, this
is eventually replaced by a desire [or recognition and prestige, and eventually
PERSONNEL FACTORS 283
when these three urges or appetites are appeased, there is added a spirit of
altruism and a desire for public service. He concludes that the latter is the ulti-
mate and most rewarding of all incentives.

The question of job appeal might be summarized, therefore, as including
serious consideration of two factors: the assignment of the right employee to the
right job, and the provision to the worker of an opportunity to realize and un-
derstand the significance of the work he is being called upon to do and to obtain
a fair measure of personal reward and satisfaction.

J PUBLIC

SERVICE

    
 
  
 

PRESTIGE

 

FINANCIAL GAIN

 

Fig. 12. Personnel incentive scale. (From Dimock, Marshall E.: The Executive in Action, New
York, 1945, Harper & Brothers.)

Certain physical factors should not be overlooked in considering job appeal.
It is a definite responsibility of administrators and supervisors to be constantly
alert to needs and methods for the improvement of the physical environment in
which their personnel must work. It has often been said, and with considerable
justification, that health departments traditionally are relegated to the least de-
sirable rooms in the basement ol a city hall, county courthouse, or a state capitol
building, preferably as close as possible to the public comfort station. Unquestion-
ably, there have been many instances of progressive public health personnel
leaving positions because ol an undesirable working environment. A health officer
should always attempt to make his department an outstanding physical example
of the cause for which it works. It is illogical to expect the public to respond to
the educational efforts or even to the statutory measures ol an organization which
tolerates being itsell housed in quarters which exemplify all the circumstances it
criticizes and condemns.

A satisfactory working environment is in reality a sign ol administrative
efficiency. It has been shown repeatedly by industrial and other studies that the
improvement of lighting, ventilation, and attractiveness is invariably followed by
a significant increase in work output, a decrease in physiologic fatigue, and greatly
improved employee satisfaction and morale. Unquestionably public health offi-
cials in the past have been guilty ol unwarranted complaisance and timidity in
competing with other public officers for desirable quarters and in the promotion
of attractive and efhicient health centers. The health officer should realize that few
things are truer than “do not ask and you shall not receive.”
284 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

Overtime. In every organization, work during time other than the regular
working hours is occasionally necessary. Emergencies and pressure periods are
certain to occur, especially in a field such as public health. It is reasonable to
expect the personnel to have sufficient interest in the program olf their organiza-
tion to do their part willingly in meeting emergency situations, and if the per-
sonnel relationships are satisfactory, no difficulty or opposition will be encount-
ered. However, the amount of overtime work should be kept at a minimum and
should be engaged in only alter careful study and with adequate reason.

Continued or repeated overtime is administratively unjustifiable. A habit
ol overtime indicates either inefficient work methods or personnel, either of which
signifies inefficient administrative management. It is patently unfair to expect
effective work and satisfactory function during the regular work day when the
employees have been mentally and physically fatigued by chronic overtime re-
quirements. When overtime is necessary, provision should always be made for
compensation either in time off or in additional pay at the rate of time and
one half. Whenever possible, the latter method should be followed. Generally
speaking, to allow addition of accumulated overtime to the annual vacation is
undesirable since it encourages deliberately sought for overtime and may result
in considerable personnel depletion for part of the year.

Leaves. Annual vacation leave with full pay of the personnel should always
be planned for and encouraged. This bears many advantages for the organization
as well as for the employee himself. The physical and psychological need for
weekend rest and for an annual vacation has been well established by social
custom and proved by scientific investigation. An organization should have a
definite policy concerning vacations. Usually an employee is not entitled to vaca-
tion until he has rendered at least six months of service. Many organizations,
however, allow one day of cumulative vacation time per month of service, which
is due the employee regardless of the date ol his employment. It is most common
at this stage of our social and economic progress to allow for an annual vacation
period of two weeks. This applies particularly to office and other nonprolessional
personnel. Scientific, professional, and educational workers often are allowed
longer vacations, perhaps in consideration ol their greater period of training,
or in relation to the vacation time ofl their prolessional brethren engaged in
teaching. Justification of this distinction is somewhat vague and untenable and
undoubtedly the ideal would be an annual leave ol about one month for all.

It is decidedly undesirable to allow employees to work [or additional pay
instead ofl taking their vacation since this defeats the purposes ol the vacation
idea and usually results in employee regret and inefficiency. Similarly it is unwise
to allow the addition ol unused sick leave to vacation time since this deleats
the purpose of sick leave. If a holiday occurs during the vacation period ol an
employee, it is only [air to allow him an extra day off. However, the additional
day off usually should be taken at a later date and not added to the vacation
period since this tends to cause difficulty in scheduling the vacations of the other
employees.

Provision [or sick leave should be considered a protection or insurance
against a time of potential [uture need and not simply an added benefit to which
PERSONNEL FACTORS 285

 

the employee is entitled whether or not he becomes ill. In an increasing number
of public agencies, it is supplemented by various forms of disability and hos-
pitalization insurance. Policies with regard to sick leave vary considerably. In
smaller organizations there are often no specific provisions made, illness among
the personnel being dealt with on an individual basis as it occurs. In other organ-
izations, especially in larger agencies, a specific number of days per year is allowed
for sick leave.

This frequently gives rise to several difficulties. Some workers look upon the
total number of sick leave days as their inevitable due whether or not they
become ill. If no administrative controls are applied, there may develop con-
siderable abuse of sick leave privileges, causing resentment by conscientious em-
ployees and an undesirable state of morale in genral. Some organizations attempt
to solve this by requiring a visit by a city physician or a report from a private
attending physician. However, this is an administrative and personal nuisance,
necessitates added expense, and develops a not unjustified feeling of resentment
among employees that they are not being trusted. It has been suggested by some
that the solution is to make sick leave cumulative. This encourages employees
to regard it as a saving or an investment and is a sound policy considering the
occasional but inevitable occurrence of prolonged and catastrophic illness.

Of course, the ideal approach to the problem is one which is aimed at the
reduction of the need for absence due to illness. This is desirable from the point
of view of both the oragnization and the employee. A number of simple principles
are involved. The first is provision for pre-employment physical examinations
and periodic re-examination. While essentially most benefit accrues the employee,
the fact that an organization requires these examinations make it duty bound
to bear whatever cost is involved.

Those returning to work following a period of illness should undergo careful
examination both from the point of view ol protecting the other employees and
of preventing premature return to work followed by a more serious and prolonged
breakdown. If necessary, provision should be made for the follow-up and correc-
tion of physical defects, and employees with physical handicaps should be as-
signed to work with this in mind and supervised with particular care. The im-
portance of a desirable working environment was previously referred to in
relation to morale. This factor is of significance also in the prevention of illness
and accidents. Many studies have demonstrated significant reductions in illnesses
and accidents following improvement of the physical circumstances in which
people must work. Inservice training will be discussed in another section but here
might be emphasized the importance of including education in personal health
and salety practices.

Provision should be made for certain other types ol leave. II an employee
is asked to serve as a witness or as a member of a jury, it represents a civic
responsibility concerning which he has no choice. It is only right, therefore, that
the meeting of this responsibility be made possible. Of similar nature are leaves
for military purposes. In no sense should absence from work for these reasons
handicap the employee’s reinstatement or his opportunities for advancement.
286 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

A number of strictly personal matters that require consideration are perhaps
best dealt with on an individual basis. If illness or death occurs in the family of
an employee or if it is necessary for him to move during a working day, it is
justifiable to grant a reasonable time away [rom work. Not infrequently em-
ployees request the privilege of extended leave without pay. If a sound reason
exists it is usually well to grant the request. However, it is administratively
unwise to allow repeated or extended leaves without pay for personal activities
that are strictly matters of choice such as extra vacations, fishing trips, and the
like. Tt is recommended that this be avoided as much as possible since it serves
to interrupt and confuse the work of the organization and since some other em-
ployees and possibly the public are apt to misunderstand the situation and con-
sider it evidence of favoritism.

Certain types ol personnel, particularly those who are members of profes-
sions, are entitled to leaves within reasonable limits [or the purpose of educational
and professional improvement. Everything possible should be done not merely
to allow this but to encourage their attending and taking an active part in the
meetings of the professional societies and associations to which they do or should
belong. Here again there is a reasonable extent to which time away from the
job should be allowed to any one person. There are occasional individuals who
tend to be professional conventioneers and who unless restrained will spend the
majority of their time attending meetings and conventions away from the job for
which they are presumably employed. Not only does the work of the organization
suffer, but the other employees are thereby prevented from obtaining their fair
share of this privilege.

Inservice Training. The process of learning should stop only with the last
breath of life. The knowledge and ability that the public health worker brings
to his job in the first instance should represent, at most, only the beginning of
an ever-growing fund of ability upon which he may base professional action. An
organization which does not aid and abet continued improvement of its employees
is remiss in its responsibilities and, in the long run, handicaps itself. There are
many ways of accomplishing the desired purpose, all of which may be included
in the term “inservice training.” As one writer? has put it, “Inservice training is
a big thing, inservice training is many little things.” The purposes of an inservice
training program have been well summarized by Palmers as follows:

1. To make up for deficiencies in technical and scientific information required for
the job generally.

To enlarge the outlook and understanding on the specific job.
3. To acquaint the staff with the fundamentals of personal and public relationships
in order to encourage smoother functioning of the day-to-day job.

4. To keep the staff abreast of newer, technical, procedural, and administrative develop-
ments as derived from experience in other jurisdictions. *

ro

A good program will follow many different approaches and most desirably
will involve in one way or another all of the personnel from the administrator
himself to the custodian. The methods used may consist of a formal orientation

*Palmer, G. T.: Quoted in Bearg, Philip A., and Stockle, Ruth: Inservice Training in a
Rural Health Department, Am. J. Pub. Health 36:1304, Nov. 1946.
PERSONNEL FACTORS 287

course or a field orientation in a well-organized health department. Of importance
are conferences, both individual and group, institutes, staff meetings, and re-
fresher courses. There is a growing feeling of a need for a more intensive prac-
tical experience comparable to an internship. Often visits to other health de-
partments are worth while in order to acquaint the personnel with problems
and procedures in other areas. As mentioned previously, attendance at business
and professional meetings and conferences should be encouraged. If an employee
has enough interest and ambition to cause him to attend a school while con-
tinuing to work, particular consideration during the period ol time involved
is often justified. A policy of granting full-time leaves for prolessional education
is a highly desirable adjunct to the effective development of a staft in a career
service. An inservice training program is as important and as possible in a small
organization as in a large one and in a rural area as well as in a city with many
facilities available. Worth-while programs have been carried out on the Federal,
state, city, and rural levels. For an interesting although elaborate experiment
in inservice training on the local level and one which may well be more ex-
tensively applicable, attention is referred to the use of a mock epidemic.?¢

Retirement. The existence ol a retirement system is rapidly becoming a key
criterion with respect to employment in public health agencies. One of the
fundamental desires of human beings is security, not simply in the present, but
for the future and especially the later years ol life when productivity and earn-
ing power are on the wane or completely absent. This is an area ol social plan-
ning where much remains to be done. While there has been a sharp increase of
membership in retirement systems in the past decade, existing state and local
retirement plans still do not cover a third ol the employees. A good retirement
system accomplishes at least three things. It aids greatly in maintaining the
efficiency ol the organization by making it possible to remove the older personnel
who perhaps have become less efficient through a natural physiological process.
This provides places for new and younger people with more recent training and
greater physical ability. Only by a good retirement system can justice be done
to all existing or prospective employees. Furthermore, a retirement system aids
in the solution of one of the greatest social problems that exists, that ol the de-
pendency of the aged. Finally, from the individual's point of view, a sound sys-
tem coupled with pre-retirement counseling represents good gerontological prac-
tice by making possible a grandual tapering off ol activities as physical stamina
decreases.

If a retirement system exists, it is fundamental that payments be adequate,
for if they are too small there will develop a tendency to refuse the pension and
to remain on the job at a salary for as long as possible, thereby defeating the pur-
poses of the plan. For the same reason and in order to conduct the retirement
system on a sound insurance basis, it is equally fundamental that participation
in the plan be compulsory.

There are two principal types of retirement plans. The first is a simple cash
disbursement plan which consists essentially of including an item in each budget
to provide for pension payments. In this system total payments are small at first
when few are entitled to benefits. As time passes, however, and more employees
28§ ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
become older and eligible, it becomes necessary to budget and therefore to tax
for greater and greater amounts, resulting in a large proportion of the budget
being for the payment of pensions rather than for actual services. Repeatedly
organizations that have used this plan have become insolvent and in many in-
stances have had to decrease or completely stop pension payments to which
they had committed themselves and to which they had led their employees to
look forward.

The second and sounder approach is through the use of an actuarial plan.
Here future retirement objectives are calculated and planned for in advance
for each employee. Such a program begins with larger payments than does the
cash disbursement plan, but it builds up a reserve, the compound interest [rom
which considerably lightens and in some instances completely absorbs the imme-
diate financial burden.

The retirement plan may consist ofl contributions from employees alone,
[rom the organization or government alone, or [rom the employees and the organ-
ization or government jointly. The last is probably the best method since it gives
both the employee and the organization an interest and a stake in the solution
of the problem. For the employee it represents enforced savings with interest
plus reward for continued good service. For management it represents an orderly
and socially responsible system [or extending security to the current employee
and separating the superannuated employee. If an employee leaves the organiza-
tion belore becoming eligible for pension payments, he should have the right
to receive the total ol whatever contributions he has made to the plan, plus
whatever interest has accrued to that total. Under such circumstances, however,
he should not expect to receive any of the contributions made by the organization
or government since that too defeats the purpose for which the plan has been
established.

The fact that public health personnel tend to move from job to job and
[rom one state to another in improving themselves and advancing themselves
professionally indicates the desirability of some type ol interagency and interstate
reciprocation with regard to retirement plans. No one would question the de-
sirability of workers in a field like public health obtaining many and varied
experiences. Rigidly provincial retirement plans already are acting as a deterrent
to this, and the solution of the problem is one that must be accomplished in the
near future.

REFERENCES

1. Parran, T.: Public Health Schools and the Nation's Health, Dedicatory Address, ‘The School
of Public Health, University of Michigan, Official Publication, 46, 35, Sept. 19, 1944.
2. Rosenau, M. J.: Courses and Degrees in Public Health Work, J. A.M.A. 64:794, March 6, 1915.
3. Committee on Professional Education: Public Health Degrees and Certificates Granted in
the Unted States and Canada During the Academic Year 1939-40, Am. J. Pub. Health
30:1456, Dec. 1940.
4. Editorial: Accreditation of Schools of Public Health, Am. J. Pub. Health 35:953, Sept. 1945;
38:100, Jan. 1948.
Institutions Accredited by the American Public Health Association for the Academic Year
1959-1960, Am. J. Pub. Health 49:274, Feb. 1959.

ot
~1

10.
11.
12.
13.
14.

15.

16.

18.

19.

20.
21.

90

23

29.
30.

31.

32.

33.
34.

36.

Rosenfeld, L., Gooch, M., and Lennie, O.: Report on Schools of Public Health, Washington,
1953, Public Health Service Publ. No. 276.

Individual Reports of the Committee on Professional Education, American Public Health
Association.

Proposed Report on Field Training of Public Health Personnel, Am. J. Pub. Health 37:
709, June 1947.

Perrott, George St. J.: A Comprehensive Training Program for Public Health Personnel,
Am. J. Pub. Health 35:1155, Nov. 1945.

Editorial: Field Training for Public Health Personnel, Am. J. Pub. Health 36:178, Feb.
1916.

Horning, B. G.: Public Health Field Experience, Am. J. Pub. Health 36:135, Feb. 1946.

Field Training Accreditation Program Started, Am. J. Pub. Health 40:901, July 1950.

Guide for Residencies in Public Health, Am. J. Pub. Health 48:1407, Oct. 1958.

Approved Residencies and Fellowships, Am. J. Pub. Health 48:1533, Nov. 1958.

The American Board of Preventive Medicine and Public Health Inc., Am. J. Pub. Health
39:425, March 1949; 49:561, April 1959.

Burney, L. E., and Hemphill, F. M.: Merit System in Public Health, Am. J. Pub. Health
34:1173, Nov. 1944.

Editorial: The Merit System of the American Public Health Association, Am. J. Pub. Health
36:793, July 1946.

Mountin, J. W., Cheney, B. A., and Simpson, D. F.: Merit System Administration in Official
Health Agencies, Am. J. Pub. Health 37:23, Jan. 1947.

Mountin, J. W., and Hankla, E. K.: Training Public Health Workers, Programs Sponsored
by State Health Departments Under Title VI of the Federal Social Security Act and the
Federal Venereal Disease Control Act (1936-44), Pub. Health Rep. 61:725, May 24, 1946.

Flook, Evelyn: Public Health Service, Personal communication.

State Laws Governing Local Health Departments, Washington, 1953, Public Health Service
Publ. No. 299.

Emerson, Haven: Local Health Units for the Nation, New York, 1945, The Commonwealth
Fund.

Report of Local Public Health Resources, 1951, Washington, 1953, Public Health Service
Publ. No. 278.

Building America’s Health, Report of the President's Commission on the Health Needs of
the Nation, Washington, 1952, vol. 3.

Sanders, B. S.: Local Health Departments, Growth or Illusion, Pub. Health Rep. 74:13,
Jan. 1959.

White, L. D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co.

Mountin, J. W.: On Making Public Health Positions More Attractive, Am. J. Pub. Health
Publ. No. 278.

Report of Local Public Health Resources, 1951, Washington, 1953, Public Health Service
Publ. No. 278.

Dimock, Marshall E.: The Executive in Action, New York, 1945, Harper & Brothers.

Upson, Lent D.: Letters on Public Administration From a Dean to His Graduates, Detroit,
1947, Privately printed by the author.

Magoun, F. A.: New Phases in Personnel Training, Pub. Health Nursing 38:592, 1946.

Allen, F. E.: Remedies Against Dishonest or Inefficient Public Servants, Annals 169:172-183,
1933.

Magoun, F. A.: Personal communication.

Underwood, Felix J.: Inservice Training in a State Department of Health, Am. J. Pub.
Health 36:352, April 1946.

Palmer, G. T.: Quoted in Bearg, Philip A., and Stockle, Ruth: Inservice Training in a Rural
Health Department, Am. J. Pub. Health 36:1304, Nov. 1946.

Darling, George B., and Fox, Leon A: A Mock Epidemic of Typhoid Fever Used in Public
Health Training, Am. J. Pub. Health 32:457, May 1942.
chapter 1 1

Fiscal management in public health

Introduction. Since, in general, public health activities are performed by
governmental agencies, it necessarily follows that public revenues must furnish
the most stable and largest part of the funds supporting them. This being the
case, it is important that public health personnel and especially the administrators
of official public health agencies constantly bear in mind that the handling and
administration of these funds represent a public trust. It is obviously impossible
to separate public health administration and public finance. Every act performed
for the promotion of public health involves an expenditure of money, whether
for supplies, transportation, or the salaries of personnel. In fact, the very nature
and extensiveness of the public health program is determined in the final analysis
by the amount of the funds available for its conduct. Accordingly, an under-
standing of the sound management of the public financial program forms one
of the most important responsibilities in public health administration.

It is amazing to realize that until 1910 no executive budget existed on any
level of government in the United States. Until that time operating bureaus and
departments approached appropriating bodies individually and directly requested
and received for the most part “omnibus” appropriations for support of their
respective activities. The following item from the budget of the city of Chicago
for 1909 may serve as an example of this highly undesirable procedure and make
evident the opportunities for inefficient if not dishonest public administration
under these circumstances.

For repairs and renewals of wagon and harness, replacement and keep of livestock,
identification, police telegraph expenses, repairs and renewals of equipment, hospital
services, printing and stationery, secret service, light and heat, 25 more horses for
mounted police, and for repair of Hyde Park station; also other miscellaneous expenses
+ $205,000.

Since about 1910, the trend on all levels of government has been toward
centralization of the responsibility for public financial management. In the
larger units of government, i.e., Federal, states, and large cities, separate fiscal
departments have usually been established to meet the need. Thus, there now
exist the Federal Bureau ol Budget, many state departments of finance, and

290
FISCAL MANAGEMENT 201

municipal comptroller offices. Within the large operating departments one fre-
quently finds a central accounting office organized as a separate bureau or division,
directed by a person specially trained and directly responsible to the executive
head of the department. The trend, in fact, has been to go even further and at-
tempt the coordination of the accounting functions with those of revenue admin-
istration, budgeting, purchasing, and, in some instances, even treasury manage-
ment. White! accounts for this trend in terms of “loss of confidence in legislative
bodies as agencies for fiscal management; realization of the desirability for fixing
responsibility for the management of fiscal affairs; rapidly rising governmental
expenditures and debts which emphasized the necessity for fiscal reform; and the
studies ol research bureaus, which made apparent the waste due to disorganized
fiscal management and which offered promising, reasonable alternatives.”*

This trend toward centralizing fiscal activities in no way removes the need
for interest and responsibility on the part of public health officers in these mat-
ters, since of necessity part of the responsibility [or fiscal matters must rest with
the operating department as well as with extradepartmental budget officers,
comptrollers, finance directors, and others. There are involved here a series of
relationships that constitute one of the most important aspects of public health
administration. In general, the functions are divided in somewhat the following
manner. The health administrator is responsible for estimating the needs ol his
organization, which the budget office has the right to review and modify. Ex-
penditures are initiated by the health department but they may require approval
by the central comptroller. The health department is responsible for the prepara-
tion of reports indicating and justifying expenditures, to provide accountants and
auditors from central fiscal offices with information necessary for their analyses.
Within the functional health department, responsibility for financial matters
rests nominally with the administrative health officer. Usually he is the one
authorized to incur expenditures, as indicated by his signature on payrolls,
requisitions, and other financial documents. In large organizations this authority
is sometimes delegated to division or bureau heads. The tendency has been to
establish a fiscal officer under the health officer to assume immediate concern
for the financial aspects of the operation of the department as a whole.

Fiscal Policy Making. Before either the health officer or the various fiscal
officers may function, it is necessary that legal policies be established governing
the operation of financial matters. Traditionally, this responsibility for determin-
ing fiscal policies and objectives has rested with the legislative branch of govern-
ment, which must provide the legal framework for the creation of a sound
financial structure to implement the public health and other objectives which
the legislature as representatives of the people outlines. Therefore, it is the
legislative branch which must decide upon the general nature and extent of the
public health services to be provided, appropriate whatever funds are necessary
to meet their cost, and put into effect whatever revenue measures are necessary
for financing the appropriations made. It must fix the authority and responsibility

*White, Leonard D.: Introduction to the Study of Public Administration, New York, 1939,
The Macmillan Co., p. 206.
292 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

for the collection and expenditure of these revenues, establish the operating units,
organize the machinery through which the operating units are financed, and
account to the public for the revenue measures enacted, the expenditures in-
curred, and the services rendered. The progressive health administrator might
well assume an honest responsibility for providing, inasmuch as possible, informa-
tion and advice lor the guidance of the leigslators in the performance of these
functions.

Financial Operations. This second phase of the public financial program
is concerned with implementation of the policies and plans of operation that have
been outlined by the legislature. It includes revenue administration, treasury
management, budgeting, accounting, and purchasing. The first two of these are
seldom of direct concern to the health officer and are mentioned here merely
in order that the public health worker will be acquainted with their general
content. Revenue administration is concerned with the assessment, levying, and
collection of taxes; the study ofl proposed tax measures; advice to the legislature,
the executive head of the unit of government, and the budget officer on problems
relating thereto; the preparation of revenue estimates and proposed revenue
measures for the executive; and the maintenance ol records and accounts ol all
revenue assessed, levied, adjusted, collected, and deposited with the treasury.
Treasury management is concerned with the custody and disbursement of public
money and the custody of whatever securities are held in trust by the govern-
mental unit. The treasury accepts money and gives receipts, assures that a cash
reserve is constantly maintained, and disburses money on the presentation of
legally authorized warrants or disbursement orders.

Budgeting. Of direct concern to the health officer is the problem of budget
ing. Since he is nominally responsible for the public funds provided to him for
the operation of his department, it is only reasonable and logical that he conduct
some system of financial bookkeeping which will give a continuous, accurate,
and verifiable account of his stewardship. A departmental budget provides such
a system.

The question might be raised concerning the fact that frequently many of
the funds that are made available, especially to local departments of health,
come from sources outside the local governmental unit, some even from private
sources. Among these are the increasing number of grants-in-aid from the state
and Federal governments, private foundations, and various voluntary health
agencies. For administrative purposes all monies, regardless of their source,
should appear in the budget and be placed in the custody of the state or local
treasurer. This, of course, does not preclude their being credited to a health
department account or fund in order to assure their being used only for the
purposes for which they were granted.

A fund may be established by the legislative body ofl the government, by a
contractual agreement, or by an executive order, and may be abolished only by the
agency establishing it. The number of separate funds should be kept at a mini-
mum since a multiplicity of them serves effectively to hamper the development
of broad, well-balanced programs. In general, funds may be considered in the

following categories:
FISCAL MANAGEMENT 293

Expendable Funds

General Fund— this usually contains most of the available funds. It represents the unrestricted
fund of the organization as far as budgeting and expenditure are concerned. It can be spent for
any legal purpose for which the organization may wish to use it and may be drawn upon for
the replenishment of other funds.

Special funds—these are restricted as to use since they are established for specific purposes. They
cannot be transferred to other funds. Some originate by means of the government levying a
special millage tax to pay for a particular function. This forms a kind of special appropriation
and is usually not considered in the budget, thereby confusing budget planning. Special levies as
a whole are undesirable. Much more preferable is a general levy adequate to cover all the needs
of a government with the exception of sinking funds, the proceeds of which however, should
go into the general fund.

Sinking funds—these are a form of special expendable funds set aside for the redemption of bonds
or other similar obligations. They are nontransferable.

Working Capital Funds

The purpose of these is for conducting the many organizational and institutional activities.
They are usually replenished by means of transfers from other funds.

Endowment Funds

The principal of these funds cannot be expended but the income accruing their investment may
be spent for the purposes specified in the conditions of endowment.

Suspense Funds

These are not funds in the true sense of the word. They consist of sums of money made available
for special purposes, their distribution and use pending transferal to other funds.

The average person interprets the word budget as meaning a complicated
scheme devised for the purpose ol saving money, a scheme he wishes he had
followed when the income tax blank arrives. In one sense, this interpretation is
correct; in another, it is not. Although it is true that a budget may help in saving
and planning for future needs, that is not its primary purpose. Quite to the
contrary, in public service a budget is most concerned with the manner in and
rate at which available resources are to be expended. In brief, therefore, a budget
may be defined as an administrative tool for the purpose ol (a) estimating [uture
needs and future resources and (b) the wise apportionment and systematic ex-
penditure ol the resources that are available during a given period of time.

The public health administrator should realize that the construction of a
budget not only [fulfills the demands of the agencies providing the funds, but
also may hold many advantages and uses [or him in his management of the health
department. It has a marked influence on the economical use of working re-
sources, since it is intended to make possible the maximum use of the facilities
and current assets of the organization. It prevents waste and conserves resources
by regulating expenditures for definite purposes and in accordance with appro-
priations established by the administrative head of the organization. A well-
constructed budget places definitely, exactly where it belongs, the responsibility
for each function of the organization. It makes for coordination, by causing all
individuals and departments of an organization to cooperate in attaining the
294 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

goals fixed by the budget. A budget presents in cold figures the best judgment of
the executive responsible for a definite organizational objective, and thus guards
against both undue pessimism, which leads to underactivity and poor work,
and undue optimism, which leads to overexpansion. By indicating variance be-
tween estimates and actual results obtained, it may serve as a danger signal for
the administrator and thereby show when to proceed cautiously as well as when
expansion may be safely undertaken. Similarly, it is invaluable in determining
the relative effectiveness and cost of activities and procedures, since it tests the
ability of the organization to make things happen in accordance with a well-
ordered plan. A very important benefit is that it compels the organization to study
its market (the people) and its own methods and services, thus disclosing ways
and means for strengthening and enlarging the organization. It provides the only
means for predetermining when and to what extent financing will be necessary
and serves as a guide to future needs, possibilities, and sources of revenue. Finally,
organizations which develop and follow a well-ordered budget plan find greater
favor from their administrative superiors or boards of directors, business asso-
ciates, and potential sources of income.

Once the decision is made to use the budget idea, certain principles should
be followed in order to assure its success and helpfulness. Perhaps most important,
and so often overlooked, is confidence in the idea and willingness to cooperate
with it. Nothing will ensure its failure more effectively than skepticism of its
value, apprehension of the work involved, and a feeling that it is simply a red-tape
requirement to which adherence after completion is not necessary. Related to
this is the importance of enlisting the interest, aid, and cooperation of all
subordinates in the preparation of and adherence to the estimates relating to
their work. Estimates should be based on past performances and existing assets
as well as upon plans for expansion and anticipated assets. The amount of esti-
mates should be based upon the total probable assets available rather than upon
that which is desired or ideal. All sources of income as well as all anticipated
expenditures should be included in the budget, which should indicate clearly
where the funds come [rom since this in itself has an educational value and paints
the total financial picture. To indicate all sources of funds may also serve to
cause awareness to future budgetary problems. This is always an important
consideration in any future program planning. It follows that the interval over
which a budget is to be effective should be restricted to a period for which de-
pendable estimates of sources and expenditures may be prepared.

The mechanical procedures involved in setting up the budget should be
kept as simple yet as useful as possible; this necessitates the attainment of a
practical balance between the two. The items might best be classified primarily
by units of organization, such as Division of Preventive Medical Services, Division
of Environmental Sanitation, Bureau of Vital Statistics, etc. Such a classification
requires a sound organization with well-defined lines of authority and responsi-
bility. Beyond this, provision should be made for reasonable flexibility within
the budget with a not too detailed breakdown of items. With regard to the rela-
tive advantages and disadvantages of a lump-sum budget as against a more de-
tailed budget, it may be pointed out that while the former provides more admin-
FISCAL. MANAGEMENT 295

istrative leeway, the latter makes possible more effective control and planning
and has an educational value entirely lacking in a lump-sum type of budget.
For further breakdown, analysis by function or type of service is one of the most
convenient and useful. This is particularly true in public health agencies since
the units of organization (bureaus, divisions, etc.) are essentially functional, e.g.,
vital statistics, sanitation, health education, communicable disease control, etc.

Expenditures may be broken down to administrative advantage in terms,
for example, of (a) operating expenses, i.e., salaries, travel, supplies, repairs,
(b) capital costs, and (c) fixed charges, e.g., interest on bonds, etc. Figures 13 and
14, which show portions of the budget ofl a large city health department, illustrate
this.

In most instances it is desirable to include a contingent [und which, however,
should be kept small (3 to 5 per cent), a large contingent fund being indicative
of poor planning and management. It should be used as sparingly as possible
and should be applicable to all items in the budget with one exception, i.e., sal-
aries should never, for any reason, be augmented [rom a contingent fund. A final
requisite, and perhaps one of the most important, to a successful budget is placing
the responsibility for its maintenance in the hands of one capable individual.
Since a budget is essentially an estimate of future needs and activities, its con-
struction should take into consideration the cost of operation on the present scale,
including administrative, functional, and depreciative costs, the anticipated cost
of operation of expanded activities, and the need for coordination of the existing
and anticipated activities into one well-blanced whole so that the expenditures
of money, time, and effort for the various activities will be in a proper and
balanced relationship to one another.

Concerning the detailed steps involved in drafting the budget, no single
method or technique exists that will satisfactorily fit all situations. It is strongly
suggested that the newly appointed public health official assume as one of his
earliest duties the acquiring of an intimate acquaintance, not only with his own
budget, but also with the total budget of the governmental unit with which he
is identified and the budgetary methods and forms being used. However, since
the budgets of all governmental agencies have the same general purpose, certain
similarities exist in their form. Geiger® has summarized these well-accepted basic
principles as including the following eight factors:

I. Expenditures of a preceding period equal in time to that for which the budget
is being prepared. The period should be closed, so that actual expenditures
as they occurred are stated in this column.

2. Budget of the present period. These figures can include only the budget as it
was set up, since expenses thereon are still being incurred while a budget for
the future is being prepared.

3. Changes in the present budget period. These figures should include any sig-
nificant changes in the present budget that have occurred or that may be an-
ticipated, such as changes in salaries or in departmental organization, which
will have the effect of modifying the present budget. This column thus has
the effect of bringing the present budget up-to-date.

4. Expenditures of the present period, given as actual expenditures to the time
the next budget is being made, and as estimates of the expenditures to the
end of the present period. The actual expenditures and estimates are totaled.
GENERAL FUND— Health—General

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Code ITEMS NUMBERED ARE THE APPROPRIATIONS. expended Budaqhlayenee Adee sae sanded as ir Rerun
Function | Object FROPRINTIONS SEE CITY CRARTER THLE Wi GHAR 1 SEC" 7 1745-46 No. Amount No. Amount Dec. 31, 1946 No. Amount No. Amount No. Amount
1} 3010 ADMINISTRATION:
2 m Salaries 66.439 72 19) 73.835 00 19 74.28700 32,707.25 19 74,182.00
3 301 Duplicating and Office Supplies 347574 4,000.00 4,000 00 1,436.39 4,000.00
4 302 Postage SW — 10,000.00 9,000.00 9.00000 4200.00 10,000.00
5 303 Reimbursement, Purchase ard Repairs of Badges 67.25 300.00 300.00 52.50 250.00
6) 405 Telcpnonie and Telegraph Services. 6,925.60 7,300.00 7.300.00 3546.56 7.200.00
7| 414 Rental of Buildings and Space en © EE 23,500.00 23,500.00 23,500.00 11,750.00 2500000) of oo ff]
8 . . I. [ESS— | I ps | .
9) Tmososal || | Tmmesseo || T| Tisasroolf © sseezo || | 12083200
10 3020 HEALTH EDUCATION
1 111 Salaries . 24,416.59 14 43,861.00 15} 44,163.00 12,631.96 15) 44,724.00
12] 301 Purchases and Rental: Educational Films, Publications and
13] Displays 138.00 600.00 600.00 53.20 600COff oo) |]
14} wed ie Be] een be fend ee
15 “mew | | mmiw|| | Twwe| mess || | wee —
16] 3030 VITAL STATISTICS:
17 111 Salaries 33,896.72 13 38,013.00 15 38,887.00 18,174.59 15 39,03200) | | | a
18, 113 Salaries—Issuing Birth Certificates 11,161.64 19,550.00 19,734.00 4,535.66 15,000.00
19] 301 Supplies 1,759.00 1,770.00 1,770.00 627.83 1,770.00
20 wn) rn el] ic Rees RO eee . a .reaa
2 Tweens || | Ts93smoo| | “eossroof| — 2ssseos fl | sseozocef —
23] 3041 SANITARY ENGINEERIN
23 m Salaries . EE — 94,617.99 3 106,420.00 31 106,940.00 48,568.74 31 107,210.00
24] 3042 SUB-STANDARD HOUSING INSPECTION:
25] 111 Salaries 39,509.83 19 53,605.00 18} 53,927.00 19,563.22 14 54,397.00
26 301 Supplies 90.79 200.00 200.00 17.27 200.00
28 “T3ee0062 || | Tssswsooff T | sa1zio0 1958049 |[ | ~ s4se700f
29] 3043 FOOD INSPECTION:
30| 11 Salaries . 289,923.92 91 325,294.00 97] 325,900.00 147,882.28 91 321,102.00

 

 

 

Fig. 13. Example of budget form for large

 

 

city health

 

 

 

 

department presenting data by unit

 

 

 

 

 

 

 

of organization and purpose.

 

HLVIH D1T8Nd NI SNOILVEIAISNOD IAILVHLSININAY

90¢
GENERAL FUND—Health—General—Continued

 

 

 

 

 

   

   

  
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Account Code ITEMS NUMBERED ARE THE APPROPRIATIONS Budget Alloyronce Adted Ale Request for 1947-48 Revision by the Mayor Revision by the Council
ITEMS POLLOWING IN DETAIL ARE EXPLANATORY OF THE AP-
foci | Objet FROPRIATIONS—SEE CITY CHARTER TITLE V1, CHAP. 1 SEC. 7. No. Rates No. Rates No. Rates No. Rotes No. Rates
1 Public Haalth Nurses 4 2,595 to 2,967 4 2505 to 2,967
2
3 15 15 5
4 3030 11 VITAL STATISTICS:
5 Deputy Registrar of Vital Statistics 1 3651 to 4285 1 3,651 to 4.285
6 Junior Statistician 1 2,657 to 3,095 1 2,657 to 3,085
7 Technical Aid (General) ..... 1 2327 to 2,459 1 2327 to 2459
8 Senior Clerk 1 2,525 to 2936 1 2525 to 2936
9 Intermediate Clerks 9 2,261 to 2393 9 2261 to 2393
10 Intermediate Typist saerens essere resin es ApS 1 2261 to 2393 1 2281 to 2,383
1 Junior Stenographer 1 2,327 to 2,459 1 2327 to 2459
wey rl soon -
13 15 15 | 15 I I
14 3041 1m SANITARY ENGINEERING:
15 Sanitary Engineer and Secretary 1 6613 to 7441 1 6,613 to 17441
16 Associate Sanitary Engineers FE 2 4,761 to 5476 2 4761 to 5476
17 Head Health Inspector. 1 4.047 to 4.761 1 4047 to 4761
18 Senior Assistant Sanitary Engineer, J. C. C. 4-23-46 . . 1 4,047 to 4523 1 4047 to 4523
19 Principal Health Inspectors, J. C. C. 4-23-46 17 3492 to 3,809 6 3492 to 3,808 6 3492 to 3,809
20 Senior Health Inspectors... 10 2,859 to 3,174 10 2859 to 3174
21 Junior Health Inspectors... 2 2459 to 2723 fl... 2 2,459 to 2723 || | nf
22 Senior Sanitary Engineering Aid... 1 3.095 to 3571 1 3,095 to 3571
23 Junior Cartographic Draftsman 1 2,723 to 3174 1 2723 to BIT Yl of el bee
24 Intermediate Clerks 4 2.261 to 2393 4 2261 to 2393 || | cm
25 Junior Stenographer ... 1 2321 to 2459 1 2327 to 2459 ||...
26 Junior Typist 1 1,752 to 1,980 1 1752 to 1980 JI |i fs
2 “a 31 “a i

 

 

 

 

 

Fig. 14. Example of budget form for large city health

department presenting data by unit of organization and function.

 

 

 

 

 

 

 

 

 

 

 

 

LNIWIDVNVIA 1VOSIA

162
298 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

Sv

Object of expenditure. This column designates each item for which expendi-
tures have been made or are requested. This should include the salary group,
classed as permanent, as temporary, or as services secured on a contract basis.
Other groups will include materials and supplies, fixed charges, foodstuffs,
equipment, and any other divisions of expenditures.

The remaining columns refer to estimates and requests for future activi-
ties, for which the preceding columns have provided a basis.
6. Budget request for the next period. Each item should be arranged in such a

manner that comparison with the present budget will be as simple as possible.
7. Comparison between the present and anticipated budgets. Since comparison
of present and requested budgets (items 2 and 6) is crucial in the considera-
tion of new budgets, this column should indicate all items for which an in-
creased expenditure is desired, items which are not changed from the present
budget, and items which are dropped or in which a decrease in allotment of
funds is desired.

8. The adopted budget. At least one column will be necessary for the budget
adopted. As many additional columns should be provided as may be de-
manded in accordance with the number of official approvals required. This
greatly facilitates the recording of recommendations by different officials empow-
ered to approve one or all phases of the budget previous to its final adoption.*

In the construction as well as in the operation of his budget, the health
officer should make it a practice to maintain contact with the budget director and
the committee on finance or ways and means of his government. He should keep
them constantly informed and call upon them for advice, causing them to realize
that the financial problems are theirs as well as his. This may present a delicate
problem in personal relationships but usually results in benefits which are well
worth the effort.

There may be a tendency for some health officers to take the attitude that
it is necessary to work on the budget only as budget time approaches. To so
restrict one’s use of this valuable administrative tool eliminates most of the pos-
sible benefits that might be forthcoming from its existence. The wise adminis-
trator works closely and constantly with his budget the year round and on a long-
term basis, using it as one method ol continuously feeling the pulse of his or-
ganization. Trial balances should be run as often as is indicated. He should
regard the budget as inviolate and as one of his most important administrative
tools. He should adhere to its contents as strictly as possible, deviating from it
only as a means of last resort. A certain amount of transferring of funds is in-
evitable but should be kept to a minimum since it is a sign of poor management
and again defeats the purpose [or which the budget was originally brought into
existence.

If an emergency or other situation which requires an unexpected and un-
predictable expenditure of funds should arise, the health officer should feel free
to appeal to the appropriating body for an emergency appropriation rather than
attempt to meet the situation by transference of monies that have been set aside
for other predictable expenditures. It is believed that in most situations, if an
honest and understandable explanation of the need is given, an additional allot-
ment will be forthcoming. In this connection it might be well to point out here
that a good administrator will not attempt to use emergency situations as lever-

*Geiger, Jacob: Health Officers’ Manual, Philadelphia, 1939, W. B. Saunders Co., pp. 31-33.
_ FISCAL MANAGEMENT 299

 

age to increase his general budget or to make up deficiencies arising out of poor
management.

In the process of obtaining the appropriations requested in his budget, the
health officer should not assume the entire burden himself but should share it
with others in the community, such as his health council and other groups of in-
terested and influential citizens. By convincing them of the need for the services
for which the money is requested, the health officer may increase the forcefulness
of his requests and arguments manyfold with greater assurance of the appropria-
tion being granted.

The efficient health officer will be constantly alert to discover new ways in
which to use the budget. He may use it to demonstrate the public health activity
in his own area or to show what is being done elsewhere, in comparable situations.
The use to which the taxpayer’s dollar is being put is always of public interest
and can be used for very effective publicity and educational purposes. A budget
may be used as the starting point for requests for state and Federal grants-in-aid
for the health program and furnishes a fundamental source of information for
self-evaluation and appraisal. It may furnish the key to the determination of the
efficiency of various public health procedures and show the way to the achieve-
ment of better results per dollar of tax money spent.

It has been pointed out that the budget should be based not on a series of
guesses but rather upon estimates arrived at, inasmuch as possible, from the past
experience of the organization. It is obvious, therefore, that to be satisfactory, the
budget should result from a careful analysis of accounting data including actual
previous experiences and current cost and price trends. Most states provide for
the installation and maintenance of a system of uniform accounting by local gov-
ernments and often provide further for periodic audits by a central state fiscal
authority. However, legal provision does not necessarily imply action, and ef-
fective enforcement of these provisions appears to be the exception rather than
the rule. The lack of an efficient system of accounting makes sound budgetary
methods impossible and often results in expenditures which comply with only
the barest minimum requirements that may be specified in the law.

A sound system of accounting serves many purposes. It provides a financial
record of the activities of an agency, reveals its financial condition at all times,
provides very necessary data upon which the departmental administrator may
base plans for future action, gives substantive protection in case of question, and
provides the fundamental starting point for audits.

From the point of view of the department head or the chief executive early and
accurate accounting reports are necessary in order to direct the course of the work and
future expenditures. They also provide the essential record to demonstrate the appro-
priate and legal use of funds, making certain that each subdivision of an organization
is actually using money for the purposes for which it was appropriated. The accounts
and supporting financial documents provide the evidence on the basis of which each
spending officer justifies his expenditures, either to the finance director or to the auditor
While the accounting system is thus essential as a means of preventing the wrongful
uses of funds, it also underlies all other types of executive control of fiscal operations.
It is the basis on which executives act to prevent deficits as well as the documentary
foundation for questioning the care and wisdom with which the funds have been used.*

*White, Leonard D.: Introduction to the Study of Public Administration, New York, 1939,
The Macmillan Co., p. 232.
300 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

 

Health departments should maintain at least the following basic accounting
records: (a) general ledger, (b) complete and detailed record of receipts and
expenditures. The general ledger, illustrated by Figure 15, is the record of the
various accounts or controls pertaining to assets, liabilities, and types of revenues
and expenses of the health department. Posting to these accounts or controls are
made [rom the books of original entry, namely, the cash receipts and expenditure
record (for an example, see Fig. 16) and the book of transfer vouchers (Fig. 17).

 

 

Unex-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or HH ims
11 1
i 1 HH
! THE
HH

 

 

 

11]
1

 

EER

 

 

 

I]
I

 

TTT

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 15. Example of general ledger form.

All departmental receipts and warrants, including their amounts, should be re-
corded in the combination cash receipts and expenditure record in their re-
spective numerical order and classified as to source and type ol expenditure. Re-
ceipts should be posted in the “treasurer account-deposits” column and classified
under the “miscellaneous account-credit” column. Similarly, the amount of each
warrant should be recorded in the column captioned “treasurer account-amount
ol warrants” and classified in [urther columns according to the monies used and
type of expenditure. The code number of the general ledger control account
should be used to designate proper postings to the general ledger. Great care
should be given to using the proper code number as this governs the final classi-
fication of expenditures.
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302 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH .

During the course of recording and posting items to the general ledger con-
trols and accounts, numerous errors will arise which, if left unchanged, will not
reflect a true statement of revenues and expenditures. For this reason the Record
of Transfer Vouchers is used to correct erroneous postings to accounts and to ad-
just and close out revenue and expense accounts at the close of each year’s busi-
ness. Full explanation for each transfer should be recorded in the space provided,
for future audit and reference purposes.

eral County Form No. 5.

Transfer Voucher

TRANSFER FROM

 

 

 

 

EXPLANATION

Accounts Affected

SIGNED

 

Fig. 17. Example of transfer voucher form.

One type ol accounting procedure which is being used with increasing fre-
quency by public health as well as other agencies is that of encumbrance control.
This is designed to ensure adequate funds for future payment of obligations made
in the present. It became best known to public health officials perhaps through
their part in the administration of the Emergency Maternity and Infant Care
FISCAL MANAGEMENT 303

Program which during the period of the recent war provided financial aid to the
expectant wives and to the infants of service men. Lump-sum allotments were
made to the states each month on the basis of the number of births estimated to
be forthcoming in the near future. In order to forestall the great possibility of
committing itself to future payments in excess of the sums allotted to it for the
purpose, each state was encouraged to set up an encumbrance control procedure
which simply deducted on paper from the total funds made available the amount
of money that eventually would be required for payment of physicians and hos-
pitals. It is somewhat as il payment were being made before the services were
actually rendered rather than on their completion some months in the future.
In this way the state could ascertain at any time the total amount of nonobligated
funds available with which to provide care for additional individuals. In addi-
tion it provided a basis on which to apply in advance for deficiency allotments.

Using the Emergency Maternity and Infant Care program as an example,
various types of services such as obstetric, medical, surgical, hospital, and nursing
services were involved. With cases of uncomplicated pregnancy and delivery the
problem was relatively simple. A standard [ee for such cases was agreed upon by
the medical profession and each state health department. Similarly, per diem bed
costs were determined and agreed upon for the participating hospitals. When a
private physician notified the health department that he was assuming the care
of a woman who was expected to deliver normally, say, six months hence, it was
a simple matter to immediately set aside or encumber a sum of money sufficient
to cover the physician’s standard fee and the anticipated hospital bill. The latter
could be rather accurately estimated as the product of the hospital's per diem bed
cost times the average number of days that patients in the locality or state stayed
in the hospital following delivery.

The procedure becomes slightly more complicated when dealing with a serv-
ice which is not as predictable as to time and cost as a normal pregnancy. Success
depends on standardized fees and costs for services and materials, in so [ar as pos-
sible: estimates of the probable extent of the services needed should be based on
averages for the particular condition and/or type of patient in the particular area,
and large sums should not be encumbered over long projected periods for the care
of patients the cost of which is impossible to estimate with reasonable accuracy.
An example of the manner in which a case of illness in an infant would be sat-
isfactorily handled is given in Table 24.

The Children’s Bureau, which was responsible to Congress for the over-all
national administration of the program, naturally did not wish large unused
and unencumbered sums accumulating in the individual states. On the other
hand, it wanted to give assurance to each state that sufficient funds would be
available at all times for payment of statements received. The states, therefore,
maintained a summary record of encumbrances and unobligated balance such as
presented in Table 25. In addition to using it for their own guidance, the states
submitted their totals each month to the Children’s Bureau to serve in deter-
mining the amount of money that should be sent to each state for the forthcom-
ing month from the United States Treasury.
Table 24. Emergency Maternity and Infant Care Encumbrance Control Record

 

 

 

 

 

|
| | Transactions: Increase—Decrease Totals to Date | Balances
| |
| | | | | |
Date | Description | Purchase | | | | |

| Expendi- | Orders Total | Total | Unex- | Accounts Unencum-

Allotment tures | Allotment | Expendi- pended | Payable | bered

| | Requisitions | tures | Balance | | Balance

| | | | | |

| |

| | | | | | | |
2/ 8/45 | (1) Medical $24.00 | |
2/ 8/45 (12) Hospital 50.00 STHO0 00 | $74.00
2/18/45 (3) Hospital 10.00 | 84.00 00 | | 84.00
2/22/45 | (4) Hospital | 860.00 C8400 | $60.00 | 24.00
2/23/45 | (5) Medical | 24.00 | 84.00 | 84.00 | | | 00
5/ 8/45 | (6) Medical C2400 | | |
5/ 8/45 | (7) Hospital 50.00 | | 158.00 | 84.00 | 74.00
5/26/45 | (8) Medical to Adjust | —24.00 | | |
5/26/45 (9) Medical | 36.00 | 170.00 84.00 | | 86.00
6/ 3/45 | (10) Medical 36.00 © 170.00 | 12000 | 50.00
6/ 3/45 | (11) Hospital to Cancel ~~ —350.00 | | | | | | | 00

| | | | | |
Explanation:

Child becomes ill and mother applies to participating physician for care. Physician decides hospital care needed, so sends in applications for medical and
hospital care. These are both authorized and funds encumbered, (1) and (2). (Maximum of $24 for 1st medical authorization and 10 days at $5 per day for
hospitalization.) Two additional hospital days are needed, so reauthorization for them is made and $10 additional encumbered (3). After hospital service ren-
dered, the hospital submits a bill for $60 (4) for which a check is made and sent. The physician, having completed care, submits a bill for $24 (5) for which
a check is made and sent.

Several months later the child again becomes ill and the standard amount of funds for hospital and medical care are encumbered as before, (6) and (7).
The physician requests further authorization to provide for a minor operative procedure for which funds are then encumbered by canceling out the previous
medical authorization (8) and encumbering the new amount necessary (9). The physician subsequently submits his bill which is paid (10) and notifies that the
care was rendered at the patient's home so the allotment for hospitalization is canceled (11), bringing the unencumbered balance to zero.

al

 

HLV3H O17719Nd NI SNOILVYH3IAISNOD IAILVHLSININAY

 
FISCAL MANAGEMENT 305

Table 25. Summary Control Account for Fund E

Record of Encumbrances and Unobligated Balance*
Maternity Care

 

 

 

 

 

 

Authorization Amount Amount Unencumbered
Date Numbers Encumbered Paid Adjustment Balance
6/30/43 (Received from
U. S. Treasury
$50,000.00)
7/ 1/43 1-50 $3,750.00 $46,250.00
7/ 2/43 51-125 5,200.00 41,050.00
7/ 3/43 126-300 12,200.00 28,850.00
7/31/43 301-499 14,000.00 14,850.00
Total [for July $35,150.00
8/ 1/43 (Received from
U. S. Treasury
$35,000.00) 49,850.00
8/ 5/43 500-650 13,000.00 $2,500.00 $500. 00f 37,350.00
8/10/43 651-675 1,750.00 5,000.00 200.00 35,800.00
8/20/43 676-801 5,715.00 5,000.00 250.00 30,335.00
8/31/43 801-950 14,235.00 7,500.00 50.00 16,150.00
Total [for August $34,700.00 $20,000.00 $1,000.00
|

*EMIC Information Circular No. 3, Children’s Bureau, Feb. 22, 1944.

tThe first entry in this column, $500, is based on the assumption that authorizations totaling
$3,000, issued early in July, were paid on August 5 in the amount of $2,500, or $500 less than the
amount encumbered. This amount is, therefore, released for the commitment and added to the
unencumbered balance in the last column.

Unit Cost Accounting. Another valuable fiscal procedure is that of unit cost
accounting which, as has been implied, is encountered in the operation of en-
cumbrance control procedures. In simple terms it involves the computation of
the complete cost of an item which may be either a product or a service. Having
originated with business and manufacturing industries, it has been widely adopted
by various governmental agencies. It has a number of administrative values. It
enables an organization to compare the costs of a procedure or activity at dif-
ferent points in time, in different areas, agencies, and jurisdictions, and makes
possible increasing efficiency by providing a basis of comparison of the cost of
different methods of approach. For example, the health department of the city
ol Detroit has for some years promoted personal prophylactic measures in chil-
dren primarily by means ol nurses’ visits. At first a practically unlimited number
ol visits were allowed in behalf of a particular child. Application of a unit cost
accounting method showed the average cost per immunization obtained to be
high. It was then [ound possible to determine the relative effectiveness ol each
300 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
successive visit and also the relative effectiveness of preceding and following visits
with postal contacts. As a result, a very considerable saving was effected by limit-
ing the number of expensive visits by nurses to any one child, substituting for
some of them postal contact of very slight unit cost. An interesting consequence
of this combined procedure was the achievement of a level of community protec-
tion higher than that which had previously prevailed.

Speaking of unit cost accounting, Vaughan* has stated:

The health officer should know the unit cost of a nursing visit, of a sanitary in-
spection, of a food service . . . none of us can afford not to keep simple basic cost and
unit records. Our appropriations depend upon public confidence. There is an increasing
tendency to demand proof of the soundness of public health arguments. When it can be
shown that by the expenditure of certain monies distinct conservations in human life
can be established in specified areas, when it can be proven that the high costs of
hospitalization and home care of incurables (the end results of tuberculosis, syphilis
and mental illness) can be saved by the spending of small sums for prevention (case
finding, locating sources of infection, closing the infectious case), then we may anticipate
intelligent public support and sympathy. . . . Money is a requisite and financial sup-
port is available only as the community learns to appreciate the reasonableness of the
annual requests made by the health officer. If it can be shown that with a given sum of
money a certain number of infant deaths can be saved annually in a defined area, there

is established an appeal not only on the basis of saving human lives but on a foundation
of economic necessity. *

Purchasing. Related to accounting or expenditure control is the question of
obtaining materials and supplies involved in the operation of public agencies.
Until relatively recently the pattern followed was largely the provision to each
individual operating department of lump sums of money for operating or mainte-
nance. There existed also a general feeling that purchases and contracts should
be distributed as widely as possible throughout the various business concerns
existing in the area served, apparently with the end in view of obtaining their
good will and support of the government and its program. Why this was felt
necessary is somewhat difficult to understand since business and industry them-
selves have always followed a more progressive and efficient course.

The recent trend, therefore, has been toward the development of central
public purchasing agencies with the authority to purchase or to formulate regu-
lations governing the purchase of all materials, equipment, supplies, and con-
tractual services for all of the public agencies in the particular unit of govern-
ment. As this approach developed, in order to promote their effectiveness public
purchasing agencies have generally been given the authority to inspect all goods
delivered, to test samples submitted with bids or deliveries, to transfer or dispose
of any materials, supplies, and equipment from operating agencies, and to main-
tain a central warehouse. Centralized purchasing has many advantages, including
lower unit costs, better delivery service, reduction of overhead costs, standardi-
zation of products and of purchasing and expenditure documents, more efficient
accounting control over expenditure, and simplification of the ordering, delivery,
and storage problems of both vendors and operating agencies.

*Vaughan, H. F.: Paper read at a special session on the Business Aspects of the Health De-
partment at the 66th Annual Meeting of the American Public Health Association. Oct. 6, 1937.
FISCAL MANAGEMENT 307

Complaints are frequently raised against central purchasing agencies, usually
to the effect that they hamper the activity of the functional department by causing
delays, red tape, and the acceptance of substitute or unsatisfactory materials. The
subject of most controversy is whether or not the purchasing agent should have
the right to modify the requisitions sent to him, to substitute for a specified ma-
terial or brand, or to refuse to place an order for materials requested by a func-
tional agency. The statutes of some states specifically allow this right, some imply
it, others deny it, and worst of all in a number of states the issue is entirely ig-
nored. It is felt that most or all of these objections may be easily avoided, pro-
vided the purchasing agency, on the one hand, constantly considers that its exist-
ence is justified only in terms of the auxiliary service it finds possible to render to
the functional agency, and if the latter, on the other hand, takes pains to make
clear to the purchasing agency their exact needs and the reasons for them. The
problem, therefore, is essentially one of proper interagency relationships and
understanding.

While a system of continuous expenditure control assures the efficiency of
operation and expenditure, only an audit following the completion of the budget
period can determine their legality. Therefore, it is necessary in the public in-
terest that there be some method of assuring not only that the public money is
being legally spent but that the public is receiving reasonable value for it. The
auditor is in effect an arm of the public's legislature which not only has established
a public program but has provided appropriation lor its fulfillment. A system of
postauditing involves the examination and appraisal of accounts, records, and
statements as well as accounting and operating procedures. It provides the legis-
lature with information and analyses arrived at independently of those who are
directly responsible for expenditures and operations. It provides data for review-
ing past and for planning future budgets, revenue and expenditure programs,
and for drafting needed additional legislation. The personnel of the functional
units subject to postauditing should, in addition, look upon it as a protection to
them and a means of providing for official and public recognition to their honest
and efficient fulfillment of the duties and responsibilities entrusted to them.

Fiscal Responsibility. The placement of fiscal responsibility in any political
subdivision may vary from place to place. However, the principle exists and must
be maintained that a public health officer must always be in the position of
knowing the current status of his budget appropriation limitations.

In a large city where there exists a highly centralized financial operation,
with fiscal controls established therein, and where an “executive type” rather
than a “legislative type” of budget is effective, it is especially important that the
health officer establish a firm fiscal basis upon which he may successfully operate.
A briel review of the successive steps involved in such a community which
adopted this newer concept of fiscal control is presented for those who may be
confronted with such an operation.

In 1952 the voters of the city in question adopted a home-rule charter that
had recently been authorized by the government of the state. The new charter,
among other benefits, established new fiscal policies for governmental operation
308 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

in the fields of budgeting, accounting practices, collection of taxes and other
revenue, and the related responsibilities thereto.

The mayor of the city was made responsible primarily for the efficient fiscal
operations of the various governmental functions, and through his finance di-
rector, the city’s principal finance officer, was charged with the responsibility of
submitting to the city council the budget requests of the various governmental
units.

The city council's authority in the field of finance was restricted in the
charter in favor of wider authority to be exercised by the mayor. The council
retained the right to adopt the annual operating budget and the capital budget,
to levy the taxes necessary for the support of the government, and to authorize
debt, contingent upon the approval of the voters. Under these circumstances, the
council is bound by the mayor's estimate of receipts and is guided in the determi-
nation of its budget appropriations by consideration of the line type budget,
with detailed justifications thereof, which is submitted to the council by the
mayor. This budget is presented on an “object detail class” basis. All the posi-
tions to be financed are segregated on a budget schedule, with separate schedules
for personnel, contractual services, materials and supplies, equipment (detailed),
and such other additional classes as the mayor recommends in his proposed an-
nual operating budget ordinance. All budget appropriations are made in lump-
sum amounts and according to the above classes of expenditure [or each office,
department, board, or commission. This approach to budgeting produces the
“executive type” budget rather than the “legislative type” budget, and gives to
the administrative officials of government more flexibility within broad limita-
tions, but does not destroy the possibility of close administrative supervision and
control. Thus, the responsibilities for fiscal direction and control is placed more
firmly on the executive, rather than on the legislative branch of the government.
The city council is required by law to adopt the annual operating budget ordi-
nance, for the next fiscal year, at least thirty days before the commencement of
that year.

Upon receipt of the approved budget, the director of finance, with the ap-
proval of the mayor, sets up allotment accounts by departments on an expenditure
class basis. Personnel appropriations may be established on a quarterly allotment
pattern, and materials, supplies, and equipment on an annual basis. In the
larger departments, allotment accounts are set up on a departmental functional
basis, with subaccount allotments for detailed object classes exceeding $20,000,
for closer appropriation controls.

The multiplicity and volume of fiscal transactions handled in a centralized
fiscal office of a large city necessitates the utilization of mechanized facilities.
Since the director of finance is the chief fiscal officer of the city, all budget, fiscal,
and accounting practices are centrally controlled in his office. There are released
from the offices of the director of finance all of the official financial statements of
the city. For day-to-day operations, the fiscal office of each department receives
a daily statement [rom the director ol finance which reflects the current status
of each of their allotment accounts. Each transaction listed on this daily state-
FISCAL MANAGEMENT 309

 

ment is documented by a copy ol the voucher related thereto. These statements,
however, do not include all of the encumbrances that may be involved in pro-
posed commitments that have not reached the stage of machine recording.
Therelore, for this and other reasons there still remains the need of a depart-
mental fiscal office. This need is apparent when the following is considered:

I. Most of the initial action in all fiscal transactions originates in the operat-
ing department.

2. The original departmental budgetary appropriation request is prepared
in each operating department.

3. The various types ol requisitions covering departmental needs are proc-
essed from each department.

4. Appropriation accounts authorized for the general fund, capital fund,
and special funds, must be maintained at the department level, in order
that the health officer may direct and plan his program during the course
of the year from the unencumbered balances. Therefore, the departmental
accounts must include those planned and proposed commitments that
have not as yet currently reached the stage of machine recording.

ot

Although payrolls may be prepared by mechanized methods in the finance
department, the initial official time record of personnel time worked
must originate and be prepared at the operational level.

6. Costing for evaluation of programs and activities is also essentially the
responsibility of the departmental fiscal office.

In the capital fund area the principles of responsibilities are practially the
same as those applicable in the general or operating fund field. However, the
details of handling are somewhat different. For example, a city council may adopt
each year a six-year capital program, wherein is listed each project to be financed
during these periods, showing the amount proposed to be spent for each of the
six future years covered. The council then would also adopt a capital-fund bud-
get for the forthcoming year, where project-wise the amounts authorized to be
spent therein are recorded.

In the preparation of the capital program and capital budget, it would be
probable that the director of finance and a city planning commission, if one
existed, would work jointly with the approval of the mayor to furnish the city
council with a budget document that would best reflect the needs of the com-
munity with regard to the various proposed capital improvements. However, the
initial budget requests would originate in the fiscal office of the operational de-
partments.

It is evident [rom the foregoing that the health officer, in order to plan his
health programs efficiently, to utilize the health dollar to the best advantage and
to remain within his budget limitations, must assure himself that he has pre-
pared his budget properly, that its terms are applied correctly, and that shifts
in programs are adjusted as the funds permit. In order to do this, he must famil-
iarize himself with the principles of the local fiscal requirements and must obtain
the best fiscal advice and aid available.
310 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

REFERENCES

1. White, Leonard D.: Introduction to the Study of Public Administration, New York, 1939, The
Macmillan Co.

2. Geiger, Jacob: Health Officers’ Manual, Philadelphia, 1939, W. B. Saunders Co.

3. EMIC Information Circular No. 3, Children’s Bureau, February 22, 1944.

4.

Vaughan, H. F.: Paper Read at a Special Session on the Business Aspects of the Health De-
partment at the 66th Annual Meeting of the American Public Health Association, Oct. 6,
1937.
chapter 1 2

Public relations in the public health program

Purposes and Objectives. Ours is a society of increasing complexity and so-
phistication. One of the demands which is placed upon both private and public
organizations operating in this type of society involves a concern for what might
be referred to as customer or patron consideration, more commonly thought of as
public relations. The term is admittedly general, if not somewhat vague, and is
used to describe a multitude of practices and activities, some good, some bad,
designed to win the good will and cooperation of people individually and in
groups. These practices and activities are never an end in themselves. Rather,
they deserve consideration merely to the extent that they enable employees to
fulfill adequately their intended responsibilities to the satisfaction and under-
standing of all concerned. The field of public relations is not only difficult of
definition, but also presents a problem when one merely attempts to list or de-
scribe the various factors that contribute to it. All too often are seen instances
of executives who point with pride and satisfaction to their publicity programs,
and refer to them as their public relations programs. While press releases, public
addresses, and the like are of great importance in their place, public relations
encompasses far more. It includes every conceivable factor and circumstance that
may influence the people's attitude toward the ‘organization, its work, and its
personnel. Most important, as subsequently will be discussed, it includes all those
seemingly incidental and casual relationships between the organization and its
personnel, and those who are served. In this sense, public relations may be looked
upon to a considerable degree as the summation of personal relations.

Another misconception with regard to the purpose of public relations ac-
tivities is that they are developed for the purpose of having a reserve of support
and defense when the going gets rough. While a really good public relations pro-
gram will go far in accomplishing this purpose, it is an incidental or secondary
effect, the primary purpose being to make the road as smooth as possible in the
first place. As one writer! has described it, “Public relations is not an ambulance
parked at the bottom of a precipice. Rather, it is a fence built at the top.”

Although the public relations problem of a public health department is
essentially the same as that of any other type of enterprise, certain differences in

311
J12 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

the reasons for the existence and manner of operation of the organization make
good public relations peculiarly important. A health department is a tax-sup-
ported public agency which belongs to the people it serves. Its existence in a
democracy depends in the final analysis upon their wish to maintain it. In the
long run, this wish can be sustained only by public understanding and satisfaction.
Such reactions naturally give rise to pride of ownership, which in turn enhances
cooperation and support. It might be pointed out [urther that modern thinking
in public health is along the lines of doing things with people, not for them or
to them. “With” is an interesting word, which, when applied jointly to a health
agency and the people it serves, implies everything that contributes to good
public relations.

General Considerations. Fundamental to a successful program of public
relations is the desire to sell the organization and its program and not the in-
dividual. It is true that the public is interested in personalities, but it soon
tires or becomes suspicious ol [requently repeated references to a particular
public employee, even though he be the health officer. Belore long the public,
subordinates, and other officials mutter “publicity hound” and ask each other,
“Who does he think he is?” and “What is he alter?” In other words, perhaps
the most important public relations consideration for the health officer is not
to regard the health program as a one-man show but to share Ireely whatever
responsibility and credit accrue. When this policy is followed, the individual
is automatically benefited. Thus, when Dr. Enion Williams, the eminent health
commissioner of Virginia, was asked to account for his long tenure of office, he
replied, “I have never tried to sell the people of Virginia on the name Williams,
but I have sold them on the Virginia State Department of Health.”

What has been said is not meant to imply that the health officer does not
have a most important personal part to play in the public relations program
of his organization. Alter all, he is the responsible leader. It is his job to ascertain
that desirable relationships are formed and maintained. Beyond planning and
directing the program he must himsell cultivate certain relationships which
he alone is in a position to do. He makes these contacts with other govermental
officials, prominent citizens, and various important key people in the sense of
running interference for his staff.

This leads to a second basic consideration to the effect that good public
relations, particularly ol large organizations, seldom if ever come about spon-
tancously. Sometimes they may appear to, but, to be effective, a public relations
program must be carefully and conscientiously planned and constantly watched.
To do this requires, first of all, a statement of the over-all policy of the organiza-
tion toward the public in relation to the purposes and aims of the agency. Cogniz-
ance of all potential contacts must be taken and, insolar as possible, arrange-
ments made for their occurrence in the most mutually satisfactory manner. Pro-
vision must be made for employee training in good public relations, followed
by checks and evaluations of the success of this aspect of the life of the agency.

With regard to the first of the two words in the term public relations, it must
be fully appreciated that there is no such a thing as “one” or “the” public. In even
the most primitive societies, more than one public exists. Usually there are many,
PUBLIC RELATIONS J/3

each with its particular interests, needs, and demands. The population of the typ-
ical community may be broken down into innumerable groups or publics on the
basis of equally innumerable characteristics, e.g., religion, economic status, educa-
tion, race, nationality, age, sex, and occupation, to mention but a few. The
public relations program must be broken down into a similar number of sub-
programs. No single approach will bring success because it will touch only one
or, at best, a few of the publics. The program must be designed as a jigsaw
puzzle which eventually succeeds in reaching, in one way or another, all of the
publics involved.

Attention should be drawn to several other general considerations. The first
of these is the often overlooked fact that public relations is a two-way process.
It involves a flow of information, reactions, and understanding, not only from
the agency to the public but also in the reverse direction. Overlooked with
equal Irequency is the part played by the many informal as well as formal con-
tacts between public employees and the citizenry. A health department may
have the support ol the press, the professions, and the business groups, and
may be doing a scientifically splendid job, but all this may be negated in the
mind of the citizen il he is slighted, dealt with flippantly and rudely, or in any
other way made to feel dissatisfied.

One final consideration, which leads to what follows, is an appreciation
ol the competition for the attention of the public. In our modern society, the
senses of the average citizen are bombarded constantly throughout his waking
hours by a barrage of publicity, propaganda, advertising, promotional and educa-
tional forces. Some of them are subtle, while others resort practically to brute
force. The public health worker must recognize all this as competition and must
devise and employ techniques which will meet it on its own ground and obtain
a [air share ol public attention. In this very real struggle for public attention
and support, the public health agency is handicapped by certain obstacles which
act as deterrents to desirable public relations. All of them relate either to the
nature ol the product (health) or to the means of providing for it (a public
agency).

Obstacles to Good Public Relations. It must be frankly admitted that only
rarely are people interested in public health. Individuals are concerned with
their individual or personal health or that of the members of their families.
By and large they are willing to pay attention to some of the larger community
aspects of health only insofar as they may readily appreciate its effect upon
them. Even then, they may weigh the possible benefits against certain other
considerations such as personal freedom of action or business advantage. In
other words, strange as it may seem to some of us imbued with the “public
health spirit,” public health is not necessarily a natural or spontaneous con-
cern, interest, or wish ol all people. It is, in fact, more than a little distressing
to find that an appreciable percentage of the population is quite ignorant of
the existence of the field and not particularly interested in enlightenment.

Another obstacle related to the product is that activities engaged in [or
the protection and promotion of health require employees with a scientific, tech-
nical, or professional background. The training and experience that contribute
JI4 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

to such a background usually stress the job to be done, the result to be accom-
plished, and ignore more often than not the human factors involved. Thus, it
becomes all too easy for public health workers to be so intent upon their activities,
programs, or goals that they lose sight of the personal and human aspects ol
the work. This professionalism may sometimes give rise to feelings of discom-
fort, awe, and even resentment on the part of the members of the public in
their contacts with the personnel of the health department. When this occurs,
it is, of course, a deterrent to good public relations and understanding.

Particular difficulties arise from the fact that public health programs are
in large part activities of official governmental agencies and therefore subject
to all of the attitudes which the public and community groups have toward
government. Generally speaking, public employment has been held in low esteem
in the United States although some improvement has been noticeable in recent
years. All too often the public servant, professional or otherwise, has been looked
upon as someone incapable of successfully engaging in private business or pro-
fessional practice and interested only in a political sinecure. This is due partly
to the traditional American admiration of rugged individualistic business and
industry and partly to the all too frequent unsatisfactory if not unsavory histories
of governmental operations. Business and the private professions have always
regarded government as a natural enemy always seeking to control or to take
over. Under the circumstances, their opposition to the development and ex-
pansion of public programs is not surprising.

Related to this and accentuated by traditionally low salaries in govern-
mental service is the not infrequent inferiority complex which has developed
in many public employees. An unfortunate method of compensation for this
is the not too rare exercise of injudicious authority based upon public position.
This, when resorted to, only aggravates the situation.

It is not difficult to understand how many citizens may misinterpret planned
public relations activities of public agencies as representing propaganda for
the purpose of self-aggrandizement at public expense to assure reappointment
or continued employment. For this as well as other reasons, the public has been
loathe to provide funds for public relations purposes, thereby often making it
necessary for the public agency to resort to subterfuge in order to accomplish
this important purpose.

Finally, it should be recognized that a great many contacts with the health
department are unwilling contacts whereby the citizen is called upon to do
something not to his liking, for instance, to obtain a permit or the like. From the
point of view of development of desirable public attitudes, the health department
finds itself with two strikes against it at the start. This makes it all the more
necessary that the personnel of the health department take full advantage of
every possible opportunity for the development and maintenance of good public
relations.

Methods in Public Relations. Since in any community there are many pub-
lics and since societies have become so complex, it necessarily follows that there
are many different approaches to the development of improved public under-
standing and support.
PUBLIC RELATIONS JI)

 

Personal Contacts. This is put first, not only because of its importance, but
also because it is so often overlooked or neglected. A health department exists
to serve the public and most of its work involves contact between its staff and the
individuals who comprise the public. It naturally follows that these contacts
should be of a desirable nature. If a contact or association of a citizen with the
personnel of the agency is unsatisfactory and leaves an unpleasant memory, the
contact is a failure despite whatever service is rendered in the process. In addi-
tion to this, if the attitude of the employees toward the public health organiza-
tion, its policies, and its management is unsatisfactory, it is certain to influence
the nature of the employees’ contacts with the public, and this in turn will ad-
versely affect the community’s attitude toward the department.

On-the-job characteristics of health department employees that influence
the reactions and attitudes of the public they meet may be considered under
the categories of appearance, behavior, and capability.

APPEARANCE. Most large private organizations have found it desirable to
impose certain requirements concerning dress and other aspects of personal
appearance upon their employees. To do so is not without risk since require-
ments of this nature if unexplained, misunderstood, or too strict are apt to
lead to considerable intra-agency [riction and personnel dissatisfaction. Most
employees, however, if worthy of employment in the first place, can be made to
realize the purpose and desirability of these requirements.

The average person on entering a business office, especially if the office is
tax supported, does not react favorably to flashy clothes or an excess of jewelry,
cosmetics, and perfume. Male employees should avoid sport clothes and dazzling
neckties in favor of more dignified or professional dress. Women should be
similarly conservative, tending toward suits and tailored clothes. The use of
cosmetics, jewelry, and perfume occupy a very real place in our culture and
are by no means to be denied. However, in a business environment their use
should be judicious and in good taste. Under all circumstances the personnel
should be neat and clean, there never being any excuse for appearance to the
contrary. That this is possible is given testimony by the level of neatness and
cleanliness maintained by many industrial workers and gasoline station at-
tendants.

No discussion of clothing can be concluded without reference to the ques-
tion of uniforms. In public health work, the problem arises in connection with
one large group ol employees, i.e., public health nurses. It is possible, as is often
done, to set forth many arguments pro and con the wearing ol uniforms. The
chief advantages to their use relate to identification and recognition of pro-
fessional standing. Many feel that the public expects to find nurses in some
type of uniform, lacking which they may be less acceptable. It is further felt
desirable by many that a corps of readily identified uniformed workers provide
visual evidence of the importance and activity of the health department. In
this sense the argument rests upon the promotion of public relations. Some go
so far as to claim that the wearing of an identical uniform by a group of em-
ployees promotes an esprit de crops. This latter is open to some question. In
turn, the opposition points to the almost universal drabness of the public health
316 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
nurses” uniforms that have been designed and worn up to the present. In reply
to the argument ofl identification, they call attention to the resentment felt
by many citizens when their neighbors see the “city nurse” knock at the door.
Added to this, they claim, is the embarrassment of both the citizen and the nurse
caused by the frequent identification of a public health field visit with veneral
disease or some other problem of similarly unpleasant connotation. The writer
does not feel it within his province to render a judgment in the matter. Rather,
it is believed to be a question that calls for separate answer by each individual
health department and its community.

BEHAVIOR. While the first impression in a personal contact is a visual one
depending upon appearance, the subsequent and most telling impressions are
ol an even more direct and personal nature. Much depends upon the manner
in which employees approach individual citizens or patrons in the office or
in the field. Everyone has at some time found it necessary to visit offices where,
after a seemingly needless wait, he has been called upon with bluntness and
curtness il not actual rudeness to state his business. In such instances, the
visitor is made to feel that he is an outsider, an intruder, an interruption, a
not too necessary evil, to be disposed of as quickly as possible. In contrast with
this are offices, equally if not more busy, where the approach is [riendly, as
one human being to another, where any delays are courteously and regretfully
explained, and where the visitor is made to [eel at home, expected, and wanted.

In their contacts with the public, there are certain principles or rules
which public health workers would do well to lollow. The key to the situation
is to look upon those contacted as the real and only reason for the job and for
the department. Each contact should be regarded as a contest, rather than a
boring routine, the goal being to win the other person over to your side, your
point ol view, your program. In order to accomplish this, the public health
worker must first attempt to put himself in the position of the caller, remember-
ing that in most instances that person would much rather be doing something
else. The measure ol success is for the visitor to depart with no regrets. At
best, the circumstances ol the contact will be strange to him, so the employee
should make every effort to call forth associations which are familiar and pleasant.
Explanations should be in simple terms, and strange and technical terminology
should be avoided. “Vaccination,” “immunization,” and “shots” are examples
ol complicated and rather [rightening words, whereas “protection” bears a
connotation ol something positive and desirable. A woman would much prefer
to be spoken ol as an “expectant mother” rather than as a “prenatal.” All of
us resent being considered cases; we are human beings worthy of address as such.

Every organization of whatever size should make provision for some type
ol information desk. In the small organization, such as the typical rural county
health department, this desk will not be difficult to find. In larger agencies,
which occupy many rooms on several floors, the information desk should be
placed as close to the main entrance as possible. The person in charge should
be selected with care. She should appear approachable, friendly, and desirous
ol being of assistance to all types of persons. Her manner, while dignified,
should be somewhat informal and it is perhaps preferable that she be allowed
PUBLIC RELATIONS 317

somewhat more leeway in the matter of dress than the rest of the personnel.
In order to fulfill their purpose, it is of course necessary that individuals in
this position possess an encyclopedic knowledge of the organization, its program,
the building in which it is housed, and also of related organizations in the com-
munity. Associated with the information desk should be an easily read and
interpretable directory which indicates the location of each of the functional
units in the organization with the name of the director of each and of any other
persons frequently sought.

Next in line of travel is the office receptionist, who, to a considerable de-
gree, conditions the attitude of the caller toward the organization. This position
is usually filled by a woman who also serves in a secretarial capacity. She should
have an air of alertness and industry backed up by competence. The position
is not necessarily an easy one since the occupant may often find herself in the
middle between the person for whom she works and the visitor [rom the outside.
By no means are all visitors important and the receptionist has the responsibility
of husbanding the limited time of the executive. On the other hand, each
visitor naturally considers himself and the reason for his call of importance,
otherwise he would not have taken the trouble to come to the office. The re-
ceptionist, therefore, must have as an outstanding qualification a sound under-
standing of human nature and the ability, whenever necessary, to turn some
visitors away in such a manner as to preserve their pride and dignity and make
them feel satisfied at least in some degree. Whether or not the receptionist at-
tempts to forstall or divert the visitor, she may by her manner convey the im-
pression that the appearance of the visitor was the most important event dur-
ing the day and that any delay or refusal is extremely regretful to her, her
employer, and to the organization.

When a visitor approaches the receptionist, she should greet him pleasantly,
arise if the circumstances warrant and the physical layout allows, and ask in
a pleasant tone of voice, “May I help you?” When a request to see the executive
is stated, the receptionist should counter with, “May I announce who is calling?”
whereupon, unless impossible, she should immediately take steps to notify her
superior. Should it be necessary to turn away truly important persons or indi-
viduals whom the receptionist feels her superior would want to see, she should,
if possible, arrange or at least suggest a subsequent appointment. If the visitor
is to be seen, she should usher him into the presence of the executive, announcing
his name, and sometimes the organization which he represents.

A most annoying problem in public relations is posed by the visitor who
never knows when to leave. The time ol most professional workers and ex-
ecutives is decidedly limited and frequently they are tempted to terminate a
call impatiently or brusquely. This is very apt to be misunderstood and resented
by the visitor, even though he has inconsiderately usurped more than a fair
share of his time. It is possible to circumvent such occurrences either by means
ol a prearranged signal to the receptionist-secretary or by routine interruption
on her part after a reasonable interval to remind the executive of another ap-
pointment. This allows the executive to terminate the contact regretfully and
gracefully.
318 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

A common cause of ill feeling toward public officials and agencies is the
manner in which visitors, clients, patrons, or whatever they may be called, are
frequently shunted from one place to another, no one taking the trouble to
ascertain exactly what they want and seeing that they get it by the shortest
possible route. This type of “run around” or “passing the buck” has proved
costly to a great many organizations in terms of their public relations. Accord-
ingly, the person at the information desk and the receptionist and secretaries
in the organization have the function of referral as another important responsi-
bility. Moreover, they should take the trouble to follow up referrals in order
to assure the satisfaction of the caller. Usually a caller has several reasons for
contacting the agency, but in each instance there is one predominate reason
for the visit having been made. Under no circumstances should the visitor be
allowed to depart with the feeling that absolutely nothing was done with regard
to that particular reason.

Some organizations singly and collectively have gone far to improve their
public relations by coordinating certain services and activities and by centralizing
the location of places to which the public must come. A good example of this
is found in connection with building permits. Ordinarily a citizen who wishes
to construct or alter a building finds it necessary to make the rounds of the
building department, water department, fire department, health department,
and possibly others, in addition to the city clerk, in order to obtain approval
of all parts of the building permit. A few communities out of consideration for
the taxpayer have brought together into one office, at adjacent desks, repre-
sentatives of each of the branches of government involved so that all require-
ments may be fulfilled in one place and in a single visit.

A great many health departments have effectively built up an extensive
backlog of ill-feeling through their public counters. This problem was magnified
during the war years as a result of the tremendous demands for birth certificates
as a prerequisite to work permits. Admittedly, the extent to which health de-
partment offices have been deluged with requests has not been conducive to
good temper and patience. Nevertheless, by attempting to be overly efficient
by the use of mass production methods, health departments have sometimes ir-
ritated large numbers of individuals. Some of the difficulty can be attributed
to personnel shortages and inadequate funds. Over and above this, however,
is the ill-advised policy followed by many organizations of placing at public
counters employees who do not seem to fit in anywhere else. It is strange that
positions which involve the most frequent contacts with the public so often are
used as reservoirs or wastebaskets for employee misfits. Examples of improper
behavior at information desks and public counters are not difficult to find.
The writer once had the misfortune of inheriting a county health department
office manager who seemed to resent the appearance of anyone and who all
but drove out physically anyone who dared enter. She was promptly relieved
of her duties. Another wellremembered instance concerned the front infor-
mation desk of the health department of a large city which was staffed by two
ex-professional employees who had become too addicted to alcoholic beverages
to render professional service. In still another agency, the office of statistics and
PUBLIC RELATIONS 3/9

records was considered more or less a place of retirement, wherein the older,
worn-out employees found it definitely not to their liking to have to get out
of their chairs to serve applicants for copies of vital records. The organization
was widely known for its outstanding achievements. Nevertheless, within its
community it was evaluated by many citizens in terms of the poor service at
the counter of the office of statistics and records.

Every public agency, including the health department, is the recipient of
many complaints. From the point of view of public relations one of the worst
things that can happen is for the public to feel that it is wasted effort to call
any dissatisfaction or shortcoming to the attention of the organization. Errors
of omission and commission are certain to occur to some degree, particularly
in an agency which must deal with large numbers of people. A forward-looking
organization should welcome complaints from those it is supposed to serve
since this is one of several ways in which the program may be improved. Further-
more, to give the citizen the feeling that his complaint or criticism was justly
and fairly received, considered, and followed through is one of the best ways
of making him a community salesman for the department. A certain few steps
should be followed in handling complaints. The first is to assure the customer
that the organization is willing and in fact anxious to hear what he has to say.
Related to this is the important necessity of allowing the complainant to tell
his complete story in his own words and as he sees it. The next step is to
check at once, il possible, whatever records exist that might substantiate or
disprove the complaint. For example, blame of the health department for failure
to deliver a copy of a birth certificate sometimes may be absolved by immediately
checking to see if the birth was registered in the first place. Following this there
should be made a clear and understandable explanation of whatever contributory
factors or circumstances relate to the situation and its solution.

Field contacts made by representatives of the health department are sub-
ject to the same public relations influences as those that occur in the office.
There should be evident a desire to help rather than to enforce or compel. The
same care should be taken to make proper and effective referrals and to secure
necessary follow-up. These are the things that decide the difference between
cooperation and resistance, or, at best, passive acquiescence. In addition there
are certain public relations circumstances peculiar to field visits. Relatively
few health departments have made any effort to give advance notice by mail
or phone of intended field visits by members of their staffs. Some may object
to the proceduce on the basis of cost or the possibility that some persons may
attempt to forestall or avoid the contact. Against the first of these objections
is the fact that notification by mail or telephone costs only three to ten cents,
in contrast with an average cost of about two dollars for a field visit. One of
the most difficult administrative problems of a health agency is the reduction
ol unprofitable field visits caused either by the patron not being at home or
having moved elsewhere. A great many of these may be avoided by a program
ol advance notice, and a considerable saving will result. As an example, the
mainstay of the diphtheria and smallpox protection program of the Detroit
Department of Health has been for years the educational home visits of public
320 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH BN

health nurses to infants between six months and one year ol age. A study in
1935 showed that of a sample of 14,028 nurses’ visits, almost 30 per cent were
wasted. In 2,568 instances, or 18.5 per cent, the family was not at home when
the nurse arrived. In 1,511 instances, or 10.8 per cent, the nurse found that the
family had moved and was unable to locate it. The procedure was instituted
of preceding the first public health nursing visit by a letter which explained
the reason for the forthcoming visit and asked for confirmation of address and
whether or not the child had already been protected against diphtheria and
smallpox. By this means, not only was the percentage ol “not home” visits re-
duced to 8.7 per cent, but in addition 33.8 per cent of those who ordinarily
would have been “unable to locate” were located by means of the forwarding
techniques of the postal department. Without presenting financial figures, it
is obvious that the procedure not only paid for itselef but also resulted in a
significant saving. In addition to the saving was the educational value of the
letter and the preparation it gave for the nurse’s subsequent entry into the
home. It was found to be of good public relations value.

The other potential objection to previsit contacting or notification that
was mentioned was that some people may be [orewarned of the visit and thereby
forestall or avoid it. Much depends, of course, on the type and content of the
correspondence or telephone conversation. II properly planned and conducted,
it may be in itsell of educational and public relations value and make the sub-
sequent visit more acceptable and fruitful. Furthermore, it may be pointed
out that not infrequently citizens, particularly housewives and mothers, are
annoyed by nurses and other health department employees arriving when they
are in the middle of their housework or caring for a child. A stated wish to
avoid doing so is certain to bring about a kindlier feeling toward the health
department.

Attention must be given by the health department to the frequency and
multiplicity of calls. Even the most cooperative citizen becomes understandably
and rightfully annoyed when health department employees arrive too often
or more than one at a time. This indicates the desirability of some form of
field activity coordinating device, something too frequently overlooked in health
department practice. One manner in which some form ol control may be ex-
ercised is by means ol a central file in which are kept all records pertaining
to each person, [amily, household, or premise. The checking out of a [older
from the file indicates that some employee is presently engaged in some activity
relating to the person or household.

One final remark concerning field visits has to do with the desirability,
whenever possible, ol following up the visit with some other type of contact
to promote good continuing public relations. The suggestion is made that
each visitor, whether nurse, sanitarian, or other professional type, ask before
leaving il there is anything pertaining to health or sanitation about which the
householder would like further information, to be provided by a mailed brochure
or a visit by some other employee of the health department.

capasiLity. The third characteristic of health department employees that
influences the attitudes of the public is the extent to which they are able to
PUBLIC RELATIONS 321

demonstrate their knowledge and ability in the solution of problems with which
they are faced. Little if anything need be said here with regard to this obvious
requirement. Capable service breeds respect on the part of the public and also
on the part of politicians. Continued capable professional service is the most
potent safeguard against political interference. When it becomes obvious both
to the public and to politicians that here is a technical and professional job
that only trained and capable professional personnel can [ulfill, that personnel
will be left alone to continue its work.

Private Life. In a certain sense, public employees, particularly those in
executive positions, have no private lives. Not only are they under constant
scrutiny during working hours, but also at all other times. Their behavior is
always associated with their public positions, the citizenry always asking them-
selves, “Is this the kind of person I want as a health officer, public health nurse,
or whatever?” They further tend to be considered on call and personally ac-
countable twenty-four hours of every day. “Isn't that what we taxpayers are
paying them for?” This perhaps applies particularly to public health workers
since the nature of their responsibility implies a round-the-clock vigilance. If
the public employee [eels that he must drink or engage in extralamilial activities
not generally accepted by society, he owes it to the organization for which he
works to avoid open scandal. As Pfiffner® has stated, large numbers of influential
citizens do not approve of the new freedom as to liquor and domestic relations.
There are ways to do things without necessarily soliciting the attention of
those who disapprove. To say this is not to suggest hypocrisy and subterfuge
but simply to point out that it is the better part of discretion to avoid attracting
public attention in such matters.

Public employees as social human beings have many off-the-job contacts
with fellow citizens. These may occur in the home neighborhood, in churches,
clubs, lodges, and many other occasions for social intercourse. In all such
circumstances the health department worker should speak and behave in terms
of the best possible representation of himself, his family, and his organization.
In addition to strictly social contacts, an important phase of ofl-the-job public
relations is the participation of the health department worker in various civic
and professional group activities. The health officer should certainly be an
active member ol the local and state medical societies. Similarly the other pro-
fessional personnel should be active in their respective professional societies.
Of a somewhat similar nature is the participation of public health personnel
in chambers of commerce, councils of social agencies, service clubs, and the like.
The individual employee must always realize that others may evaluate his
organization through him. In relation to this subject, it is felt inadvisable for
a public health worker to develop a reputation as a perennial “joiner,” “hand-
shaker,” or “back slapper.” Membership in organizations should be judiciously
and carefully decided. More than one prominent public servant has been em-
barrassed by association with politically or socially unsavory organizations. In
most communities there exist one or two outstanding groups or organizations
which are the most influential and professionally valuable. They do not always
appear to be so on the surface. In one city it is a women’s club, in another an
322 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

athletic club, and in a third it is a voluntary tuberculosis and health association
around which cluster the most prominent and influential citizens. The health
officer and his co-workers would do well to evaluate the organizations in their
community and ascertain, il possible, health department representation in each
ol the most significant.

Belore leaving the subject of behavior in private life, some comment should
be made concerning gifts or gratuities. A large segment of the public takes it [or
granted that public service is characterized by a strong inclination toward gralt
and corruption. Almost every health department employee in a position of any
degree ol authority is certain at some time or another to become aware ol this.
Restaurant owners will suggest {ree meals, and gifts ol liquors, cigars, and other
things will be offered. Such forms ol apparent Iriendliness always carry some im-
plication of future reciprocity. It is doubtful that any citizen likes a public servant
so much that he will freely press him with gifts. Once an employee falls into
this trap it is most difficult to escape. Few such gilts are worth the psychological
quandary which usually results. The best and only policy lor the public health
or other public worker to follow is consistent refusal accompanied by a pleasant
explanation that the gilt is not expected by the worker or allowed by the
position.

Telephone. Each day about 200 million telephone conversations are held in
the United States. Most of these are in relation to business and public affairs. The
possibility that both Iriends and enemies may be made over the telephone is
often overlooked, many people apparently feeling that the absence of physical
and visual contact allows a certain amount ol leeway in behavior. It is an inter-
esting psychological [act that everyone engaged in a telephonic conversation con-
sciously or subconsciously visualizes the person with whom he is speaking. Em-
ployees, therefore, should approach telephonic contacts in the same manner as all
other types of contact. The rule suggested by the telephone companies themselves
is to “phone as you would be phoned to.” The goal should be to make these con-
tacts briel, [riendly, and [ruitful. Persons calling the organization should never
be left holding a silent phone [or any length of time. If a protracted delay is an-
ticipated, the caller should be so notified and asked if he wishes to be called back
later. Particularly annoying is the practice of having phone connections com-
pleted by one’s secretary who must then ask the person called to hold the line
while the one placing the call is located. In other words, il you place a call, be
immediately available when the connection is made.

In any type of contact, the first words are of great importance in conditiong
the tone ol the entire relationship. This is particularly true ofl telephone con-
tacts since the relationship is entirely auditory. When a call is received, the
person called should identily the organization and perhaps himsell in a pleasant
and friendly tone of voice: “Jones County Health Department, Mr. Smith speak-
ing.” Or il a receptionist or information clerk answers, “Jones County Health
Department, may I help you?” II the person placing the call neglects to state
"rather than “Who are
you?” or “What do you want?” No offense can be taken ol the former, while
the latter tend to make the backs ol most people stiffen.

his name, it is proper to ask “May I ask who is calling?’
PUBLIC RELATIONS 323

If the department is large enough to justily a private switchboard, the op-
erators should be chosen with great care, as in the case ol information desk at-
tendants. They must be quick and accurate, with a pleasant and even disposition,
and have a complete knowledge of the organization and its personnel. All of these
characteristics are necessary. I recall a delightful lady who operated the switch-
board of a large health department with the greatest efficiency. She was always
cheerful and had an uncanny knowledge of where everyone was and what they
were doing. Her attitude had much to do with the development of public good
will toward the department.

If an employee or a division is called by mistake, the courteous and wise
thing to do is to assist the caller in making contact with the right person or the
one who can best help him. Thus, “That problem is handled by the Nursing
Division. If you wish, I will have you conntected with it.” If it is uncertain which
unit or agency is indicated, the employee, in the interests of good public rela-
tions, should say, “I am sorry, but that is not handled by this division. I you wish,
I shall find out whom you should speak with and ask him to call you.”

Courtesy demands that the person placing a call should identily himsell as
soon as a connection is made. This should be immediately followed by a state-
ment ol the reason for the call. For example, “This is Dr. James ol the Jones
County Health Department, may I speak with Mr. Smith?” The business at hand
should then be discussed as briefly as possible, giving the other person a chance
to express his opinion, and then the call should be terminated.

Correspondence. A significant proportion of the contacts of an organization
occurs through the medium ol correspondence. It is often overlooked that a piece
of written or printed material may be as personal as an expression on a face or an
inflection in a voice. Both friends and enemies may be made by a piece of paper,
so it is advisable that an organization give special attention to this important
form of social and business intercourse. It is desirable, therefore, that a health de-
partment establish a definite [avorable organizational tone to its written con-
tacts with the public rather than to leave the matter entirely up to chance. There
are several ways in which this may be accomplished. The organization should
have a written standard practice with regard to incoming and outgoing corres-
pondence with which all employees should become familiar. Tt should give con-
sideration to matters ol routing and handling of mail, restrictions concerning who
in the organization should write what letters, priorities in answering, and even
matters of phraseology. An important phase of correspondence control is to in-
clude instruction relating to it in preservice and inservice training programs.

In so far as possible, letters should be personalized since the average reader
enjoys seeing his own name in print. Certain words should be avoided as much
as possible. Among these are “I, must,” and similar words im-

Ge

plying egocentricity, compulsion, or command. By like token, “you,” “your con-

Gc

6 4

we,” “order,

venience,
The use ol standardized, impersonal, printed form letters should be avoided.
When there is indication for their use, such as when large numbers of persons
must be contacted [or the same reason, it is still possible to personalize the written
contact. An example of a situation of this sort is the routine followed by many

your cooperation,” and similar words and phrases should be stressed.
324 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH
health departments in the promotion of diphtheria and other immunizations.
The natural tendency is to run off thousands of copies of a letter on a mimeo-
graph machine, each starting with “Dear Madam” and referring to “your baby.”
In a few instances, use has been made of electric typewriters which operate auto-
matically in a manner similar to a player piano. A master roll is cut to provide
for the automatic typing of the routine parts of the letter. The machine stops
automatically when certain personal items in the letter are reached so that names,
birth dates, “he” or “she,” him” or “her” may be typed by hand or by a punched
card. Thus it is possible to write a letter which is both standardized and per-
sonalized such as the following:

Mis. James Smith
234 Church Street
Glenview, Michigan
Dear Mrs. Smith:

According to our records, on July 27, 1948, you gave birth to a fine baby boy whom
you named George Arthur. It is our wish to assist you wherever possible in maintaining
George's health and well-being. Accordingly, we are writing you at this time to suggest
that you take George to your family physician in order that he may obtain protection
against . . . , etc.

Several studies have indicated a significantly greater response to this type of
written approach, which, while slightly higher in cost per letter, is well worth
the difference in terms of results.

Employee Training. It has been pointed out that good public relations do
not just happen. They result only from a planned program of employee training
and example. It does little good for the few at the top to formulate techniques
and programs to promote good feeling on the part of the public if the rank and
file of the employees of the organization are not brought into the picture, the
planning, and the action. If the employees are not provided with opportunity
to develop feelings of pride and loyalty toward the organization, if they are kept
in the dark with regard to the program and its progress, if they are not taken
into at least the general confidence of the organization concerning plans and
aims for the future, and if they are not impressed with and shown the importance
of each of their contacts with the public, the organization cannot hope to achieve
that atmosphere, employee-born, that speaks for good public relations.

Some industrial concerns have found it much to their advantage to pursue
a consistent employee training program for public relations. One of the most
outstanding of these is the program of the Bell Telephone Company, which is
well worth a few sentences of description. All persons employed, before they
report for work, receive a manual by mail entitled “You are the Company.” On
reporting for work, the new employee is assigned to a school for an induction
course. This has three phases. First the employee is told about the electrical and
communications industry as a whole. Then he is told about the company in
which he is going to work. Finally, he is told about the department in which he
is going to work, the job he is going to do, and its relation to the company, the
industry, and society. Following this he begins on job training to enable him to
master all the technical details of his specific work. Finally, the employees are
PUBLIC RELATIONS 325

rated periodically by their instructors and office managers at the end of the first,
third, sixth, and twelfth month. It is of interest that one phase ol the customer
interview rating procedure used by Bell Telephone Company is controlled by the
employee himself. They record transactions and listen back, comparing them
with standard records. They may stop or start or discard records, depending only
upon their wish. After they have listened back to a recorded transaction, they
are allowed to dispose of the record.

Programs and techniques such as these are well worth trial and development
by public health agencies. Certainly every health department employee should be
made to feel that he is taking part in much more than a means to a personal liveli-
hood. II he feels this, and it can result only [rom planning and encouragement
from the top ol the organization, his contacts with the public are certain to be
more satisfactory.

Quarters and Equipment. If the appearance of the health department em-
ployees is important, so too is the appearance of their quarters and equipment.
One of the most unfortunate characteristics of official health agencies is that
they are so often forced to be satisified with physical facilities left over after all
the other branches ol government have done their picking. So common is this
that the saying is well known throughout the country that “the typical health de-
partment occupies a few dark, dirty rooms in the basement ofl the city hall or
county building, preferably next to the public rest rooms.” For many years, there-
fore, the physical appearance ol many health departments was the antithesis of
what they attempted to preach and, even more serious, of what they demanded
of others. Under the circumstances there is little wonder that many people do not
take too seriously proposals of health departments. To require that others be
what one is not oneself is hardly conducive to good public relations.

Fortunately, the situation has been undergoing considerable improvement.
Many local health departments have moved into quarters similar to those occu-
pied by business organizations. An increasing number are housed in buildings
designed especially as health centers. In addition to going far to provide health
departments with community dignity and respect, these trends have the added
value ol removing the public health agency from physical connection and asso-
ciation with the centers of partisan politics and all they denote in the public's
mind.

A few specific details are worthy of mention in connection with the reactions
ol the public. Health, in the public's mind, is intimately associated with clean-
liness. This being the case, the premises of the health department, of all agencies,
should be clean and bright. Soap and paint alone considerably improve even
old quarters. If there is any question, attention is directed to the remarkable
change that has taken place in the appearance of gas stations, earth-moving equip-
ment, heavy duty trucks and the like during the past decade. If they can look
neat, certainly so too can a health department. If at all possible, dark woodwork
and dark, heavy [urnishings should be avoided. The present trend in office
architecture is away [rom a multitude of stuffy poorly lighted cubicles toward
the open office type of layout. An increasing number of private agencies even
place important executives in the large open office layout, set apart perhaps by
326 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

a railing. It is thought that this general plan is conducive both to better personnel
morale and efficiency and to better public relations since the visitor receives a
strong impression ol serious business activity.

As few movable items as possible should be kept on the top of desks. In fact,
it is stated with good reason that only papers and other items in immediate
use should be visible at any given time. In this regard, a modern filing system
contributes importantly to the general air of neatness and lack of confusion, as
well as to efficiency. It should always be remembered, however, that files are
business tools, and not completely enclosed wastebaskets simply for the purpose of
getting things out ol sight.

Avenues of Publicity. In any society in which they are available, the formal
channels of community communication play a very important role in public re-
lations. Predominant among these communication channels are the press, radio,
and television.

The Press. One ol the most important phases of public relations deals with
how to get and retain the cooperation of those who command the channels to
community public opinion. Outstanding among these are the representatives ol
the press. There are in the United States about 2,000 daily and 10,000 weekly
newspapers which blanket the population. Rare indeed are individuals who do
not have some contact with the product of the press. An ever-present problem
facing the health officer is how to reconcile his interests and those of the news-
paper published in his jurisdiction. As one authority? has pictured it, the ideal
situation would be one in which the press and the institutions in the community
would have similar noble interests and in which the press could fulfill all the
varying demands of all the community's institutions. No such situation exists,
however, for there are no perfect newspapers with perfect publishers, editors, and
reporters, and there are no perfect directors ol community institutions. It is
from these imperfections and also from healthy, honest differences of opinion
regarding the nature ol community institutions and their proper place that prob-
lems in press relations arise. It must be realized that publishing a newspaper is
a big business and that each paper has a policy regarding what it considers to be
news and what it will publish. That policy, while colored somewhat by altruism,
idealism, and civic interest, in most instances is determined primarily by what
the publisher thinks the public wants to read, which will therefore sell more
newspapers and thereby attract more advertising. The average newspaper will be
inclined to print material relating to health and to the health department, only
if it feels that it is in, and of, the public interest.

It must also be remembered that the press is traditionally a critic ol govern-
ment and its agencies. Fortunately, in most instances, this critical attitude is
potential since the press generally offers strong support to what it considers a
good government or a good health department. Nevertheless, because it regards
a government, a public health department, or any other public agency as po-
tentially inadequate and their personnel as potentially sell-seeking, the press is
constantly alert, acting as the guardian ol the public interest.

Each newspaper has its own style which has been developed over a period of
time. It has been developed lor the purpose of reader appeal. In order to accomp-
PUBLIC RELATIONS 327

lish its purpose the newspaper must write in a manner simple and interesting
enough to appeal to the largest possible number of the people. This means that
technical and scientific information must be translated into simple language that
can be understood by the average or subaverage person. General, tedious, verbose
statements must give way to sharp, precise, concise, and specific information
readily applicable to the reader. It is true that sometimes emphases are changed
and important points missed, but by and large the press has proved itself amaz-
ingly competent in getting rather complex ideas across to the average citizen.
Any particular newspaper style is not something that the health department em-
ployee can expect to master overnight.

Because of this, and in the interests of good press relations, it is best that the
public health worker respect the newspaper man as a specialist in his field. There-
fore, it is worth while to consider the following suggestions [rom an experienced
newspaperman to public officials. These suggestions resulted from years of prac-
tical experience and contact with public agencies.

I. If T were a city official, T would have a clearly defined and systematic policy in all
press relations. T would either supervise execution of such policies myself or have
a responsible person, preferably with a knowledge of news and reporting techniques,
do so under my direction. I would not deny reporters access to department heads
but IT would consult with the latter from time to time on matters of policy in regard
to their own press relations.

2. 1 would, after this policy is clearly understood, arrange conferences with the pub-
lishers and city editors of each of the local newspapers. I would ask their advice on
how to clear the news for their convenience, and how to make that news accurately
reflect the best values in public administration. I would discuss the result of these
conferences with the reporter on my beat and get his reaction to them. He is my
daily contact; T would never make him feel T was “going over his head.”

3. 1 would arrange a convenient, regular “press conference” time to see all newspaper-
men, although I would never deny any one of them admittance at any time.

4. T would develop my own “nose for news.” 1f I found it necessary to make off-the-
record statements, T would be sure the reporter understood at the outset that I was
talking off-the-record. T would be free and helpful to reporters in their news-gather-
ing jobs and answer all questions I thought fair and proper. If I could not answer
a question, T would, if possible, explain why. If a reporter were after a story which
would be detrimental to good government if announced prematurely, T would tell
him all the facts on that story, appealing to his sense of fair play in holding it. How-
ever, I would promise his paper an equal “news break” when that story was ready.

ot

I would sce that news breaks were distributed as evenly as possible between the
morning and evening papers. If I talked to competitive reporters individually 1
would be careful to give cach exactly the same story

6. I would not exagierate the occasional petty criticisms that newspapers print so
long as my general press relations were good.

~1

If a “news leak” occurred and the report, because of inadequate information, was
misinterpreted, T would call in newsmen and explain the proper interpretation to
them.

8. I would ask editors to give me a fair chance to answer critical “letters-to-the-editor”

in the same column printing such letters.

9. T would insist that all municipal and departmental reports designed for public read-
ing be written in terms understandable to the layman, with the qualities of clarity,
simplicity, and directness, and with a format that would make people, including
newspapermen, want to read them.
328 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

10. On major public reports I would make the matter available to reporters from time
to time before the report itself is actually published, if that is possible. These re-
leases would be carefully timed. I would point out to the reporter the significance
of more complicated passages in these reports and interpret them so he could write
accurate and intelligent stories. I would also point out to him the infinite possi-
bilities in various departments for news features and special Sunday articles. T would
help him to get pictures for such articles.

11. I would prepare releases or formal written statements only on those stories of im-
portant policy where misconceptions or misquotes might result. Newspapers gen-
erally prefer to do their own local stories in their own way, and if T have the right
to contact with them I can explain any story clearly.

12. IT would look upon newspaper people as intelligent men engaged in a reputable
work, and T would instruct all department heads and employees to treat them with
respect and courtesy.

13. Finally, I would make the newspaper an effective instrument in accounting to the
public for my stewardship, and I would keep in mind the significant motto of a
great newspaper chain: “Give light and the people will find their way.”*

A number of additional hints may be made with regard to relationships
with the press. Occasional public health workers, particularly some health officers,
have a tendency to irritate if not insult reporters and editors by adopting a
superior professional air. Overly impressed by their own apparent importance,
their attitude is one of suspicious condescension. Much more is to be gained by ac-
cepting the newspaperman as an equal. The public health director can often
profit from the advice and criticism of the reporters assigned to his beat. They
and their editors can often give invaluable advice regarding public feeling, an-
ticipated reactions, and timing of reports and anouncements. It is much better
to follow their opinions in these matters than to demand arbitrarily that a
certain item appear on the front page of this evening's paper.

Articles should emphasize problems, programs, and the organization, not the
individual. Both the press and the public soon tire of the health worker who ap-
pears to want his name in every issue of every paper. Share the credit; stress
the organization. In submitting copy the customs and requirements ol the trade
should be followed. Material should be typed, double spaced, on one side only,
with extra space at the top of the first page in place of a headline. Let the reporter
reword, revise, and cut the material and write his own headline. These are his
professional prerogatives and the things that allow for individuality and pride
in his work. The best safeguard against errors in reporting and headlining is to
state and emphasize clearly the basic idea to be communicated. Advance copies
of announcements, speeches, or articles are always appreciated by busy reporters
and editors. They should not be expected, however, necessarily to use all material
submitted. After all, the newspaper is theirs, and so should be the choice of
material.

Persons writing copy should guard against verbosity. We each tend to feel
that what interests us must naturally interest everyone and that every word
we take the trouble to write is worth everyone's time. Newspaper writing and,

*Hazelrigg, H.: A Newspaper Man Looks at City Hall, Public Management, March 1938,
pp- 67-70.
PUBLIC RELATIONS 329

for that matter, newspaper reading are specialized forms of writing and reading.
News items must be presented “in a nutshell” for that is the form in which the
newspaper reader wants them. Feature articles are seldom read in toto. Brevity
and conciseness, therefore, are the characteristics to be sought. A page and a
half, double spaced, is a moderately long story, two typewritten pages is too long
for most purposes, three and a half pages make a whole column and except in
most unusual circumstances is an imposition upon any editor.

Care must be given to impartiality in the handing out of newsworthy stories.
Papers and editors are in competition with each other and natually resent signs
of favoritism. One of the first things a public health worker should do on begin-
ning work in a new community is to make a complete list of all papers published
in the area. Those most apt to be overlooked are the county papers in contrast
with those published in the county seat, weeklies as against dailies, and foreign-
language papers. The latter are of particular importance in many metropolitan
cities which contain large numbers of non-English-speaking residents.

A final suggestion to be made in the interest of improved press and therefore
public relations is that consideration occasionally be given to inviting reporters
and editors to “come and see.” If an opportunity is provided for them to visit the
various activities ol the health department and to take part in field trips and
other inservice training activities, benefits will be reflected in better appreciation
and reporting.

Audio-visual Methods. No one medium of publicity can be used to the ex-
clusion of all others. While the press is unquestionably of great importance, it is
often credited with more power and influence by the general public and many or-
ganizations than most editors and reporters would care to give it. As some news-
papermen have pointed out, if the press does appear to have more power and in-
fluence than any other community institution, it is probably because the other
channels of publicity and public education have been neglected. One probable
reason for this neglect is that these other approaches are not as easy to use as is
the press. They are more expensive, require more specialized skills and equip-
ment within the health department, and are more time consuming, and require
planning, rehearsing, or construction. Yet it must be realized that the press is ap-
plicable only to certain problems and even then only serves one phase of the
total publicity. The same, of course, is true of all avenues of approach to the pub-
lic. Thus, an important program may be announced through the press, on the
radio, on posters, or in organized meetings. The actual launching of the program
may be accomplished by exhibits, leaflets, demonstrations, and personal visits. Fi-
nally, there must be publicity follow-up, presenting the progress and results of
the program.

Among the audio-visual approaches to the public, radio and television are
among the most important. Most stations [eel some responsibility for public wel-
fare and betterment. In order to meet this responsibility they follow the policy
of setting aside a certain proportion of their air time for nonprofit programs of an
educational nature, among which may be some dealing with public health and
the health department. There are certain reservations with regard to the value of
such programs. In the first place, the time periods which radio and television
330 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH B
stations donate are most apt to have low listener ratings. This is understandable
since, alter all, the stations are in a costly business and naturally reserve their
most valuable time for the profitable commercially sponsored programs, particu-
larly broadcasts over nationwide hookups. Another handicap is that the writing
and presentation ol satisfactory programs is a highly technical and fairly ex-
pensive job and not one for amateurs. There is a tendency on the part of many
professional people, including those engaged in public health work, to feel that
everyone is ready and willing to listen to their every word. They ignore the
fact that radio and television developed primarily along the lines of entertain-
ment media and that the busy housewife or the tired workingman is not par-
ticularly interested in avidly following the serious opinions ol a public health
worker presented more often than not as a monotonous monologue. To insist and
persist in the presentation of such performances is poor public relations, to say the
least. The average member of the listening public, if he happens to hear the pro-
gram at all, is most apt to turn the program off with a groan. In order to do even
that involves interruption and physical effort which the average listener is apt
to resent. ®

Despite this, radio and television may occupy real places in the educational
and public relations programs ol the health department. In order to do so, careful
planning and judicious use are required. The very [act that it is primarily a means
ol entertainment may be used to advantage. Many people simply turn a good
program on and leave it on, tolerating short commercial or spot announcements
in the knowledge that in a lew minutes another entertaining program will be
forthcoming. It is suggested, therefore, that more consideration be given to the
use of spot announcements by health departments.

Beyond these short, attention-getting auditory contacts which are essentially
ol a sensitizing nature, health departments may find value in certain types of
longer programs ol fifteen or thiry minutes’ duration. They should not, however,
take the form of talks or addresses. Instead, the patterns long since proved of
value in other fields should be adapted. Certain types ol audiences are attracted
by quiz programs, others by round-table or town-hall types ol discussion. For
many, the drama has great appeal. In any case, the total program should be
planned and written by professional producers and writers and, if possible, pre-
sented by prolessional actors. The period ol novelty ol television is past in
many parts of the country. The role it will play eventually in social and cultural
life is not yet fully determined. Already, however, it has brought about very
real changes, some desirable and others not desirable, in family life. Indications
are that it will become a significant means ol public education as well as enter-
tainment. In fact, it may eventually replace, in large measure, not only the radio
and the motion picture, but also to some degree the newspaper. Already, many
health departments in urban centers are using it as an effective means of health
education of the public.

*For one interesting analysis, see Radio Listening Habils of Mothers Who Attend Well
Baby Clinics by Murray and Turner.®
PUBLIC RELATIONS 331

Other media of public relations as well as educational value are exhibits,
public talks, and such miscellaneous approaches as billboards, film strips, street-
car and bus advertisements, throwaways, “comic” books, and paid advertising.
Each ol these may be made to serve particular purposes and to reach certain
groups. No one of them is an end in itself but must be a part of and tied in with
a larger over-all program. If poorly done, they do much more harm than good and
should therefore be carefully planned and evaluated.

Many public health officials attach considerable importance to their annual
reports as implements for the development and maintenance of good public rela-
tions. Annual reports may well be made to serve this useful purpose, but there
is cause for serious doubt that they actually do, in most instances, as currently
published. It is the uncomfortable truth that, from the viewpoints of both content
and format, most health department annual reports make very poor reading.
Financed usually by inadequate funds, they are often poorly printed on cheap
paper and consist largely of a series of disconnected reports [rom each of the [unc-
tional units of the organization and are illustrated merely by uninteresting
columns of statistics plus perhaps the photographs of the members of the
board.

An interesting and pertinent analysis of municipal public reports was made
by the editors of Public Management in 1938.6 Their criticisms, which deserve
serious consideration by public health workers, may be summarized as follows:

Complete failure to make any kind of report.

Extensive use of uninterpreted statistics.

Use of graphs and statistics that may be falsely interpreted.

Use of superfluous statistics unrelated to any purpose or accomplishment.
Poor make-up, arrangement, paper, type, and printing, and poor or no
illustrations.

6. Lengthy financial statements of interest only to a few individuals.
Disconnected combining of a collection of unrelated divisional or de-
partmental reports rather than the synthesis of one general over-all report.

CU a 00 IO =

~1

The distribution of annual reports presents a problem in itself. The typical
picture is one in which several thousand are printed and copies sent to the mem-
bers of the board of health, city councilmen or county supervisors, prominent
citizens, representatives ol voluntary health and social agencies, and fellow public
health workers elsewhere in the country. In many instances, a sizable proportion
of the edition rests in a storeroom awaiting some future house cleaning. The point
of significance is that rarely is a copy seen by the average citizen. This gives rise to
the question whether or not the annual report should be regarded at all as an
education tool or a public relations technique. There appears to be a growing
opinion in public health circles that the essential purposes and objectives of an
annual report should be redefined. This opinion is given substance by the trend
toward fulfilling legal requirements by submitting typewritten or mimeographed
descriptive and statistical reports to city or county officials, conserving other efforts
and funds for attractive picture-magazine types of publications designed spe-
cifically for wide public appeal and distribution.
332 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

 

Community Groups. Most citizens of civilized society live two lives—one as
individuals, the other as members of groups. Aristotle had this in mind when he
observed that the man who can live without society is either a beast or a god.
Furthermore, even among primitive people, a single group seldom if ever satisfies.
Thus there may be found the family group, the clan or tribal group, the secret
male societies, the religious groups, to mention but a few. This is the basis for
the statement that there is no such thing as one public but that every community
consists of many publics, each with its own characteristics. These community
groups or publics manifest themselves in most instances in some form of organiza-
tion. Advantage may be and should be taken by public health officials of the ex-
istence ol these organizations, since they serve the triple functions of channels,
audiences, and reviewing boards. It therefore is most important for those in
responsible public health positions to establish and maintain close and friendly
relationships with those who are in command of these valuable channels. Such
relationship is dependent upon three things: mutual interest, mutual understand-
ing, and mutual respect.

It should be realized that public health agencies do not operate in a vacuum.
Problems of public health are interrelated with many other community problems.
In other words, many other individuals in the community have public health
as a subsidiary professional or occupational interest. The personnel of official pub-
lic health agencies, therefore, should be constantly on the lookout for other com-
munity programs, agencies, organizations, or groups to which the public health in-
terest can be attached. There should be a deliberate effort to make the public
health problems their problems.

While no single approach is universally applicable, there are a few planned
or formal steps that may be taken to achieve greater success. It is suggested that
there be compiled a list of all groups or organizations known to exist in the
community. This list, in many cases, will be lengthy and may include some
listings which will never be of value. Nevertheless, it is well to have the informa-
tion ready at hand in case it is needed. A few of the many categories of groups
and organizations under which listings should be made are political, religious,
racial, nationality, educational, professional, occupational, social, financial, and
fraternal.

There are certain characteristics of organized community groups that must
be kept in mind. It should be remembered that each is usually built around
some special interests. Therefore, if the list that is suggested takes the form of a
private file, notations may well be made of any pertinent items of information
relating to leadership, influence, age and social representation, chief and subsidi-
ary interests, prejudices, and the like. This specialization referred to influences
the fraction of the population that is attracted to membership in each organiza-
tion. Yet, membership not infrequently overlaps several groups. Thus, the same
individuals may be found in the Eagles fraternal society who are also members
of various labor unions. The Parent-Teachers Association may often have many
members in common with the League of Women Voters and the Association of
University Women. Because of this, if a group cannot be reached through one
organization, they may often be approached through one or two others. Signifi-
cantly, members of city councils, state legislatures, or county boards may fre-
PUBLIC RELATIONS J333

quently be contacted under desirable circumstances through service clubs and
other community organizations.

It should also be realized that the majority of service, social, and business
clubs and organizations represent the more favored in the community. As a result,
they may be excellent for prestige and influencing public opinion but poor for
obtaining direct results. This brings us to the most difficult aspect of the prob-
lem. Despite what was said concerning man’s need for society, it is a curious fact
that a large proportion of the population of any community does not appear to
belong to any organized community group. Several studies have been made of the
subject, one of the most complete having been conducted in Springfield, Massa-
chusetts, in 1944. It was found that in that community almost two thirds of the
population appeared on the surface to belong to no organized group, including
churches and labor groups. It is certain that the proportion is subject to consider-
able variation and it is probable that two thirds is unusually high. Nevertheless,
it is of greatest significance that those in the community who are in greatest
need are usually those not included in an organized group. In other words, the
people who do not come to meetings or participate are the very ones who need
the help.

In planning a program or activity, the public health worker should be syste-
matic in his analysis of the community groups and organizations that may be in-
volved. It is suggested that the following several lists be made:

1. A list of the problems of the community and of the health department

2. A list of each group of the population affected by each problem

3. A list of all individuals, groups, agencies, and organizations that also may
be concerned with or interested in each problem and that therefore may
be considered a potential source of help

4. From the foregoing, a list of methods or channels of attack

A program for the control of venereal diseases may serve as an example. The
first three lists might appear in summary somewhat as follows:

Problems of the Community and the Health Department

Incidence Rehabilitation
Case findings Education
Control of infectious cases Etc.
Treatment

Groups Affected

Young adults Infants
Lower income group Prostitutes
Newlyweds Etc.

Groups, Individuals, Agencies, and Organizations Concerned

Health department Churches

Private physicians Industry

Private laboratories Family and other social service agencies
Hospitals Welfare agencies

Pharmacists Recreation agencies

Police Housing agencies

Schoo’s Etc.
334 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

In view of the foregoing, it is evidently possible to classify community groups
and organizations according to their representation and potential use. The fol-
lowing is one such suggested classification that may be of value in planning and
conducting the public relations and education programs ol health departments.

I. Top Level (for prestige, political, professional, and financial support)
Governmental officials—elected and employed
Medical and other professions
Business and industry
Influential citizens

II. Middle Level (for influencing opinions ol large key citizen groups)
Numerous, e.g., PTA, A A.UW, CIO, AFL, Grange, etc.
III. Lower Level (for neighborhood or individual contacts)
Very numerous, e.g., local churches, unions, [raternal organizations,
veterans organizations, etc.

1V. Schools (too often overlooked as important to public relations program)

Several of the categories are worthy ol special mention. The health officer
has an important public relations job with regard to elected governmental officers
and to his fellow public officials. Above all, he must impress the elected repre-
sentatives ol the people with his practicality. In order to do this he must have
some understanding of the total problem ol civic government and management
with which these representatives are faced. This may be exemplified in a negative
sense by occasional county health officers who have read in a book that a health
department budget should be of a certain magnitude. Lacking an appreciation
of the limited tax resources ol county governments and ol the existence of outside
potential sources ol funds, they may make a request to their county supervisors
for a local budgetary appropriation equivalent to most ol the county income.
From then on, the members ol the county government will look upon the health
officer as [ull of fancy book learning but ignorant ol the facts of lile.

In Chapter 30 the relationship between the medical profession and the
health department with regard to medical care is discussed. It may be well to
point out here that the achievement and maintenance of good relationships with
this particularly important group depends upon observance ol a number of con-
siderations. Private physicians and the professions and institutions related to
them have the same ultimate objective as public health agencies—that of rais-
ing the level of health of the people. Often, attention must be called to this
fact. Few things will contribute as much to obtaining the support of the medi-
cal profession as competent performance on the part of the health officer and
his staff. In the past, health departments have not always enjoyed good standing
with the medical profession because members of their staffs have not been compe-
tently trained. This situation is undergoing rapid change. It is important that
the health officer keep the medical group informed with regard to new programs
which the health department is planning or is going to institute. If a physician
in practice hears for the first time from some other source that the health de-
partment is going to do something, he will very probably react critically. If, on
PUBLIC RELATIONS 335

 

the other hand, he with his fellow practitioners has been taken into the confi
dence of the health officer and his advice and opinions solicited, he will be most
apt to be cooperative.

The health officer, of course, should be a member ol the local medical society
and, if possible, an active member of its public health committee. He should, if
possible, serve as secretary or some other officer of the organization. Adequate
medical representation on boards ol health and advisory committees is naturally
important. Wherever possible and convenient, meetings of the medical society
should be held occasionally in the health department quarters. If the department
sponsors clinics, an attempt should be made to have the medical work performed
by private physicians on a part-time or hourly fee basis. In that way, particularly
if the work is rotated among all the practitioners, they will become more familiar
with the purposes and programs of the health department and will feel a personal
interest in it. Finally, when the health officer and his department receive credit or
praise, as, for example, in the form of an award for service, the praise and credit
should be [reely shared with the medical profession as well as all other groups in
the community that may have played a contributing role.

Belore leaving the subject of public relations, reference should be made to the
relatively recently developed technique of public opinion polls. Frequently it
is desirable to determine the attitude ofl the public toward particular problems
and activities. This is practically a virgin field of public relations activity as far
as public health agencies are concerned and one which should bear many fruits
if properly utilized. It would seem possible for health departments through the
efforts of their staffs to develop modest but effective sampling systems for this
purpose. In addition to aiding in the planning of programs in a manner to which
the public is receptive, the technique would undoubtedly cause many citizens to
feel that the health department was truly concerned with its opinions and
interests. *

There is one final method of positive publicity and public relations which is
readily at hand yet usually overlooked—the employees of the public health agency
itsell. If each employee is kept currently informed about problems, programs,
activities and goals, and is actively encouraged to serve as a purveyor of informa-
tion, a very significant proportion of the public may be reached both directly and
indirectly. Consider, for example, a city of one million persons. Its public health
department may have a total ol 400 employees. It is certainly not unreasonable
to expect that cach one has a circle of relatives and close [riends totaling an av-
erage of about twenty five persons. For the entire group this means about 10,000
persons, or 1 per cent ol the population, within easy potential reach. A rather
good lawn would result from such a seeding! This emphasizes again the inti-
mate interrelationship ol the various aspects of public health administration, in
this case, the relationship between personnel development and public relations.

*For examples of the application of this technique to public health see The Modern Public
Opinion Poll by Guernsey” and Public Opinion Measurement as an Instrument in Public Health
Practice by Calver.
330 ADMINISTRATIVE CONSIDERATIONS IN PUBLIC HEALTH

REFERENCES

1. Harral, Steward: Winning Community Confidence Through Public Relations, Education
61:168, Nov. 1940.

2. Pfiffner, J. McD.: Public Administration, New York, 1946, The Ronald Press Co.

3. Maurer, W. H.: Public Relations and the Press, Talk Presented at an Inservice Training
Course on Public Relations, School of Public Health, University of Michigan, Oct. 8, 1945.

4. Hazelrigg, H.: A Newspaper Man Looks at City Hall, Public Management, 20:67, March 1938.

5. Murray, M. L., and Turner, C. E.: Radio Listening Habits of Mothers Who Attend Well
Baby Clinics, Am. J. Pub. Health 33:952-954, Aug. 1943.

6. Editorial: Seven More Sins, Public Management 20:33, Feb. 1938.

7. Guernsey, Paul D.: The Modern Public Opinion Poll, Am. J. Pub. Health 32:973, Sept. 1942.

8. Calver, H. N., and Otis, T. W., Jr.: Public Opinion Measurement as an Instrument in Public

Health Practice, Am. J. Pub. Health 37:426, April 1947.
part 3 pattern of public health activities
in the United States

Although the chapters of this section are devoted essen-
tially to a consideration of the activities commonly pursued by
public health agencies, an appreciation by the reader of the point
of view from which they are discussed is requested. A deliberate,
and not necessarily easy, attempt has been made to avoid descrip-
tions of details of program content and technical procedures.
These change too rapidly and relate more to practice than to
administration. Each of the several fields discussed has merited
numerous textbooks which provide program details and pro-
cedures adequately for those who are interested. The intention
here has been, therefore, to limit discussion as much as possible
to some of the administrative considerations involved in each
of the various components of the public health program. The
presentation is necessarily incomplete, which in a sense is per-
haps desirable if its serves to provoke discussion or even dis-
agreement.

337
= rrr

i
:

 

 
 

Caiaeite ae B oo

 
 
chapter 1 3

Present organization of official public

health programs

 

Introduction. It is probably an understatement to say that official public
health programs in the United States are organized along rather complex lines.
That this should be found in a nation with a reputation for organizational
ability is frequently puzzling not only to visitors from other countries, but also to
citizens of this country whose activities and occupations bring them only oc-
casionally into personal contact with public health agencies. This complexity ol
organization is attributable chiefly to the form and structure of government estab-
lished in the nation and shows the influence of democratic and more or less de-
centralized development. One ol the clearest over-all pictures yet presented is that
devised by Mountin and Flook to illustrate their concise and valuable Guide to
Health Organization in the United States.)

Generally speaking, official public health activities may be considered on four
levels: local, state, Federal or national, and international. The first is often sub-
divided into municipal programs and those of rural areas. As in the case of the
government as a whole, while each political level has its own public health struc-
ture, no one of them is by any means completely independent of the others.
Quite to the contrary and increasingly there is a merging of local public health
functions and responsibilities into those of the state, and in turn of state func-
tions and responsibilities into those of the Federal government. This interrelation-
ship is implied in Figure 18 which depicts the levels ol governmental health
activity.

Local Health Organization. On the lowest or local level, where in the last an-
alysis most service to the public is actually rendered, there are a number of agen-
cies with varying degrees of official concern for the public health. It is here that di-
rect person-to-person contact is made between the individuals comprising the
public and their locally employed public health personnel. While the most per-
sonal of all health services are rendered by private practitioners of medicine, den-
tistry, and nursing, their place in the picture will not be presented at this point
other than to include them in the diagrams. Similarly, the part played by the

339
340 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

voluntary agencies is simply included diagrammatically here and discussed in
Chapter 31. Local health departments, therefore, are designed to render on-the-
spot, direct service to a local governmental jurisdiction and the people it contains.
The units of local governments may be municipalities, towns, townships, counties,
or combinations of them. Organizations concerned with the health of towns and
cities were established relatively early in our history. In an attempt to serve the
more rural areas, townships or civil districts have been used extensively in the
past. With the development of good roads and rapid transportation, however, this
makeshift has been undergoing a process of abandonment in favor of the estab-
lishment of county-wide health departments. Of additional significance is the re-
cent trend toward the formation of joint city-county health departments.

 
  
 
   
  

 

= EE —
FEDERAL

GOVERNMENT qu
{ ~~.

 

 

 

 

STATE
GOVERNMENT

   
   
 

   
   

LOCAL GOVERNMENT

LE 3 mi 444 an

oo be 4 A LE ]

VOLUNTARY
AGENCIES

  

 

Fig. 18. Levels of health organization. The complete health structure. (From Mountin, J. W.,
and Flook, Evelyn: Guide to Health Organization in the United States, Washington, 1953, U. S.
Government Printing Office, Public Health Service Publ. No. 196.)

The necessity for the establishment of public health organizations on the
basis of these larger units of government or combinations of them has been forced
upon us by a consideration of the number of people and the size of area adequate
to raise enough public tax funds to support at least a minimum staff of qualified
public health workers. In most instances, it is recommended that an area should
contain at least 50,000 people before it considers the establishment of a health
unit of its own. Exceptions are recognized to exist, of course, depending essentially
upon wealth, density, health problems, and geography. As of 1957, there were
1437 full-time local health departments of one sort or another serving 2274 coun-
ties, including about 300 cities, and covering areas with a combined population
of approximately 150145 million people. They serve almost nine tenths of the
population of the United States. Many of these programs are still inadequate as
to quality and quantity.

It is interesting to observe, for the moment, the characteristics of the 775
counties in the United States no part of which have organized health services.
Haldeman? has summarized them as follows:
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 341

 

1. They are located in 27 states, primarily in the western Great Plains and Rocky
Mountain areas.

2. They have small total populations and are sparsely inhabited.

3. The median age of their population is relatively high.

4. Generally, they have lost population in recent years.

5. A high proportion of the population is employed in agriculture and relatively
few in manufacturing.

6. They have a significantly smaller percentage of non-white inhabitants than the
country as a whole.

7. They have a relatively high family income and educational level.

8. They have a higher percentage of occupant-owned dwellings than the rest of
the county. *

Returning to areas which have organized full-time health services, the pat-
tern throughout the nation is by no means uniform. Tremendous variation may
be observed with regard to numbers and qualifications of personnel, types of
programs, and financing. Personnel and finances, hence programs, are especially
thin in areas where local health services are provided by state district health units.

As a consequence of these inadequacies and inequities and because of the
general broadening scope of the field of public health, recent years saw the
development of a forceful movement to achieve complete coverage of the nation
with adequate and practical full-time local health units. Keynoted by the Emer-
son Report Local Health Units for the Nation* and promoted by a series of
national, regional, and state conferences, the movement culminated in attempts
to obtain legislation to provide Federal subsidization of local health units through
state health departments. Emerson and his committee suggested as a goal the
establishment of a total of 1197 units to include 318 single-county units, 821
multicounty units, 36 county-district units, and 22 city units including the District
of Columbia and one unit of three cities. The populations of these units ranged
from 10,200 to 7,455,000, with an average of 110,000; 86 per cent had populations
of 45,000 or more; 171 of the county or district units contained a total of 198
cities of 50,000 or more people. There were 154 units with one city each, and
44 cities in the remaining 17 units.

Despite these extensive efforts, only few additional full-time local health
units have been created. In 1947 there were 1,284 units covering 1,874 counties,
and by 1957 they had increased to only 1,437 units covering 2,274 counties. This,
in conjunction with a recognition of the nature of the uncovered areas such as
presented above, has led to a re-examination of the bases upon which full-time
local health units should be established—or might conceivably not be practical
or needed. In reflecting upon the saturation point that seems to have been
reached in the establishment of such units, Haldeman states:

This may stem from the many changes in health problems which have occurred
over the years. It may be that new and additional resources such as voluntary health
agencies, industrial health programs, insurance schemes and other prepayment plans are
now providing, more acceptably, some services which in the past were supplied by the
health department. Or perhaps the greater interest of private physicians in preventive
medicine coupled with better methods of communication and transportation and in-
creased public enlightment regarding the individual's own responsibility for his personal
health have reduced the need for organized health departments.*

© *Haldeman, J. C.: Unpublished data presented at Annual Meeting of National Advisory
Committee on Local Health Departments, March 18, 1958.
342 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES ~

Another not necessarily conflicting viewpoint might hold that the reason
for the plateau in organizational development is temporary and a reflection of
the transition between a period of public attitude and professional programming
based essentially upon communicability and one based essentially upon the com-
plexities ol chronicity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOLUNTARY OFFICIAL AGENCIES PRIVATE
AGENCIES co T Tom PRACTITIONERS
HOUSING AGRICULTURAL
1 1 AUTHORITY AGENT
civic PARENT
clues TEACHER SPECIAL ueoteat
ASSN POLICE BOARDS SOCIETY
DEPARTMENT OR
COMMISSIONS
TUBER- DEPT OF MEDICAL
RED cuLosIS PUBLIC WORKS PUBLIC SERVICE
CROSS ASSN OR _ HOSPITALS PLANS
encine€ring | I 1
DENTAL
SOCIETY
SPECIAL i . 1
CLINICAL A wo
SERVICES ASSN DEPT OF DEPT OF HEALTH I
EDUCATION WELFARE DEPARTMENT
MEDICAL
COMMUNITY CARE & 1
HOSPITALS ene MD 0DS
PLANS 1
| (854s
ee T

 

 

 

Fig. 19. Levels of health organization. The ground floor of the health structure—local official
and voluntary agencies and private practitioners. (From Mountin, J. W., and Flook, Evelyn:
Guide to Health Organization in the United States, Washington, 1953, U. S. Government Print-
ing Office, Public Health Service Publ. No. 196.)

The usual pattern of organizational interrelationships involved in the provi-
sion of health services on the local level is shown in Figure 19. Necessarily, a
health department on the local or on any other level cannot expect or be ex-
pected to include within its organization personnel and facilities for the solution
of every phase of the public health problems of the community. Many other
persons and agencies play important roles. In rural areas, county farm agents and
home demonstration agents are active in nutrition and health education. The
department ol public works has a most important responsibility [or sanitary waste
disposal. Departments of education, welfare, police, and others all contribute in
some degree to the community health program. Nevertheless, the local health
department should be the focal point, the catalyst, and the leader in activities in
this field.

The basic program ol satisfactory local health departments should include
at least the following: (1) vital statistics, (2) environmental sanitation, (8) com-
municable disease control, (1) laboratory services, (5) maternal and child health,
(6) chronic disease control and promotion of adult health, and (7) health edu-
cation. According to the American Public Health Association, as presented in an
official policy statement,” to achieve an effective program the local health depart-
ment should provide the following methods.
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 343

I. Recording and analysis of health data

II.

111.

A.

B.

F

Recording and analysis ol reports of births, deaths, marriages, di-
vorces, and notifiable diseases

Maintenance ol registers ol individuals known to have certain spe-
cific long-term diseases and impairments

Conduct of special surveys to determine the prevalence and resultant
disability from various diseases

Collection and interpretation ol morbidity data [rom such sources
as clinics, hospitals, organized nursing services, prepayment plans,
industry, and workmen's compensation and disability insurance
programs

Maintenance of continuing records on the number and qualifica-
tions of all types ol health personnel, the quantitative and qualita-
tive resources ofl available facilities, and the types and extent of
health services provided through various voluntary and public
programs

Periodic evaluation of community health needs and services

Health education and information

A.

Stimulation of the public to recognize health problems that exist,
to study the resources available for meeting the problems, and to
develop and put into action programs designed to solve them
Cooperation with and assistance ol official and voluntary organiza-
tions such as departments ol education and civic, youth, and other
community groups in the development of their health programs
Provision ol individual instruction by public health nurses and
other personnel, as in the case of families in which communicable
disease has occurred, ol mothers attending well-baby conferences, or
ol diabetic and other patients who are taught to follow the regimen
prescribed by the family physician

Organization ol lectures, classes, and courses, such as mothers’ and
fathers’ classes, courses for food handlers, classes for diabetics, and
lectures to community groups

Use ol mass educational and informational media such as news-
papers, magazines, pamphlets, movies, radio, and television
Development ol a well-rounded program ol professional education,
designed to assist the local health professions to maintain and im-
prove the quality of service

Supervision and regulation

A.
B.

=o 0

Protection of food, water, and milk supplies

Control of nuisances, sanitary disposal of wastes and control of
water and air pollution

Prevention ol occupational diseases and accidents

Control of human and animal sources ol infection

Regulation of housing
344 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

III. Supervision and regulation—Cont’d

F.

Inspection of hospitals, nursing homes, and other health facilities
by means of

1. Public education and individual instruction

2. Issuance of regulations

3. Laboratory control

4. Inspection and licensure

5. Revocation of permits and, as a last resort, court action

IV. Provision of environmental health services (as necessary)

VI.

VII.

A.
B.

C.

Construction of pit privies

Drainage, and larvicidal treatment of mosquito-breeding areas,
residual spraying of homes for insect control

Rat proofing of buildings, and other insect and rodent control
measures

Administration of personal health services

A.

B.

Immunization against infectious diseases and other preventive meas-
ures such as the application of fluoride to children’s teeth

Advisory health maintenance service, as in child health conferences,
prenatal clinics, parents’ classes, and public health nursing visits
Case finding surveys of the general population, such as chest x-ray
surveys, serological tests for syphilis, cancer detection programs, and
school health examination. Adult health inventories and “multi-
phasic” surveys for the detection of various groups ol diseases may
also be included

. Provision of diagnostic aids to the physicians, such as laboratory

services and crippled children’s, cancer, cardiac, and other diagnostic
and consultation clinics

Provision of diagnostic and treatment services for specific diseases
such as syphilis, tuberculosis, dental defects in children and ex-
pectant mothers, and orthopedic, cardiac, and other crippling im-
pairments in children

Operation of health facilities

A.
B.

Operation of health centers and clinics
Operation of general or special hospitals (as necessary)

Coordination of activities and resources

A.
B.

Provision of effective leadership in meeting community health needs
Encouragement of coordination of various official and voluntary
agencies to avoid duplication and overlapping and to assure efhi-
cient and economical administration

. Participation on interdepartmental or regional boards dealing with

public water supplies, sewage and refuse disposal, control of at-
mospheric pollution, housing, city planning, hospital planning,
zoning regulation, development of recreational areas and other
public programs which have significant implications for community
health.
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS JS

In order to carry out its mandate, the official public health agency in essen-
tially rural or small urban situations requires only a relatively simple type ol
organizational structure. Legal responsibility [or the public's health is commonly
placed in a local board of health, the members of which are appointed by the
locally elected officials, i.e., in cities by mayors and in counties by the boards of
supervisors or their equivalent. The board of health usually appoints and em-
ploys a county health officer, frequently subject to approval by the state health
department. Increasingly, state health departments have been establishing stand-
ards and qualifications that must be met by those appointed to local public
health positions. This particular type of state supervision has met with relatively
little local resistance since in most instances local units of government have found
it necessary to turn to the state health department for assistance in finding capable
candidates for the position. While assistant medical personnel are occasionally
found in county health departments, the nationwide shortage of personnel and
the general inadequacy of local funds have served to preclude the employment
of more than one physician in a great many county health departments.

The employment of all other personnel is customarily a prerogative of the
local health officer but is subject to Civil Service regulations if they exist. This,
of course, is as it should be. His staff usually consists of one or several workers
in environmental sanitation, public health nursing, office management, and occa-
sionally a health educator and a laboratory worker. Infrequently encountered as
yet, except in larger units, are nutritionists, public health dentists, and representa-
tives of other professions. The workers in environmental sanitation may consist
of any combination of engineers, professionally trained sanitarians, or on-the-
job trained sanitary inspectors. The preferred situation for most county health
departments would probably be a sanitary engineer supervising an adequate
number of professionally trained sanitarians. Ordinarily, approximately one hall
of the funds and one half of the positions of the local health department are
devoted to public health nursing. This means that of the various professions nurs-
ing will be most represented. Even the smallest local health unit will or should
have several nurses on its staff. This being the case, while an actual division of
public health nursing may not exist structurally, one ol the nurses, selected on
the basis of training, experience, and personality, should be appointed as super-
vising nurse. Where several office workers are employed, one should be singled
out to act as office manager and to supervise the work of the others. In this way,
responsibilities are much more apt to be clear cut and understood by those con-
cerned. All members of the staff, as indicated in Figure 4 on page 239, should be
ultimately responsible to the county health officer who in turn is responsible to
the board.

Current standards suggest the employment of the following types and num-
bers of professional personnel in order to provide the minimum desirable services
to a community:

Medical personnel—1 per 50,000 population (the best qualified to serve as
health officer, the others preferably to direct the school health program,
the maternal and child health program, and the epidemiology program)
346 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

Sanitary personnel—1 per 15,000 population (one preferably a public health
engineer)

Stall nursing personnel—1 per 5,000 population (one per 2,500 population if
bedside nursing is included)

Supervisory nursing personnel—1 per 6 to 8 staff nurses

Office personnel—1 per 15,000 population

Other specialized personnel—as problems demand and funds make possible

When funds and candidates are not available to make possible the employ-
ment of other types ol personnel that may be needed or when full-time employees
are not practical, as is sometimes the case in staffing clinics, the gap may be filled
by the part-time employment of private practitioners or by the use ol the services
of district or state agencies. Wherever possible, however, the employment of full-
time personnel is recommended.

In the larger local units of government, particularly municipalities or com-
binations of them with their surrounding county areas, more extensive personnel
and organization obviously are required. In general, the distribution ol types of
personnel per unit of population is similar to that followed in the smaller areas
with various numbers of different types of specialists added to meet the problems
and demands inherent in the particular situation. The increased total number
ol employees naturally leads to the formation ol a more [ormalized organizational
structure with the bringing together of similar and related [unctions into divisions
and bureaus. The general pattern still holds with the same basic principles of
organization [ollowed. Although there is no standard organizational structure,
certain [unctional divisions are nevertheless almost universally encountered. Thus,
there usually exist divisions of vital statistics and records; sanitation, sanitary
engineering, or environmental health; maternal and child health; public health
nursing, either as an entity or integrated into the activities of several of the other
divisions; laboratory service; cpidemiological services or communicable discase
control; and health education. Each functional category, now large enough to
comprise a unit, should have its director and possibly subdirectors. The direct
professional service activities of those in the top administrative positions become
greatly minimized giving way to functions of a managerial and supervisory na-
ture. An example of a more extensive agency is presented in Figure 11 on page
251.

State Health Organization. Still more varied is the pattern of public health
organization on the state level. In each instance more than one agency has respon-
sibility for activities in this field. A study’ made by the Public Health Service in
1950 indicated a total of sixty different types ol state agencies contributing in
some way to state health programs. The diversity of these agencies may be seen
from the [ollowing consolidated tabulation.

Department of health

Department of welfare, social security, emergency relief, general assistance, ctc.
Department of agriculture

Department of labor, labor and industry, labor and immigration, etc.

Department of education, public instruction, etc.

Special boards, commissions, or independent offices established specifically for the activity
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 347

indicated (tuberculosis board or commission, cancer commission, workmen’s compen-
sation commission or bureau, industrial accident board, dairy and food commission,
hotel commission, livestock sanitary board, water resources board, commission for
the blind, crippled children’s commission, mental disease commission or depart-
ment, state toxicologist, state veterinarian, etc.)

Board of control of affairs, department of state institutions, etc.

Independent state hospital, independent state laboratory

Department of conservation

State university or college

Department of mines and minerals

Department of engineering, department of public utilities

State experiment station

Independent licensing and examining boards

Department of motor vehicles, department of public safety

Department of civil service and registration, department of registration and education

Other departments or offices of state government

The variety of State agencies participating in health activities is not measured alone
by the aggregate count. Dispersion of health responsibility is also extreme and varied
when viewed within individual States. The number of agencies performing health activi-
tives in a single State ranges from 10 to 32 . . . The variation among States in assign-
ment of responsibility for health functions is duc in great measure to two main factors:
Complexity of State governmental organization and extent of health services provided
by the State. The former is probably the more important in determining the total
number of agencies. . . .

Numerous agencies are often responsible for a single activity within a State. As many
as 13 separate agencies are engaged in accident prevention work in one State, while a
total of 12 participate in some form of health education in another. Other programs
in which 7 or more individual agencies participate in at least one of the States are
mental hygiene, crippled children’s services, prevention and treatment of blindness,
licensure for health reasons, medical care, vocational rehabilitation (restorative meas-
ures) maternal and child health, hygiene of housing, and school health services. With
this multiplicity of agencies concerned with a single health program within a State, it
is casy to imagine some of the difficulties encountered in developing uniform standards
of performance and achieving common goals. *

However, in every state, without exception, some one agency is invested with
primary responsibility for the public health program. Usually this is a state de-
partment of public health, although in one instance, the state ol Maine, public
health is a subdivision of a department ol welfare. As on the local level, the
state health department should provide the leadership on its governmental level
in public health matters, all other agencies acting in this field as contributory or
auxiliary agencies. This relationship ol a state department of public health with
other agencies on its level has been illustrated by Mountin and Flook as in Figure
20).

In all except a few states, the direct personel service functions of state health
departments are decidedly few and are limited largely to the provision of travel-
ing specialized personnel and mobile equipment to local areas unable themselves
to afford them. Many state health departments, [or example, stall, equip, and
maintain mobile chest x-ray units, dental clinics, and facilities for the examina-

*Distribution of Health Services in the Structure of State Government, 1950, Washington
1952, Public Health Service Publ. No. 184, Part 1, pp. 14-15.
38

 

 

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOLUNTARY OFFICIAL AGENCIES PROFESSIONAL
AGENCIES SOCIETIES
DEPT OF STATE aA a

RYATION NI
CONSERWTION | UNIVERSITY JEOARD OR
OTHER 1 LICENSED
VOLUNTARY L I— (re PROFESSIONAL
AGENCIES DEPT OF DEPT OF ENGINEERNGY
ENGINEERING INSTITUTIONS GROUPS
STATE
CANCER INDEPENDENT
SOCIETY LICENSING BOARDS STATE
DEPT. OF nes TORE NuRSIS
STATE . AGRICULTU p
SOCIAL LABOR ASSNS
HYGIENE F
STATE
MENTAL Ju— STATE
HYGIENE DENTAL
ani DEPT. DEPT STATE DEPARTMENT SocIETY
OF oF oF
T) HOSHITAL
UNIVERSITIES WELFARE | EDUCATION HEALTH
STATE
STATE MEDICAL
TUBERCULOS! SOCIETY
ASS'N

 

 

 

 

 

 

 

Fig. 20. Levels of health organization. The second floor of the health structure—state official
and voluntary agencies and professional societies. (From Mountin, J. W., and Flook, Evelyn:
Guide to Health Organization in the United States, Washington, 1953, U. S. Government Print-
ing Office, Public Health Service Publ. No. 196.)

tion and treatment of the venereal diseases. In general, the functions of a state
health departments are the following?®7:

I.

12.

13.
14.

To represent the public health interests and goals of the state to the elected govern-
ing body of the state

To promulgate and enforce public health rules and regulations applicable throughout
the state

To determine state public health policy and to provide a state-wide coordinated public
health program with clear objectives for the guidance of local health departments

To promote the establishment of full-time local health units

To develop an appropriate plan for the coordination of local health services with re-
lated hospital and medical programs which may be developed on a regional basis

To provide financial assistance to supplement the resources of local health departments
To make consultation and other special services available

To assist localities to set up demonstrations on a temporary basis

To establish minimum and stimulate optimum standards of performance

To develop a recruitment and training program for local health department personnel
To delegate certain legal responsibilities of the state health agency, in so far as feasible
and practical, to well-organized and adequately staffed local health departments

T'o carry on all relationships with local citizens and groups through the medium of or
in cooperation with the local health departments

To carry on a state-wide program of health education

To evaluate continually or periodically existing state and local programs

From this list it is possible to summarize state health department functions
into the few categories ol state-wide planning, state-federal relations, intrastate
agency relations, and certain state-wide regulatory functions. But above all else,
the chief raison d’étre for a state health department is the extent to which it
helps local health departments to do a satisfactory job. In the performance of
these functions, state health agencies engage to varying degrees in many specific
activities, most of which are included in the following list:
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 349

 

Vital statistics

Acute communicable disease control

Tuberculosis control (prevention and treatment—including hospitalization)
Venereal disease control

Maternity hygiene

Infant and preschool hygiene

School health services

Industrial hygiene

Workmen's compensation

Sanitation of water supplies and sewage disposal facilities

Housing control

Plumbing control

Smoke, fumes, and odors control

Rodent control

Garbage collection and disposal

Shellfish sanitation

Milk sanitation

Malaria control

Pest mosquito control

Supervision of hotels, restaurants, tourist camps, and other facilities for the traveling public
Food and drug control

Mental hygiene (prevention and treatment—including hospitalization)
Care of crippled children

Cancer control

Prevention and care of blindness

Vocational rehabilitation

Penumonia control

Hookworm control

Health services for migratory labor

General medical care of the needy

Dental services

Laboratory services

Health education

Research activities

Licensure of professions and agencies significant to the public health

Of these activities, however,

. only about one-fifth of the 33 public health and preventive services listed are
invariably lodged in State health departments. Slightly more than one-half of such
services are found in at least three-fourths of the health departments. When activities
are placed elsewhere, they are most apt to be distributed in this manner: School health
services are delegated to the department of education; mental health services to the de-
partment of welfare, department of institutions or board of control, and a special board
or commission; heart disease control to the State university or college hospital; water
pollution and plumbing control to a special board or commission; and milk, general food,
and shellfish sanitation to the department of agriculture. Occasionally, control of hotels
and camps is under a department of agriculture, labor, or conservation. . . .

While arthritis, rheumatism, and hygiene of aging services are comparatively new,
over one-third of the States have such a program, performed mainly by hospitals of
State universities or colleges, and in a few instances by the health department, a special
board or commission, or department of institutions or board control. State responsibility
for the human blood and diabetes control programs has not been accepted on a Nation-
wide basis, but State health departments provide such services to nearly one-third of the
states . . . . Home, farm, and recreational accident prevention is performed in slightly
more than half the States—principally by the department of health.
350 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 26. Relative Frequency With Which Designated Types of State Agencies
Have Major Responsibility for Specified Health Activities*

 

 

 

State Agency Chiefly Responsible
“© ov =
x ~ TIE 8
© el 2 S| Sl J
s | | | |v |r |ss53| 3 S155 | &
Activity ¥ = Xp = = $8 zed 5 E5e Sew 2
3 S 3 3 I= 2 | §= 2 So or
PO0RIES| ROBE SE |RER| Ep oumilaell i
ss | 55] S| 5. | SF | BE ude) RE REE Rds) Ss
S35] 25 2 | 23] $8 188s sS | g55| 838] “8
SE | 8S | 82 a5 | 85 | 48 258) 2% |E3&8|5:58 58
~- TORN H | nO [QS B13 [SQ [S80 | =e
|
Public health and preventive services: |
General communicable disease con- |
trol 48
Tuberculosis control 47 | 1
Venereal disease control 48 |
Cancer control 46 | 2
Heart disease control 40 6
Diabetes control 14 11 2
Arthritis, rheumatism and geriatrics 3 1 1 13 23
Mental health services 31 4 v 3 1 1 30
Dental services 48 1
Maternal and child health services | 48
School health services 34 16
Human blood program 13 1
Prevention and treatment of blind- 34
ness 10 22 2 11 2 1
Health services for migratory labor 16 1
Water pollution control 38 10 31
Control of water supplies, bathing
places, garbage, and sewage dis-
posal facilities 48
Mosquito and other insect control 41 1 5
Rodent control 44
Control of hotels and camps 40 3 1 2 2 4
Plumbing control 34 5 0
Hygiene of housing 18 1 1 3 25
Milk sanitation 26 19 1 1 1
General food sanitation 26 19 1 1 1
Shellfish sanitation 28 9 2 9
Drug control 21 9 1 13 1 1
Occupational health services 45 2 2
Accident prevention: 1
Industrial and mine 1 30 7 7 3
Traffic 46
Home, farm, and recreational 16 1 3 1 5 1 ”
Nutrition services 48 1
Health education 48
Laboratory services 47 1
Vital statistics 47 1
Medical and custodial care:
General illness 2 29 5 2 1 2 7
Tuberculosis hospitalization 23 5 5 10 1 5
Mental hospitalization 1 10 15 15 7
Cancer hospitalization 13 3 1 1 14 16
Crippled children’s services 26 9 3 5 1 4
Expansion and improvement of hos-
pitals 40 1 4 2 1
Licensure:
Physicians 7 3 35 3
Osteopaths 7 3 31 1
Chiropractors 5 3 32 4 4
Nurses 2 4 33 1
Dentists 4 3 37 1
Midwives 15 1 5 1 2
Hospitals— other facilities: 6
General and allied special hos-
pitals 32 1 1 3 1 10
Tuberculosis hospitals 32 1 1 1 13
Maternity hospitals 34 4 1 1 :
Mental hospitals 24 3 9 2 -
Nursing homes 30 8 1 9

 

 

 

 

 

 

 

 

 

 

 

 

#This tabulation is based on information reported to the Public Health Service by authoriti
. ! A . nation rit
in 1950 in connection with the study Distribution of Health Services in the Structure of Stato Wt horities of state government
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 351

Hygiene of housing is an official State function in less than half. When it is, au-
thority is exercised primarily by the health department. Less than one-third of the
States have health services for migratory labor; in all but one, these services are a func-
tion of the health department. All States now have services for the prevention and treat-
ment of blindness. This activity is a function of the department of welfare in about
half the States, of the department of health in 10, and of special boards and commissions
in 11 States.*

Further details of the distribution of state public health services by agency are
obtainable [rom Table 26.

In attempting to carry out the many activities listed above, each of the filty
states has developed its own unique pattern. Some of them have constructed
strongly centralized organizations in contrast with others, the activities of which
have been decentralized in so lar as possible. As discussed and illustrated in
Chapter 9, the subdivisions or functional units within the structure of state
health departments vary extensively both in number and in manner of emphasis
and arrangement. No two state patterns are identical, but similarities are to be
noted. At the time of Mountin and Flook’s earlier study, major organizational
units (divisions, bureaus, or services) were usually found to have been set up
for certain few functions. Thus, of the 48 state health departments, which existed
at that time, all had major units for general administration; maternal and child
health, 47 states; laboratory services, 46 states; general sanitation and vital sta-
tistics, 45 states. About two thirds of the state health departments had major
units for communicable disease control, local health administration, and public
health nursing. Major units for tuberculosis control, venereal disease control,
dental services, health education, food and drug control, and industrial health
existed in about one hall ol the state departments ol health. In general, the
tendency in the past has been too great a [ractionation ol functions with the de-
velopment of far too many major divisions or bureaus.

In summary, the trend ol recommendations has been [or state health depart-
ments to restrict direct services as much as possible, to limit the number of major
organizational units to about a hall dozen in order to make possible an effective
executive span ol control, and to decentralize activities particularly in larger
states.

Federal Health Organization

General. The most complex organizational picture of all in public health
in the United States is found on the Federal level. The history and development
of some of the Federal public health agencies have been discussed in Chap-
ter 2. The purpose at this point is merely to describe briefly the more important of
them and to bring out their interrelationships. Until recently, in place of a Fed-
eral department ol health there existed an illogical maze of miscellaneous depart-
ments, bureaus, offices, agencies, commissions, services, and authorities, each
responsible for one or several aspects of the Federal government's concern with
health. This situation came about through a pyramiding of special legislation,
often originating [rom executive requests, bureaucratic expansion, or the pressure

*Mountin, J. W., and Flook, Evelyn: Guide to Health Organization in the United States,
Washington, 1953, U.S. Government Printing Office, Public Health Service Publ. No. 196, p. 53.
352 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

of special interest groups. Once an agency is formed or designated to deal with a
particular interest, that interest and the independence of the agency involved are
jealousy guarded. An extreme result of such a procedure is well illustrated by the
fact that the responsibility for the health of the inhabitants of the Pribilof
Islands is vested in the Fish and Wildlife Service of the Department of Interior.
Recent years have seen several attempts to consolidate this perplexing and mush-
rooming group ol Federal agencies, the most recent having been President Roose-
velt’s Committee on Administrative Reorganization and the monumental efforts
ol the Hoover Commission. At best, consolidation of governmental affairs is a
slow process, but progress was gradually made, resulting first in the formation
ol the Federal Security Agency in 1939 and eventually in the establishment on
April 11, 1953 of a Department of Health, Education, and Welfare. *

The many Federal agencies that have been established up to now which deal
with one or more aspects of public health may be separated into four primary
categories. The first is more or less concerned with broad general interests. The
only example is the United States Public Health Service. A second group of
agencies is concerned with the welfare ol special groups in the population. In-
cluded here are the Children’s Bureau, the Women’s Bureau, the Farm Security
Administration, the Agricultural Extension Service, the Office ol Indian Affairs,
the Medical Divisions of the Army and the Navy, and the Veterans Administra-
tion. A third category of agencies includes those concerned with special problems
or programs, such as the Office of Education, the Office of Vocational Rehabili-
tation, the Food and Drug Administration, the Federal Trade Commission, the
Division of Labor Standards and the Bureau of Labor Statistics, the bureaus
within the Department of Agriculture dealing with animal industry, entomology,
and plant quarantine, dairy industry, livestock production and marketing, human
nutrition, and home economics, the Bureau of Mines, the Maritime Commission,
and the Tennessee Valley Authority. The Social Security Administration and the
Bureau of Employees Compensation may also be included in this category in the
sense that they provide medical care to special groups. A fourth category that may
be considered is made up of certain quasi-independent institutions such as St.
Elizabeth’s Hospital and the Freedmen’s Hospital. A fifth category might be
considered to handle the international health interests ol the government of the
United States. The functions of all of these agencies vary from direct personal
service to regulation, consultation, demonstration, research, education and finan-
cial grants-in-aid. Table 27 presents a summary ol the Federal agencies engaged
in health work with their health functions and methods of administration.

As stated above, the most important of the Federal agencies which deal with
public health matters have recently been brought together to form the Depart-
ment of Health, Education, and Welfare, the organization of which is shown in
Figure 21. This agency was created with the purpose of grouping under one
administration those agencies ol the government, the major purposes of which are

¥For examples of legislative attempts, see H. 184 (Jan. 3, 1949); H. 782 (Jan. 5, 1949); H.
1402 (Jan. 13, 1949); H. 2361 (Feb. 7, 1949); and S. 1581 (April 14, 1949) and Reorganization
Plan 1 of 1953?
DEPARTNENT OF HEALTH, EDUCATION, AND WELFARE

 

Under

Ass

 

 

SECRETARY

SPECIAL ASSISTANT FOR HEALTH AND MEDICAL AFFAIRS
nts to the Secretary

Secretary

 

 

 

SECRETARIAT TO
DEPARTMENTAL COUNCIL

 

OFF ICE OF
INTERNAL SECURITY

 

 

ASSISTANT SECRETARY

OFFICE OF PUBLICA-
TIONS AND REPORTS

 

OFFICE OF
LEGISLATIVE LIAISON

 

DECEMBER 11.1953

 

 

or
PROGRAM ANALYSIS

 

 

 

 

 

    

 

 

COMMITTEE ON AGING

OFFICE OF THE
GENERAL COUNSEL

 

 

     

PROGRAM ANALYSIS
AND GERIATHICS

Mooi 1
ASSISTANT FOR

ADMIN STRAT 1 On

DIVISION OF

PUBLIC HEALTH

DIVISION OF
FOOD & DRUGS

 

 

 

OFFICE OF
ADMINISTRATION

 

ASSISTANT SECRETARY
for
FEDERAL-STATE RELATIONS

 

 

 

OFFICE OF DEFENSE
COORD INATOR

SPECIAL ASSISTANT
ON FEDERAL -STATE
PROBLEMS

 

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S1oN OF DIV SERVICE
SURPLUS it GRANT-IN-AID AM.PR HOUSE
PROPERTY AUDITS FOR BLIND

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BUDGET & FIN ADM PLANNING

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OFFICE OF FIELD

 

LIATSON WITH
| SPECIAL insTITUT IONS

 

 

 

STATE MERIT
SYSTEMS

 

HOWARD
UNIVERSITY

 

 

 

 

 

SOCIAL SECURITY

 

 

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OFFICE OF VOCATIONAL

 

 

 

SAINT ELIZABETHS

 

 

 

 

 

 

 

 

 

  
  

 
  

 

 

 

 

 

 

 

 

 

   
      
   

   

 

  

 

 

  
  

 

 

 

 

 

PUBLIC WEALTH SERVICE OFFICE OF EDUCATION
ADMINISTRATION ADMINISTRATION REHABILITATION HOSPITAL
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Div STATE & DIV HIGHER DIV BUSINESS DIVISION OF DIVISION OF DIV MEDICAL DIV. MEDICAL DIVISION OF

LOC SOM SYS EDUCATION OPERATIONS REGULA MGT ADMINISTRA SERVICES SERVICES | ADMINISTRA
OFF ICE OF THE och o BUREAU OF OLD-AGE

Divovi IV INTERNAT D1V. PROGRAM Div STATE Div PROGRAM DIV RESEARCH
sien coon a HH si sit [some Mews, | [ame Hove

DIV SCH.ASST DIVISION OF DIVISION OF SERVICES FOR DIV ST PLANS
BUREAU OF FED- AFF AREAS BUREAU OF PUBLIC MED IC INE F000 THE BLIND AND GRANTS
STATE SERVICES ASSISTANCE
DIVISION OF DIVISION OF D.C REWAB
MICROBIOLOGY ANTIBIOTICS SERVICE
NATIONAL INST CHILDREN'S
151
Totes or nea aunt evista or Lhjonvision or
DIV PHARMA
BUREAU OF CHEMISTRY
MEDICAL SERVICES
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OPERATIONS
FREEOMEN
HOSP I TAL
FIELD ORGANI ZATIONS |
J Secretfffy

Fig. 21. Organization of the Department of Health, Education, and Welfare.

COLUME. INST
FOR DEAF

SWVYYHdDO0Hd AvIDI440 =O NOILVZINVOHO LN3IS3dd

 

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Table 27. Federal Agencies Engaged in Health Work*

Participating Agency

Department of Health, Education

and Welfare:
Public Health Service

Social Security Administration:

Children’s Bureauf

 

Health Activities

Maintenance of research laboratories for study of cause, pre-
vention, and treatment of disease

Assistance to states in establishing and maintaining proper
sanitation facilities, general public health services— includ-
ing dental health, occupational health, training of per-
sonnel, and extension and strengthening of full-time local
health organizations—and special programs for the control
of the venereal diseases, tuberculosis, mental health dis-
orders, cancer, heart disease, water pollution, and for devel-
opment of hospitalization plans and construction of hos-
pital facilities

Provision of hospitalization, general medical and dental care,
and preventive health services for American merchant sea-
men, members of the United States Coast Guard, Coast
and Geodetic Survey, and other legal beneficiaries of the
Service

Operation of special hospitals (leprosarium and narcotic hos-
pitals)

Provision of treatment for general and allied special illnesses
of Negroes in the District of Columbia and surrounding
areas

Establishment and operation of Federal employee health
service programs to promote and maintain the physical
and mental fitness of government employees

Conduct of studies of mental diseases and drug addiction, and
investigation of needs for narcotic drugs for medical and
scientific purposes

Assistance to institutions and to competent research workers
for research in medical and related sciences

Assistance to medical institutions for treatment of cancer

Cooperation with official and nonofficial national organizations
and institutions on health matters

Estimation of requirements of controlled materials for civilian
health, and arrangement for allocation of materials for this
purpose during the emergency

Collection and publication of vital and public health statistics,
including epidemiological data

Control of the spread of communicable diseases in interstate
traffic

Assistance to states, municipalities or interstate agencies for
defraying expenses in connection with plans for construc-
tion of waste treatment works

Assistance to states, municipalities, or interstate agencies for
construction of necessary waste treatment works§

Supervision of milk, food, and water used on interstate carriers

Training of public health workers

 

Production and dissemination of health information
education materials

Protection of this country from the importation of communi-
cable diseases from abroad

Supervisory control and licensure of biological products used
in the prevention and treatment of diseases

Control of diseases in the event of epidemics and disasters

and

Administration of medical care and public health among
Indian wards of the government and natives of Ala

Assistance to other Federal agencies in the discharge of (heir
health functions

Collaboration with foreign governments and with
national organizations on world health matters

 

inter-

Assistance to states in extending and improving maternal
and child health and crippled children’s services

Cooperation with official and nonofficial national organiza-
tions and institutions on maternal and child health and
crippled children’s matters

Collaboration with foreign governments and with interna-
tional organizations on maternal and child health and
crippled children’s programs

Collection and dissemination of information in the field of
child life and maternal health, and results of research
studies under way in universities, schools, child welfare
institutes, and other public and private agencies

 

 

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

Method of Administrationt

Direct service; research

Grants-in-aid; studies and
demonstrations; advi-
sory service; loan of per-
sonnel; regulation

Direct service

Do

Do

Direct service; advisory
service; loan of person-

nel
Studies and demonstrations

Research grants

Loan of radium
Advisory service

Direct service; advisory

service
Do
Direct service; regulation

Grants-in-aid; advisory
service

Advisory service; loans

Direct service; regulation

Grants-in-aid; direct
service

Direct service

Direct service; regulation

Do

Direct service; regulation;

advisory service
Direct service

Advisory service; loan of
personnel
Advisory service; loan of

personnel; studies; infor-
mation
Grants-in-aid; studies; ad-
visory service
Advisory service

Studies; advisory service;
information: loan of per-
sonnel

Studies; information and ed-
ucation

*Adapted from Mountin, J. W., and Flook, Evelyn: Guide to Health Organization in the United States, Washington, 1953,
U. S. Government Printing Office, Public Health Service Publ. No. 196, pp. 6-13.

TAs used here,

“direct service’

' refers to services actually performed or directly purchased by the designated Federal agency;

“grants-in-aid” are funds allotted by the Federal agency to state or local agencies for performance of service; advisory service is
limited to the giving of advice and setting of standards.
+Agencies to which Public Health Service officers are detailed for assistance in administration of the functions described.
§Funds have been authorized but not appropriated for this purpose.
Table 27.

Participating Agency

PRESENT ORGANIZATION OF OFFICIAL PROGRAMS

Federal Agencies Eng

355

aged in Health Work—Cont’d

Method of Administrationt

 

 

Social Security Administration——

| Health Activities

ont. |
Bureau of Public Assistance? | Assistance to states for public assistance payments (which

Office of Vocational Rehabilitation?

Food and Drug Administration

St. Elizabeth's Hospital

Office of Education?

Department of Agriculture:

Agricultural Research Adminis-

tration

Bureau of Animal Industry}

Bureau of Human Nutrition and

Home Economics

Bureau of Agricultural and

Industrial Chemistry

Office of Experiment Stations

Bureau of Dairy Industry

Bureau of Entomology and

Plant Quarantine

Bureau of Plant Industry, Soils,
and Agricultural Engineering
Farmers Home Administration

Extension Service

Forest Service

Rural Electrification Adminis-

tration

Production and Marketing

Administration

Bureau of Agricultural
Economics

Office of Foreign Agricultural

Relations

may include provision for medical care) to the aged, to
dependent children, to the blind, and to the permanently
[ and totally disabled
| Assistance to states in rehabilitating persons who are voca-
tionally handicapped because of a mental or physical
disability
Rehabilitation of disabled residents of the District of Colum-

bia
Stabilization of the quality of foods and drugs through inspec-
tion, analysis, and control of labeling

Provision of care and treatment for certain civilian bene-
ficiaries of the Federal government and for residents of the
District of Columbia suffering from mental disorders

Stimulation of education in the fields of public health, school
health, and physical education

Assistance to states for vocational education which includes
training in health fields

Collaboration with national and international groups in fields
of school health and physical education

Direction and coordination of physical and biological research
activities. many of which have a direct bearing on health

Investigation of the cause, prevention, treatment, and control
of diseases affecting both man and animals

Control of sanitation and wholesomeness of meat or meat-food
products sold in interstate and foreign commerce

Conduct of research on food and other goods essential to
healthful everyday living; studies of housing and equip-
ment; and dissemination of information obtained

Investigation of the properties and industrial utilization of
farm products for foods, feeds, drugs and other products
of health significance

Assistance to states in cooperative research in agriculture,
rural health, nutrition, and diseases affecting man and
animals

Promotion of dairy industry and development of sanitary
methods of handling milk and the processing of milk
products

Control of the manufacturing or processing of renovated
butter

Investigation and control of insects affecting the health and
well-being of man, and collaboration with state, foreign,
and other organizations on control of such injurious pests

Promotion of improvement of design and sanitary aspects of
farm homes, buildings, and storage facilities

Provision of supervised credit and loans to farmers for con-
struction or repair of houses and farm buildings, and for
meeting the needs for family living, including health serv-
ices, sanitary facilities, and insect pest control

Promotion of rural health and better farm living, environ-
mental sanitation, and improved farm housing

Provision of sanitary facilities in the National forests and
supervision of general sanitation of forest areas

Improvement of rural sanitation facilities and water supplies

Assistance, through state agencies, to schools having non-
profit school lunch programs in the interest of better
nutrition and health of children

Establishment and enforcement of stancards of purity and
wholesomeness of various food products and control of the
manufacture and sale of insecticides, fungicides, rodenti-
cides, and disinfectants to prevent injury to man and
other animals

Administration of defense functions with respect to availa-
bility of farm equipment, fertilizer, znd the supply and
allocation of foods for proper nutrition

Collection, analysis, and distribution of statistics of health
significance such as farm accidents, incidence of disease,
and patterns of health care

Cooperation with Food and Agriculture Organization of the
United Nations and with Federal agencies on international
programs to raise the level of nutrition and standards of
living, and to improve conditions of rural populations

 

(Continued on next page)

 

Grants-in-aid; studies; ad-
visory service

Grants-in-aid; advisory
service

Direct service

Direct service; regulation;

research; advisory serv-
ice
Direct service; research

Studies and demonstrations;
advisory service; infor.

mation

Grants-i in aid; advisory
service

Advisory service; informa-
tion

Direct service; advisory
service

Direct service; payment of
indemnities; studies; reg-

ulation; research; advi-
sory service; informa-
tion

Regulation; direct service

Studies; research; informa-
tion’

Research

Grants-in-aid; advisory

service

Direct service; studies and
demonstrations

Regulation

Direct service; regulation;
research; advisory serv-
ice

Research

Direct service; credit and
loans

Grants-in-aid; advisory
service; information
Direct service

Direct service; advisory
service
Direct service; grants-in-aid

Direct service; regulation;
advisory service

Direct service; advisory
service

Direct service; surveys and
studies; advisory service;
information

Advisory service;
tion

informa-
356

 

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 27. Federal Agencies Engaged in Health Work—Cont'd

Participating Agency

Health Activities

Methcd of Administrationt

 

Department of Commerce:
Bureau of the Census

Maritime Administrationt

Business and Defense Services
Administration

Coast and Geodetic Survey

Department of Defense:

Department of the Interior:
Bureau of Mines

Fish and Wildlife Service?

National Park Service
Department of Justice:
Immigration and Naturalization
Service?
Bureau of Prisons}

Department of Labor:
Bureau of Labor Standards

Women's Bureau
Bureau of Labor Statistics
Wage and Hour and Public

Contracts Divisions

Bureau of Employees’ Compen-
sation}

Bureau of Employment
Security?

Department of the Treasury:
United States Coast Guard}

 

Collection and publication of basic statistics of population,
housing, agriculture, industry, and other data for use by
other agencies in planning health programs and services

Provision of medical and dental care for enrollees of the United
States Maritime Service and for Cadet-Midshipmen of the
United States Merchant Marine Cadet Corps; operation
of health and sanitation program at merchant marine
training stations

Distribution of controlled materials needed to meet the needs
for civilian health requirements and coordination of other
Federal, state, and local agencies in obtaining such mate-
rials

Insurance of safe navigation of coastal and intracoastal waters
by means of surveys and charts of coastal areas; provision
of emergency health and medical services to shipwrecked
and destitute persons in Alaska and other remote localities

Provision of basic policies, plans and programs in the medical
and health fields as will provide guidance for the several
military services in safeguarding the health of military
personnel and their dependents

Operation of health and medical care programs for military
personnel and their dependents

Provision of pure water for military posts and the District of
Columbia, and improvement of navigable rivers, harbors,
and waterways in the interest of flood control, maintenance
of water supply, abatement of water pollution, and other
use of water

Training of personnel for health work

Cooperation with other Federal agencies on health and medi-
cal problems

Direction of research, in and out of the Department, toward
solving health problems arising out of military operations

Investigation of causes of mine accidents; inspection of mines;
training in mine rescue and recovery work

Production of lightweight, noninflammable gas helium used
in nonexplosive anesthetics and in the treatment of some
respiratory diseases

Promotion of programs for control or destruction of wild
animals that endanger men or domestic animals through
the transmission of diseases

Detection and elimination of stream pollution hazards

Conduct of research on methods of canning or processing of
fishery products to insure a sanitary and wholesome food

Provision of medical and health services for the inhabitants
of the Pribilof Islands and destitute natives

Provision of safe water and sanitary camp facilities in national
parks

Provision of physical and mental examinations of immigrants,
and medical care of quarantined aliens

Provision of medical, psychiatric, dental and nursing services
to inmates in Federal prisons and correctional institutions

Promotion of industrial health and safety

Coordination of enforcement of wage, hour, industrial home
work, child labor, and safety and health laws

Training of state and foreign personnel in health and safety

Promotion of the welfare of wage earning women and conduct
of studies on health and working conditions of women in
industry

Collection and analyses of data on environmental conditions
in industry significant to health and publication of reports

Administration of Fair Labor Standards Act to insure mini-
mum wage rates and the proper use of child labor in the
production of goods for interstate commerce

Administration of health and safety standards in industries
under government supply contracts in excess of $10,000

Administration of benefit payments to injured workers for
necessary medical and hospital services and compensation
for disability and death

Provision of medical and health services for migratory farm
laborers at reception centers and while enroute to and from
work contractor and reception centers

Enforcement of regulations to insure the safety of life and
property on high seas and navigable waters under juris-
diction of the United States

Provision of medical and surgical aid to crews of United States
vessels, and to shipwrecked and destitute persons in Alaska
and other remote localities

 

Direct service; advisory
service

Direct service

Direct service; advisory
service

Direct service

Do

Direct service; advisory
service
Research

Direct service; studies and
demonstrations; infor-
mation

Direct service

Do
Do
Research

Direct service

Direct service

Direct service; regulation

Direct service

Direct service; studies and
demonstrations

Direct service; advisory
service

Direct service

Studies; advisory service

Direct service; investiga-
tions and studies; infor-
mation

Regulation

Direct service

Direct payment of benefits

Direct service

Direct service; regulation

Direct service

 
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS

357

 

 

 

Table 27. Federal Agencies Engaged in Health Work—Cont’d

 

Participating Agency
Bureau of Narcotics

Atomic Energy Commission

Defense Production Administration]
Federal Civil Defense Administra-

tionf

Federal Trade Commission

International Cooperation Admini-
strationt

Housing and Home Finance Agency

Interstate Commerce Commission
National Science Foundation

National Security Resources Board

Selective Service System

Tennessee Valley Authority

Veterans Administration

 

 

Health Activities

| Enforcement of Federal narcotic laws and regulation of quan-

tities of narcotic drugs to be imported, manufactured, or
exported for medical purposes

Production and distribution of radioactive materials used in
medical research

Conduct of medical and clinical research at field installations
and hospitals, and provision of research guidance in the
physical and biological sciences

Training in radiological safety in the interest of civil defense

Control of distribution of information regarding the use and
safety of radioactive materials

Establishment of policies regarding health manpower needs
and the expansion of production and general allotment of
strategic materials used in meeting civilian and military
health needs

Assistance to states for protective equipment and facilities

Provision of a coordinated plan for the protection of civilian
life and property from enemy attack

Control of unfair or deceptive advertisements of food, drugs,
devices, or cosmetics in interstate commerce

Assistance to foreign countries to promote health and eco-
nomic development

Training of foreign students in public health and other fields
through educational exchange programs

Assistance to local public housing authorities for planning,
financing and construction of safe, sanitary, and adequate
dwellings for low-income families

Asgistance to state and local governments for repair of dam-
ages and rehabilitation of disaster-stricken areas

Promotion and enforcement of health and safety standards in
the railroad industries and in the operation of railroads
and motor carriers in interstate traffic

Development and strengthening of a national policy of basic
research in the medical, biological, physical, and other
health sciences, awarding of scholarships and graduate
fellowships in these fields

Coordination of activities of Federal agencies with respect to
manpower and natural resources as they affect national
health and security; provision of advice to the President
on the coordination of these resources

Provision of health data of draftees examined for military
service

Maintenance of medical and public heal:h service for em-
ployees

Cooperation with state and local health authorities in the
control of insects, water pollution, general sanitation, and
other public health services for the area

Provision of authorized health and medical services, including
hospitalization and rehabilitation to former members of
the armed forces

Administration of training benefits for veterans of the armed
services; through this program more trained personnel
will be made available for health work

Training of personnel in health work

 

 

Method of Administrationt

 

Direct service; regulaticn

Direct service; advisory
service

Direct service; grants-in-
aid; research; advisory
service; information

Direct service; research
grants

Direct service; advisory
service; information

Direct service; advisory
service; loans

Grants-in-aid

Direct service; advisory
service; public educa-
tion

Regulation

Direct service; grants-in-
aid; studies and demon-

strations; advisory serv-
ice; information

Grants-in-aid; advisory
service; loans; studies

Grants-in-aid; advisory
service

Investigations; regulations;
advisory service

Direct service; advisory
service

Direct service; advisory
service

Direct service

Do

Direct service; advisory
service

Direct service; research

Training grants

Direct service

to promote social and economic security, educational opportunity, and the health
ol the citizens of the nation.

Public Health Service. From the broad over-all point of view of public health,
the principal organization included in the Department of Health, Education and
Wellare is the United States Public Health Service. Most of the functions of the
Public Health Service take the form ol research, demonstrations, interstate and in-
ternational quarantine, advice on technical matters and loan of officers to state
and local health departments, and other Federal agencies with particular health
interests. Probably its most significant contribution is made through financial
grants-in-aid to state and territorial health agencies for the expansion and im-
provement of their programs and those of the local jurisdictions they include.
The functions of the Service may be summarized as follows:
 

358

®

 

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

Study of the causes and means of propagation and spread of the diseases of mankind,
and the development of methods of prevention and control. In this work the Public
Health Service maintains several research laboratories, chief among which are those of
the National Institute of Health, the Communicable Disease Center, and The Taft Sani-
tary Engineering Center. In addition to investigations carried on at the Institute and its
field stations, financial assist

 

ance is given through research grants to universities, labora-
tories, and other public and private institutions for research projects, upon recommenda-
tion of Service advisory councils. Funds are also available for research fellowships, both
in the Institute and in various university medical schools.

Maritime quarantine and inspection of passengers and crews of vessels and airplanes
arriving from foreign ports, for protection of the country from the importation of quar-
antinable diseases from other countries. Examination of immigrants for detection and
isolation of persons suffering from mandatorily excludable disease. Medical inspection of
aliens is performed in collaboration with the Immigration and Naturalization Service
of the Department of Justice.

Interstate quarantine for prevention of the spread of diseases from state to state. The
Federal health agency prescribes conditions under which persons and things may move
in interstate commerce. It assists states in controlling epidemics and may, on request,
take complete charge of serious outbreaks. Regulation of conditions existing within the
boundaries of a particular state is a duty that remains under state jurisdiction.
Dissemination of public health information, including collection and publication of
reports of disease prevalence in the United States and foreign countries, and other per-
tinent information regarding conservation of the public health.

Assistance, through grants to states, counties, cities, and health districts, in establishing
and maintaining proper sanitation facilities, general public health services—including
industrial hygiene, mental hygiene, and cancer control—and special programs for the
control of the venereal diseases and tuberculosis. Grants made under this authority
represent the actual transfer of funds from Federal to state treasuries for employment
and training of personnel for state and local health work, purchase of supplies and
equipment, provision of appropriate facilities for care and treatment of designated ill-
es include the loan of personnel
for temporary duty, and the provision of consultation and advice to state and local
health departments. Assistance is also furnished states in the development of hospitaliza-
tion plans and construction of hospital and allied health facilities.

 

nesses, and payment of general operating CXPCHSes. Serv

Supervisory control and licensure of the manufacturers of biological products—vaccines,
serums, toxins, antitoxins, arsenicals, and similar preparations—used in the prevention
and treatment of diseases. This control has been established to insure safe and standard
products.

Study of mental diseases and drug addiction and investigation of legitimate needs for
narcotic drugs.

Provision of hospitalization, general medical and dental care, and preventive health
services for American merchant seamen, members of the United States Coast Guard and
the Coast and Geodetic Survey, and for other legal beneficiaries of the Service. In this
connection, the Service operates 16 hospitals and 25 outpatient clinics and contracts for
service in over 100 other places not served by Public Health Service hospitals. It assigns
medical and dental officers to ship duty to provide medical and dental care at sea for the
Coast Guard and Coast and Geodetic Survey. The Public Health Service, in cooperation
with the Burcau of Prisons, also maintains a medical and health program in Federal
prisons. ‘The Public Health Service also provides medical care and public health services
to Indians and Natives of Alaska.

Operation of special hospitals—the National Leprosarium and two hospitals specifically
for the care of mental patients and persons addicted to the use of narcotics.

Cooperation with other Federal agencies in discharging their various health functions,
through assignment of personnel for assistance.

Collaboration with and participation in the functioning of international health organ-
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 359

 

izations. In carrying out this service, particular attention is given to the direction of
programs for the exchange of international health and related personnel.

12. Collection and publication of data on vital statistics, which are basic materials for public
health programs and give valuable information concerning public health trends.
Through measurement of death rates from different causes, the progress of health pro-
grams directed toward reduction of particular diseases or conditions can be evaluated.

13. St. Elizabeth’s Hospital is the principal hospital for treatment of mentally ill civilian
beneficiaries of the Federal government. Freedmen’s Hospital is a general hospital with
specialized departments. Tt is affiliated with the Howard University Medical School.
Both of these hospitals are under the direction of the Surgeon General of the United
States Public Health Service.

The work of the Public Health Service is directed by a Surgeon General ap-
pointed by the President. It is organized into four administrative units: The
Office of the Surgeon General, the Burcau of Medical Services, the Burcau of State
Services, and the National Institutes of Health. In addition to these is the Na-
tional Medical Library guided by a board of regents, and administered by an
executive director who reports to the Surgeon General. (Fig. 22.) For decentraliza-
tion of services and assistance to states, eight regional offices are maintained in
New York, Charlottesville, Chicago, Atlanta, Kansas City, Dallas, Denver, and
San Francisco. At the present time, in addition to a National Advisory Health
Council, there are advisory councils for cancer. mental health, heart disease,
dental research, arthritis and metabolic diseases, neurological diseases and blind-
ness, allergy and infectious diseases, water pollution control, health research
facilities, radiation, and training. In addition, there is related to the Office of the
Surgeon General the Federal Hospital Council, with both advisory and opera-
tional duties related to the administration of the Hill-Burton Hospital Survey
and Construction Act. The Surgeon General also calls an annual conference of
state and teritorial health officers and whatever special conferences or committees
as may appear indicated.

Children’s Bureau. Next in importance to the Public Health Service is the
Children’s Bureau, formerly located in the Department of Labor, but now in
the Social Security Administration of the Department of Health, Education,
and Welfare. From a functional viewpoint the separate existence of the Children’s
Bureau has always appeared somewhat illogical. Its justification has been linked
to the two arguments that the needs of children must be considered as a whole
and that they form a population group unable to organize and to speak for them-
selves. A chiel function of the Bureau is to enable each state to extend and im-
prove the health services for mothers and children. This is accomplished through
assistance to states in the support of prenatal, postnatal, and well-child clinics, of
demonstrations of delivery and other services, and ol public health nursing serv-
ices for maternal and child health supervision. The Bureau has played a most im-
portant role in the establishment and development ol divisions of maternal and
child health in all of the state health departments. It also sponsors a cooperative
Federal-state program of services for crippled children. The programs of the
Children’s Bureau are carried on in a manner similar to the Bureau of State
Services of the Public Health Service, primarily through grants-in-aid to the
states and through consultative services. During World War 11, the Bureau served
3060 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

PROFESSIONAL OFFICERS ADVISORY
TO THE SURGEON GENERAL

DEPARTMENT OF
HEALTH, EDUCATION, AND WELFARE
PUBLIC HEALTH SERVICE

 

1968

 

IMMEDIATE OFFICE OF THE
SURGEON GENERAL

 

Chief Dental
officer

Chief Sanitary
Eng. officer

Chief Nurse
officer

 

 

 

 

EXTERNAL ADVISORY GROUPS

 

WJRGEON GENERAL
Deputy Surgeon General

 

Executive Officer

 

INTERNAL ADVISORY GROUPS

 

 

 

 

 

OFFICE OF SURGEON GENERAL

Deputy Surgeon General:
Executive officer:

 

Chief:
Deputy Chief:
Executive officer:

 

Div. of Administrative Services

Div. of Finance

Div. of Personnel

Div. of Public Health Methods

Office of Emergency Plans and
Requirements

 

BUREAU OF MEDICAL SERVICES

 

Dental Resources
Foreign Quarantine

Hospitals
Indian Health
Nursing Resources

 

 

 

Hospital and Medical Facilities

 

 

|

 

BUREAU OF STATE SERVICES

Chief:
Deputy Chief:
Executive officer:

 

Director:
Associate Directors:

Executive officer:

 

Division of General Health
Serv.
Division of Special Health

Communicable Disease Center
Division of International Health
Division of Dental Public Health
Division of Radiological Health
Division of Public Health Nursing

NATIONAL INSTITUTES OF HEALTH

 

Nat'l, Cancer Institute
Nat'l, Heart Institute
Nat'l. Inst, of Allergy &

Services Infectious Diseases
Division of Sanitary Engineering Nat'l, Inst. of Arthritis &
Services Metabolic Diseases

Nat'l, Inst. of Mental Health

Nat'l, Inst. of Neurological
Diseases & Blindriess

Clinical Center

Div, of Biologics Standards

Nat'l, Inst. of Dental Research

 

 

Div. of Business Operations
Div, of Ge
Div. of Research Or

Div, of Research Services

 

 

 

 

 

 

 

 

 

PHS REQIONAL MEDICAL DIRECTORS -— NATIONAL LIBRARY OF MEDICINE

 

 

 

Director:
Executive officer:

 

Fig. 22. Organization of the Public Health Service.

as the administrative agency for the Emergency Maternity and Infant Care Pro-
gram [or the wives and infants of servicemen. By early 1949 when the program
was terminated, close to one and a hall million expectant mothers and about
one third of a million infants had been provided with care by private physicians
of their choice, paid through the program. As discussed elsewhere, this program
not only represented a nation-wide experiment in medical care but also provided
invaluable experience in administration for many public health workers.

By collecting and distributing information, the Children’s Bureau maintains
a clearinghouse on research-in-progress in the total field of child life, both inside
and outside the Federal government. It conducts surveys and studies on the
nature and extent of child health problems and analyzes and reports statistics
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 361

 

 

on maternal and child health and crippled children’s services provided under
grant-in-aid programs. It provides Federal financial aid for specialized training
projects in services to children, to students and workers in child health, and to
teaching institutions.

Individually, or as a team of specialists in maternal and child health, con-
sultants of the Bureau visit state health and crippled children’s agencies to advise
on the operation of state programs, standards ol service, and ways ol extending
and improving health services to mothers and children.

In carrying out its responsibilities, the Children’s Bureau cooperates with
official and nonofhcial national organizations and institutions; stimulates interest,
participation, and cooperation on the part of educational, social, and welfare
agencies for the coordination ol resources and services; and participates in a
broad program of international cooperation.

Other Federal Agencies. The United States Office of Education of the De-
partment of Health, Education, and Welfare is engaged in several activities re-
lated to health. It promotes programs ol health education, school health and
safety, engages in investigations relating to medical examination ol school chil-
dren and their teachers, promotes school lunch programs, and administers a
grant-in-aid program for vocational education in health.

The Food and Drug Administration is a Federal organization, now located
in the Department ol Health, Education, and Welfare, chiefly concerned with the
quality of foods and drugs. Its efforts are directed toward the promotion of purity,
standard potency, and accurate labeling of substances within its jurisdiction,
which include food, drugs, cosmetics, tea, certain milk products, and poisons.

Outside the Department ol Health, Education, and Wellare there are a
number of branches of the Department ol Agriculture which engage in pro-
grams concerned with health. The Bureau of Animal Industry inquires into the
cause, prevention, and treatment of diseases of domestic animals, which naturally
have an influence upon many phases of human health. Federal meat inspection
services are administered by the Office of Production and Marketing Administra-
tion which also administers the Insecticide Act. The labor branch of this office
finances medical care and health services for migrant farm workers. The Bureau
of Dairy Industry is active in investigations and education relating to the san-
itary production and handling of milk. The Bureau of Entomology and Plant
Quarantine, while primarily concerned with the protection of crops from para-
sitic insects, necessarily contributes much knowledge and service to the control of
insects affecting man. Active in research and service relating to foods, nutrition,
and dietary habits is the Bureau of Human Nutrition and Home Economics
which, with the agricultural extension service in cooperation with state land grant
colleges, has accomplished much in the improvement of rural health and nutri-
tion. Of importance and interest in the provision of medical and dental care
is the Farm Security Administration within the Department of Agriculture. Its
beneficiaries are chiefly low-income farm groups. Needed medical and dental
care is made available through county-wide group health services in cooperation
with local practicing physicians and dentists.
362 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

In the Department of the Interior are a number of agencies with specialized
interests in public health problems. The Bureau ol Mines conducts an important
health, sanitation, and safety program in relation to the mining and quarrying in-
dustry. In company with the Fish and Wildlife Service, it is concerned with cer-
tain phases of the problem of stream pollution. The latter agency also contributes
to health protection by promoting rodent control programs. Until recently, the
Department ol the Interior, through its Office ol Indian Affairs, has had respon-
sibility for the operation of hospitals and programs for the general improvement
ol health and sanitation on Indian reservations. In 1953, this responsibility was
transferred to the Public Health Service.

Federal Agencies in International Health Affairs. Originally the interests of
the United States Government in international health affairs were limited to
measures designed to prevent the introduction ol certain diseases. Developments in
world history, economics, and in methods ol transportation, however, have made
it necessary to adopt a broader viewpoint and to assume responsibilities of great
significance to international public health. These newer responsibilities are of
two types: first, participation in development ol public health programs in other
specific nations, and second, participation as one ol a number of partners in the
promotion ol world-wide health. The most important Federal agencies involved
in these activities are the International Health Division of the Public Health
Service and the International Cooperation Administration of the Department of
State.

The International Health Division of the Public Health Service was estab-
lished to coordinate and give general direction to all Service activities in the in-
ternational health field; to maintain liaison with agencies in this field; to repre-
sent the Service in international health conferences; to direct a program on in-
ternational exchange of health personnel and educational material; to draft sani-
tary conventions and regulations and health reports required by international
agreements; to collect and distribute data relating to foreign medical and health
institutions; to supervise special health missions to foreign countries; to advise
the State Department regarding development of plans, programs, and policies for
consideration by the World Health Organization; and to advise the Surgeon
General on international health matters.

In relation to the foregoing, the United States Government has representa-
tion in the World Health Organization, the Pan-American Sanitary Bureau,
and the Anglo-American Caribbean Commission.

The bilateral international health activities of the United States government
are centered in the International Cooperation Administration of the Department
of State. In the planning, staffing, and conduct of its programs, it relates intimately
not only to the International Health Division ol the Public Health Service and
to other significant parts of the Federal government, but also to several state
health departments and to a number of universities, schools of public health,
and schools of medicine. Its activities and those ol the multilateral international
health agencies are described in more detail in the following section.
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS  J03

International Health Organization.

Introduction. A consideration of the field of international health may be
approached [rom several directions: first, from the standpoint of the specific
preventable diseases and health problems which exist under various local, na-
tional, or regional circumstances; second, [rom the standpoint of the various
organizations which are or have been active in the field; and finally, from the
standpoint of the relationship to present or potential public health organiza-
tions or structures in the various political units of the world. In the final analysis
it is this latter which is the most important. It must always be borne in mind
that effective, fruitful, lasting action can occur only on the local level where
the people, their problems, their communities, and their governmental structures
are found. Therefore, international health work cannot be thought of as a
field unto itself. It has meaning only in its relation to the many national and
local components of the total world health picture. Tt is with this reservation
that certain aspects of international health activities are presented.

World Health Organization. Before World War II various activities had
occurred in the international health arena. Most notable of these was the devel-
opment of the Pan-American Sanitary Bureau in 1902, the International Office
of Public Health in 1907, and the Health Organization ol the League of Nations
in 1921. In 1923, the International Office was absorbed into the Health Organ-
ization ol the League which continued to function, as did the Pan-American
Sanitary Bureau, through the period of World War II

In 1944, while the war was still in progress and Paris was occupied by the
Nazis, an international conference was held in Montreal to discuss the fate
of the Health Organization of the League. Stemming [rom this and culminating
at a further conference in New York in 1946, a constitution for a World Health
Organization was signed by sixty-one nations. The organization began official
existence on September 1, 1948. The duties and powers of the Health Organiza-
tion of the League of Nations and the health functions of the temporary United
Nations Relief and Rehabilitation Administration were transferred to the new
agency. Subsequently, the Pan-American Sanitary Bureau, while retaining a
separate identity, became the World Health Organization regional office for
the Americas.

By January 1, 1959 the World Health Organization had a membership of
eighty-eight nations, which made it the largest of the specialized agencies of
the United Nations.

The constitution of the World Health Organization, particularly in view
ol its definition of health as “a state of complete physical, mental, and social
well-being and not merely the absence of disease or infirmity,” has been aptly
referred to as the Magna Charta of health because of its affirmation that health
is “one ol the fundamental rights of every human being, without distinction of
race, religion, political beliel, economic or social condition” and because of
its recognition that “the health of all peoples is fundamental to the attainment
ol peace and security.”
364 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

The headquarters of the World Health Organization is in the Palais des
Nations in Geneva, Switzerland. Regional offices have been established at Brazza-
ville, for Africa; Washington, for the Americas (Pan-American Sanitary Bureau);
New Delhi, for Southeast Asia; Copenhagan, for Europe; Alexandria, for the
Eastern Mediterranean; and Manila, for the Western Pacific. It is financed by
prorated and special contributions from active member nations and from the
United Nations Technical Assistance Board. An annual World Health As-
sembly which determines international health policy and program is the agency's
legislative body. Each member nation is allowed three delegates but only one
vote at the Assemblies. An executive board has the responsibility of putting
into effect the decisions and policies of the Assembly and deals with emergency
situations in the name of the Assembly. Normally this technical nonpolitical
group of eighteen health experts, who are elected at the Assembly, meets twice
a year. A secretariat headed by a director-general includes a technical and an
administrative staff of about 1,000 persons located at the Geneva headquarters
and in the regional offices. It is responsible for the day-to-day work of the organ-
ization. The World Health Organization avoids one of the basic errors of the
health office of the former League of Nations, that ol overcentralization, in that
it provides for six regional committees comprised of representatives of the mem-
ber states in each region. These regional committees formulate regional policies
and supervise the activities of the regional offices. In addition, twenty-five ex-
pert panels and committees have been established to advise the World Health
Organization on technical aspects of its activities and to keep it up to date on
current scientific research.

The functions of the World Health Organization have been summarized
as follows:

1. Itis the one directing and coordinating authority on international health
work. It is not a supranational ministry of health, but rather a world-
wide cooperative through which the nations help each other to help
themselves in raising health standards.

2. It provides to member countries various central technical services, i.e.,
epidemiology, statistics, standardization of drugs and procedures, a wide
range of technical publications, etc.

3. Its most important function is to help countries to strengthen and im-
prove their own health service. Upon request it provides advisory and
consulting services through public health experts, demonstration teams
for disease control, visiting specialists, etc.

The World Health Assembly has given top priority to six major problems,
i.e., malaria, maternal and child health, the control of tuberculosis, the control
of venereal diseases, environmental sanitation, and nutrition. Programs for the
control of parasitic and virus diseases and activities in the field of mental health
have been given a second grade of priority. Technical assistance in the field
of public health administration while originally placed in the second priority
group has been receiving ever increasing attention.
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 305

 

 

There are two important distinctions between the health office of the League
of Nations and the World Health Organization which replaced it. First, the
functions and activities of the latter are very broad. For the first time in in-
ternational affairs emphasis is placed not upon quarantine, checking epidemics,
and other defensive measures, but upon positive aggressive action toward health
in its broadest sense. The second difference is that whereas the former organiza-
tion was an integral part of a political body, the World Health Organization,
although related to the United Nations, is nevertheless a separate independent
agency with its own constitution, membership, and sources of funds. As yet
it is too early to determine with assurance what the future holds for this organiza-
tion. Much depends upon the ability of the nations of the world to live with
one another in peace and cooperation. It has been commonly said that, despite
its political affiliation, the old health office was the most successful part ol the
League of Nations. In view of that, one might hope with reason that the new
organization has an even greater chance of success, effectiveness, and permanency.

Pan-American Health Organization. The turn of the century saw the estab-
lishment in 1902 at the Second Inter-American Pan-American Conference in
Mexico City of the Pan-American Sanitary Bureau, more recently renamed the
Pan-American Health Organization. Its headquarters is in Washington, D. C.
This was the first permanent international health agency and the longest-lived
up to the present. It was organized to be governed by an elected directing council
and a director-general. It is supported by annual financial quotas contributed
by each of the American Republics. Under the provisions of the Pan-American
Sanitary Code which was ratified by all twenty-one of the American Republics
in 1924, it became the center of coordination of international action and infor-
mation in the field of public health in the Western Hemisphere. It holds an
annual conference of high quality which is attended by delegates from all mem-
ber nations. Through its development it has been given the responsibility and
authority to receive and disseminate epidemiologic information, to furnish techni-
cal assistance upon request to member countries, to finance fellowships, and
to promote cooperation in medical research. It subsequently became the World
Health Organization regional office for the Americas while nevertheless main-
taining its own identity.

United Nations Children’s Fund. This is an agency whose history and activ-
ities have been intimately related to those of the World Health Organization.
At the demise of the United Nations Relief and Rehabilitation Administration
in 1946 certain of its funds were transferred to a newly formed agency organized
to assist especially the children of war-torn countries. The program gradually
expanded to include other activities and other areas, particularly underdeveloped
countries. Over the past few years as an emergency agency, the Fund has spent
large sums of money especially on food and supplies for child and maternal
wellare activities throughout the world and particularly in war-torn areas. Be-
yond this, however, and usually through partnership with the World Health
Organization it has been carrying out very large and significant programs of
B.C.G. vaccination, yaws control, and malaria control demonstrations. Organized
originally as a temporary emergency agency, it has filled such a need and attracted
366 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
such support that in 1953 it was given permanent status and its name was changed
to the United Nation's Children’s Fund.

International Cooperation Administration. So far we have been considering
the development of what have been commonly referred to as the multilateral
organizations in public health, i.e. organizations the financing, staffing, policy
making, and operations of which are entered into and shared by more than two
and usually many nations. In addition, there exists, another type of international
health cooperation which is carried out by what are now referred to as bilateral
agreements and organizations. This comes about when two nations, for reasons
of mutual interest, agree to work together on certain matters dealing with
public health.

The United States government became significantly involved in bilateral
international public health activities as a result ol World War II. In January,
1942, the Foreign Ministers of the American Republics, concerned over the turn
ol world events, considered areas wherein cooperation among the Republics
ol the Western Hemisphere was necessary for the common good and survival.
Health needs were placed high on the list. They recommended that through
bilateral and other agreements the necessary steps be taken to solve the en-
vironmental sanitation and health problems ol the Americas and that to this
end, according to capacity, each country contribute raw material, services, and
funds. The United States was asked to accept the responsibility of leadership
and an Office ol the Coordinator of Inter-American Affairs was established. Origi-
nally it was attached to the office ol the President of the United States but later
assumed a governmental corporate structure with the name Institute of Inter-
American Affairs. It was given the responsibility of initiating and conducting
bilateral technical assistance programs in health, agriculture, education, and
other fields.

Promptly, in intimate relationship with each of the other republics involved,
eighteen cooperative health programs were established. The activities of each
program were financed by contributions [rom both the United States and the
other government concerned, and the programs were determined jointly by an
official of the host government, usually the minister or director ol health, and
the chief of the group ol technicians assigned by the United States to the host
country.

From the beginning, the program had four chiel areas ol emphasis: (1) the
development of local health services through health centers; (2) sanitation of
the environment, with particular emphasis on water supply, sewage disposal,
and insect control; (3) the training and full-time employment of professional
public health workers; and (4) education of the public in health matters. It
has stressed complete community health development under full-time trained
direction, with active community participation.

Stimulated by the tremendous needs for rehabilitation throughout the world,
by requests [or assistance by newly formed nations, and by the proved value of
the programs ol the Institute of Inter-American Affairs, the United States has
organized since the end of World War 11 a succession of agencies, each to serve
PRESENT ORGANIZATION OF OFFICIAL PROGRAMS 307
certain problem or areal needs. Predominant among these were the Mutual
Security Administration and the Foreign Operations Administration. In July,
1955, these and the Institute of Inter-American Affairs were all joined to form
the International Cooperation Administration. While organizationally within
the Department of State, this is in effect a semiautonomous agency of the govern-
ment in that its funds are appropriated separately by an annual Mutual Security
Act.

The International Cooperation Administration cooperates with other nations
by providing military assistance, economic assistance, and technical assistance. A
significant component of the latter is technical assistance in public health matters.
At the present time (December, 1959), the Office of Public Health of the Interna-
tional Cooperation Administration is actively engaged in cooperative health pro-
grams in thirty-six countries throughout the world. These health programs are
ol considerable magnitude, necessitating a budget in 1958 ol about 80 million
dollars. More than 300 public health workers [rom the United States, representing
a wide spectrum of professional disciplines are involved in the work. One of the
most significant contributions of the International Cooperation Administration
and ol its predecessors has been in the field of training. Fellowships for advanced
training in the United States and elsewhere have been granted to several thousand
professional health workers of other countries, and many thousands more have
been given in-service training in connection with on-going cooperative health
programs.

Nongovernmental Agencies. No summary of international health coopera-
tion would be complete without emphasizing, though briefly, the great contribu-
tion which has been made by nongovernmental agencies. As far as “shirt sleeve”
technical assistance is concerned, undoubtedly the earliest endeavors were those
of the various church missions and medical missionaries. In addition have been
certain philanthropic foundations with interest in international health based
upon the highest altruistic motives. Outstanding among these organizations
have been the Unitarian Service Committee, the American Friends Service Com-
mittee, the various Catholic Mission groups, the American Bureau for Medical
Aid to China, the Foreign Mission Agencies of the Baptist and Methodist churches,
the Near East Relief Agency, and many others. Representatives of all of these
have preformed yeoman service, working hand in hand with the people of
villages and farms in many lands on a basis of true [riendship and equality.

Among the foundations, the Rockefeller Foundation is the best known in
the field of international assistance in health. It has operated in almost all of
the countries of the world in the five decades of its existence. Its contributions
and successes are many and great and include such activities as the control of
malaria and yellow fever, the development of recognized centers of learning
in medicine and public health, the provision of postgraduate fellowships to
many individuals, and the demonstration of sound methods of organization and
operation of health programs. More recently it has been joined by several other
foundations, notably the Kellogg Foundation which is especially interested at
the present time in the further improvement of professional education in the
Latin American countries.
368 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

Conclusion. To some it may appear as if the programs of international
health are too many, too varied, too dispersed, and too confusing. While this
may be true to some degree, it has been by no means unexpected or undesirable.
The field of international cooperation for mutual development is rather new.
It was necessary and logical to approach it somewhat on the basis of caution
and trial and error, rather than to attempt at some premature date to establish
a fixed pattern which might have stifled future growth and thought. The last
few years have seen the beginning of a process of pulling the pieces together
both in the multilateral and in the bilateral areas, and it is to be expected that
the future will see an ever more logical and fruitful organizational approach
to the tremendous problems which still exist in public health throughout the
world. The names of some organizations may have changed frequently. If so, it
should be borne in mind that only results count and that titles are incidental.

Finally, it must be realized that there will always be an important place
for all three types of international health work, i.e., the multilateral, the bilateral,
and the nongovernmental. Each in its way provides support to the others. Sound,
effective, and cooperative correlation of all of their activities may result in the
ultimate achievement of the universally desired goal of world health and through
it indirectly in world peace.

REFERENCES

1. Mountin, J. W., and Flook, Evelyn: Guide to Health Organization in the United States,
Washington, 1953, U. S. Government Printing Office, Public Health Service Publ. No. 196.
2. Sanders, B. S.: Local Health Departments, Growth or Illusion, Pub Health Rep. 74:13,
Jan. 1959.
3. Haldeman, J. C.: Unpublished data presented at Annual Meeting of National Advisory Com-
mittee on Local Health Departments, March 18, 1958.
4. Local Health Units for the Nation, Report of Sub-Committee on Admin. Practice, American
Public Health Association, Commonwealth Fund, New York, 1945.
5. The Local Health Department—Services and Responsibilities, An Official Statement of the
American Public Health Association, Adopted Nov. 1, 1950. Am. J. Pub. Health 41:304,
March 1951.
6. Distribution of Health Services in the Structure of State Government, 1950, Washington, 1952,
Public Health Service Publ. No. 184, Part 1.
The State Health Department—Services and Responsibilities, An Official Statement of the
American Public Health Association, Am. J. Pub. Health 44:235, Feb. 1954.
8. H. 184 (Jan. 3, 1949); H. 782 (Jan. 5, 1949); H. 1402 (Jan. 13, 1949); H. 2361 (Feb. 7, 1949);
and S. 1581 (April 14, 1949), Congress of the United States.
9. Reorganization Plan 1 of 1953, Approved April 1, 1953 (67 Stat. 18; 5 U. S. C. 623).

~1
chapter 1 4

Vital statistics

 

Introduction. Vital statistics, or the bookkeeping of public health, is one of
the essential activities of every public health agency on every level of government.
So important is it that it not only constitutes a primary legal responsibility of
health agencies but also provides the foundation upon which all other parts
of the public health program are constructed. It is impossible to imagine a sound
program of maternal and child health, communicable disease control, environ-
mental health, or even laboratory services in the absence of this invaluable ad-
junct. Its influence, if properly used, permeates every fiber in the fabric of the
organization; on one end of the personnel scale it determines what visits should
be made during the daily rounds of the staff nurses or sanitarians, and on the
other end of the scale it assists in deciding matters of over-all policy for the top
administrator.

When satisfactorily organized and conducted, the vital statistics office serves
literally as the “brain center,” continually giving answers to “What is the score?”
and “What next?” Its constituent parts taken in toto present the composite life
history of a community, state, or nation. It is the storehouse of indispensable in-
formation which reflects the strengths and foibles, successes and failures, joys
and sorrows ol the group. It is the key that opens the door to a competent, sound,
and efficient administration.

It is probably difficult, if not impossible, for a public health worker to be
either successful or satisfied without an intelligent and sympathetic apprecia-
tion of the vital statistics of the arca he serves. Unfortunately, too many regard
this activity as a necessary chore or evil to be delegated to a few inadequately
trained clerical employees working in an out-of-the-way office. It should be realized
that although the real material of statistics may appear to be scraps of paper con-
taining crooked little integers, each represents a human interest story which with
its fellows leads to a gleaming final product—a philosophic plan for the allevia-
tion of human misery and the attainment of health for all.

The compilation of vital statistics is ofl ancient origin. Enumerations of
people were carried out long before the birth of Christ, notably in China, Egypt,
Persia, Greece, and Rome, primarily for purposes of taxation and to determine
the military man power. Data relating to births, deaths, and marriages were re-

369
370 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

corded in elementary form in the old church registers of England. The oldest
known copy of these co-called “Bills of Mortality” can be seen in the British
Museum and is dated November, 1532. These Bills were compiled by parish
priests and clerks for more than a century before John Graunt, in 1662, published
his book Natural and Political Observations Mentioned in a Following Index
and Made Upon the Bills of Mortality. Vital statistics in the modern sense can
be considered to have originated from the publication of this book.

The late eighteenth century saw the beginning of the modern national
census. Priority is somewhat open to question. The outstanding claims are Canada,
1666, Sweden, 1749, and England and the United States, 1790. Regardless of the
earliest claim, it may be stated that the United States Census had a tremendous
influence on the spread of the idea throughout the rest of the world. The in-
stitution of a national census in America has, with good reason, been called
a political accident since the provision for our decennial enumeration arose
[rom the conflict between the small and large states. The former demanded equal
representation in the national legislature, whereas the latter felt that their larger
populations justified more power. The compromise solution was to establish
a bicameral legislature consisting of the Senate, in which states were equally
represented, and the House of Representatives, with representation in proportion
to population. This compromise solution made necessary some provision for
the periodic inventory of the population. As a result the following was included
in the Constitution: “Representatives shall be apportioned among the several
States according to their respective numbers, counting the whole number of
persons in each State, excluding Indians not taxed. The actual enumeration
shall be made within three years alter the first meeting ol the Congress of the
United States, and within every subsequent term of ten years in such a manner
as they shall by law direct.”* It should be noted that all that was required was
a simple count. From this basic purpose and requirement, there has developed
a national census of great complexity and detail which provides data ol great
value far beyond what was envisioned by the [ramers of the Constitution.

It is significant that vital statistics, or more specifically public health statistics,
is considered to be one of the basic functions in public health. With substantial
reason it may be stated that all of the other functions depend essentially upon
the adequate fulfillment of this primary function for their success. Statistics have
come to be regarded as an indispensable administrative tool for the proper plan-
ning, performance, and evaluation of any modern business or public program.

Sources of Public Health Statistics. The most fundamental information upon
which activities in public health must be predicated is a knowledge of the quan-
titative and qualitative characteristics of the population to be served. This
implies some form of a count or estimate of the people within a jurisdiction.
On the surface it would appear that the decennial census, to which reference
has been made, would supply whatever data is necessary. This was the case in
the more stable or immobile societies which preceded the era of paved highways,
rapid transportation, and industrialization. Reasonably adequate intercensal pop-

*Art. I, Sec. 2, Para. 3, modified by the 14th Amendment.
VITAL STATISTICS 371

ulations could be estimated by means of rather simple arithmetic or geometric
projections. The situation has been drastically changed in recent years however,
particularly as a result of World War II. In 1940 a very detailed census was car-
ried out. However within little more than a year, the nation became engaged in an
international conflict of great magnitude requiring the enlistment and draft of
several millions of citizens. In addition, new and old industries underwent spectac-
ular expansion, necessitating the movement of additional millions of persons in
order to serve them. Many communities, within a short space ol time, found their
populations doubled or trebled, while others were noticeably depleted. It soon
became evident that neither the 1940 census data, which by this time had been
released, nor any estimates based upon them could serve much valuable present
purpose. Many attempts were made to find suitable substitutes in the form of
school attendance records, work records, or ration card applications. Of the
group, the latter was probably the most useful. It was hoped that the confused
situation would be ol a temporary nature, but soon statisticians, economists, and
public health workers were convinced that our national mode of life had been
so deeply alfected as to require some new form of population determination
and analysis. During the same period ol time, a new business and social study
technique, the sample survey or poll, came upon the scene and began to serve
a valuable purpose. The ultimate answer to the population data problem will
probably take the form ol relatively simple, easily made enumerations, such
as those the framers of the Constitution had in mind, augmented by frequent
representative sample surveys in order to determine the internal characteristics
ol the total enumerated population.

Next in importance to the population base are data obtained from admin-
istrative reporting procedures. The most significant of these relate to the vital
events of birth, death, and morbidity. Again, in order that these data may be
ol value in the planning of public health programs, there must be some as-
surance of their qualitative and quantitative dependability. This need has led
to the establishment of birth and death registration areas by the Bureau of the
Census. The death registration area was organized in 1900 and included the
states ol Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire,
New Jersey, New York, Rhode Island, Vermont, and the District of Columbia.
At that time, these areas contained about 40 per cent of the total population
of the United States. The birth registration area was established in 1915 and
included originally Connecticut, Maine, Massachusetts, Michigan, Minnesota,
New Hampshire, New York, Pennsylvania, Rhode Island, Vermont, and the
District ol Columbia, accounting for 31 per cent ol the total population. By
1933 all states had become members ol both the birth and the death registration
areas. Membership is based upon two criteria: satislactory state registration laws,
and 90 per cent completeness in reporting.

Certain limitations are found in relation to the value of birth and death
reports. The most obvious is the lact that as yet some of these events go unre-
corded. An analysis in 1950 by the Bureau of the Census indicated that after
thirty-five years of birth registration 97.8 per cent completeness had been achieved,
although each year in the United States about £0,000 babies are born who
 

372 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
are not registered. Other problems are related to the inadequate reporting of
stillbirths and babies born out of wedlock.!

Efforts to secure bettter reporting of both live and stillbirths require constant
vigilance on the part of registrars and directors of vital statistical offices. Many
different approaches have been used and it would appear that no one alone
is satisfactory. Education of the public, of attendants at birth, and of hos-
pitals must be conducted constantly. In addition to this is the use of many types
of checks. Hospital records, baptismal records and, of much less value, newspaper
announcements have been recommended for this purpose. Probably the most
common and accurate check of completeness ol birth reporting is that of deaths
of infants under one year of age. When corrected for residence, this group con-
stitutes a more or less representative sample of the infants born in the area.
Other groups that have been used are entering school children in states re-
quiring a birth certificate for school attendance, and children attending well-
baby or child hygiene clinics. In some states, especially where most births occur
in hospitals, an arrangement has been made with many of the hospitals to pre-
pare a birth certificate at the time the prospective mother enters the hospital,
complete except for the date of birth, sex, and name of the child, which can
be readily filled in after birth at the time the physician signs the certificate. In
addition to producing very satisfactory results, this procedure has added value
in that the certificates are usually typed and therefore are more legible than
they otherwise might be.

The problem ol reporting illegitimate births has been approached in several
ways by the various states. Three distinct trends are evident? The first of these
is to make mandatory provision for the attendant at birth to file the birth certi-
ficate of an illegitimate child directly with the state office of vital statistics
rather than to have it pass through the hands of the local registrar. Some feel
that this weakens the local registration system and is therefore undesirable. The
second trend, found in many states, is the provision that the certificate of an
illegitimate child not differ from that ol a legitimate child—once the child in
question has been adopted or legitimized. The objection that has been raised
against this is the necessity ol preparing new certificates. The third chief trend,
and the least desirable, is to delete the item ol legitimacy entirely. This has
been successfully promoted in a few states by wellare agencies. The objection,
of course, is that this precludes knowledge concerning the extent of illegitimacy
and of the many social and health problems relating to it and may give rise
to a number of legal complications.

Two compromises should be mentioned which offer perhaps the best solu-
tions up to the present. Many states have removed the item of legitimacy from
the certificate proper and have placed it on a supplementary portion. Perhaps
more satisfactory is the policy of a few states of including the item on the certi-
ficate but eliminating it on certified copies ol the certificate, usually by the gen-
eral use of an abbreviated copy of the certificate.

One other phase of birth reporting that causes difhculty is delayed registra-
tion of births. This problem came to a head during the first half of the 1940's
when a birth certificate, as evidence of citizenship, was required for employment
VITAL STATISTICS 373
in the large numbers of war industries. As Bailey? has put it, “the system has un-
dergone its baptism of fire and, in general, has emerged unscathed.” Two out
standing questions have arisen. What evidence should be required to support
the application for delayed registration of a birth? Should this evidence be re-
viewed by the registrar or by the courts? The manual on Uniform Procedures
for Delayed Registration prepared jointly by the American Association of Reg-
istration Executives and the National Office of Vital Statistics seems to provide
the answers as to the nature of acceptable evidence. Since routine court evalua-
tion is unwieldly, particularly by virtue of the numbers of applications involved,
most states now have the evidence reviewed by the state registrar, with recourse
to the courts in case of a rejection. This seems to be a satisfactory and advisable
pattern.

Because of burial requirements, deaths are reported to a greater degree of
completeness than are birth. The value of death certificates is impaired, however,
not only by some inadequate reporting but also by the subjective nature of
much of the data requested on the form. It is still not rare for the cause of a
death to be misstated deliberately in order to circumvent potential social stigma.
This occurs, not only in relation to syphilis, but also in some degree to tubercu-
losis, cancer, and some hereditary aliments. Incorrect diagnoses present a con-
stant problem to the vital statistician. Numerous studies have been made of
the degree of accuracy of the physician's statement of cause of death. The figure
varies considerably by time and place. The magnitude of this error is subject
to steady reduction by virtue of improved medical education and the develop-
ment and use of new laboratory and clinical diagnostic techniques. Beyond this,
the most that can be hoped for at present is for each jurisdiction, for its own
purposes, to attempt some estimate of this source of error by means of checking
with autopsy reports and by consultations. Even the most conscientious physician
is faced with the difficult problem of deciding the primary cause of death as
against contributing causes. This problem has been partially solved by the publi-
cation and wide adoption of the World Health Organization International Classi-
fication of Diseases which presents primary and secondary causal preferences
for all possible combinations of diseases.

With but two exceptions, responsibility for the collection and processing
of reports of births and deaths is delegated to the state health department, and
in the majority of instances the state health officer is designated by law as the
state registrar of vital statistics. In Massachusetts, the Secretary of State and,
in Alaska, the State Auditor are the officers responsible. In all of the states and
territories, collection is accomplished through local registrars who receive re-
ports directly from attending physicians, midwives, undertakers, and others.
With regard to the definition of local registration areas and the appointment
of local registrars, Mountin and Flook?® in their analysis of state health depart
ment organization found:

The basis upon which local registration districts are formed and the method by
which local registrars are appointed are prescribed by State law. For the most part,
political subdivisions of a county constitute the basis for establishing local vital statistics
registration districts. Cities, villages, towns, townships, election districts, magisterial
districts, or similar minor civil divisions form the local registration areas in 42 States.
374 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

In the remaining States, geographic rather than political characteristics are the factors
which determine the boundaries of local registration districts. Convenience of com-
munication, transportation facilities, and mail service are items usually considered under
this plan. There is even greater variation with respect to the method of appointing
local registrars. In over two-fifths of the States, either the State board of health, the
State health officer, or the director of the bureau of vital statistics makes the appoint-
ments; in a dozen more, they are appointed locally by the board of county commissioners,
the local health officer, the board of town trustees, the mayor, or board of aldermen;
in 10 States the duties of city or town clerk or of local health officer automatically
include the collection of vital statistics; while in the remaining half dozen States,
the office is elective—by popular vote of the community. *

The routing of reports of births and deaths is subject to much variation. A
study in 1939 of thirty-six states brought out the following practices. In four
states, certificates are either filed with the county health officers, who transmit
them to the state health departments, or are routed by the local registrars through
the county health departments. In twelve states, registrars send the certificates di-
rectly to their state health departments. In one of these states, the local registrars
also send copies to the county health departments for their use. The remaining
twenty states combine the two procedures described above. Certificates are lor-
warded by local registrars directly to the state health departments except that in
counties or districts with full-time local health departments certificates are sent to
them [or transmission to the state office.

In all but two states, birth and death certificates are forwarded to the state
health department once a month. One state receives them but once a year, a prac-
tice conducive to error and inadequate use. The other exception requires that
certificates be forwarded weekly. Among other values, this makes it possible for
the public health nursing service of that state health department to establish
educational and other contact with families in which there is a new baby, within
one or two weeks ol delivery. It would appear desirable that, whatever routing
procedure is followed, four basic principles should be adhered to:

1. Certificates should be made promptly by medical or other attendants.

2. There should be a system ol routine checking by registrars of all certifi-
cates for correctness and completeness.

3. Certificates should be forwarded to the state agency at intervals of not
longer than one month.

4. Pertinent data on certificates should be made readily and promptly avail-
able to local health departments, preferably by means of their acting as
intermediaries in the transmission of certificates [rom local registrars to
the state department. If this is not provided for, much ol the value of
the reporting is lost.

Morbidity reporting presents a problem peculiar unto itsell. Information
relating to the incidence of disease in a community is obviously necessary for
a public health program of any logical design. Upon this data depends whatever

*Mountin, J. W., and Flook, Evelyn: Central States Services Affecting All Branches of Public
Health Work, Pub. Health Rep. 58:262, Feb. 12, 1943.
VITAL STATISTICS J75

steps the organization may take in many of its other activities. The incidence
ol various types of disease points to the extent of hospital, laboratory, and home
nursing facilities needed. The prevalence ol enteric diseases gives an index of
the adequacy of the environmental sanitation and the food and milk control pro-
grams. Information concerning disease is one of the most potent items in the
armamentarium ol the health educator. With increased interest in problems
ol older citizens, data depicting their illnesses are fundamental to the crystalliza-
tion of a program for their benefit.

Completeness of morbidity reporting is subject to great variation depending
upon states laws and local regulations, the presence or absence, adequacy and
inadequacy of local health departments, the types and severity of diseases com-
mon in the area, the professional and social attitudes of the physicians practicing
in the area, and the customs and economy ol the people.

An analysis in 1944 ol state laws regarding reportable diseases indicated
great variation both in the total number of diseases reportable and in the
specific diseases included. The total number varied [rom twenty-eight in Virginia
to sixty-six in Iowa. Reports ol occupational diseases are required in addition
in twenty-four states. Only twelve communicable diseases were reportable in
all states: conjunctivitis, diphtheria, measles, meningitis, poliomyelitis, scarlet
lever, smallpox, syphilis, typhoid fever, tuberculosis, undulant fever, and whoop-
ing cough. Similar variation has been noted with respect to morbidity reporting
procedures.® Only two requirements are uniform in all the states. First, every
state requires that cases of notifiable diseases be reported by the attending phy-
sician or, in the absence of a physician, by householder, head of the family, or
person in charge of the patient. Second, the reports are to be made to the local
health authority. Forty-six of the fifty states use report cards. Seventeen use
the same card for all diseases, thirteen have a special card for tuberculosis, and
twenty-nine lor cases ol veneral diseases. Format varies [rom no regular form
(four states), to single (twenty-seven states) and multiple (nine states) case pen-
alty cards, stamped cards (two states), cards requiring postage (three states), and
forms other than a postcard (four states).

The usual practice is to route morbidity reports through the local health
department to the state health department. Some states require only that copies
ol daily, weekly, or monthly summaries be sent to the state health department.
A lew states follow the unreasonable practice ol requiring physicians to send
reports both to the local and to the state health departments.

Certain factors must be taken into consideration in the use of morbidity
data. Fundamental is the need to prepare and educate those in the community
from whom reports are expected to be obtained. The most important of these
are private physicians, hospitals, and schools. Two other sources worthy of
mention are the dental profession and industry. Too often there is an inclina-
tion to require reports of too many diseases and in too much detail, whether
or not any practical use can be made ol the information. Physicians and other
reporting agencies soon form a conclusion concerning the practicality of the
request and the use made of it. If they decide that the information is merely
received and filed away, they soon become careless in their reporting. In all
376 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
fairness, they can hardly be blamed if no one takes the trouble to explain the
purpose of the items requested.

An additional important factor is the amount of work involved in making
the report. Busy practitioners are loathe to spend much time in writing out
details of cases for official agencies. The problem of “red tape” is very real. The
average physician practicing in an American community today finds it necessary
to have readily available a number of different official and semiofficial report
forms which must be filled out for births, deaths, communicable diseases, pre-
marital examinations, acts ol violence, workmen's compensation, veteran's bene-
fits, and insurance examinations, to mention but a few. The least that can be
done is to standardize and simplily some of these forms insolar as possible.
In the case of morbidity reporting, requirements and methods should be reduced
to the barest essentials. Thus, an increasing number of official health agencies
accept reports of cases ol communicable diseases in the form of telephone calls
or preaddressed postcards, requiring only the diagnosis and the name, age, and
address of the person affected. It is significant that the patient's name, address,
and age and the name of the disease are the only items common to the morbidity
report forms of all of the states. From there on, it is the responsibility of the
public health personnel to obtain what further details appear necessary for the
adequate public health management of the case.

West,” in an analysis ol the completeness of morbidity reporting, found
that while physicians are the most important and in some areas almost the only
source, in other areas hospitals, schools, visiting nurse associations, industrial
plants, health department clinics, staff members, and householders were also
valuable reporting sources. Within given areas she found that some diseases,
particularly scarlet fever, were reported almost entirely by physicians, while other
sources were more important for certain other diseases, notably tuberculosis.
As a result she suggests the use of certain indices for the estimation of the level
ol reporting of various diseases. In the areas studied, it was found that for the
childhood diseases—chickenpox, diphtheria, German measles, measles, mumps,
scarlet fever, and whooping cough—the level of reporting of cases included in
the school records furnishes useful information as to the completeness of reporting.

For meningococcal meningitis, pneumonia, and poliomyelitis the complete-
ness of reporting of cases in general hospitals provides a very useful index. For
diseases for which there is available no one source representative of the population
at risk, an index representing an upper limit to the completeness of reporting can
be obtained by combining the available data in the form:

All reported cases

All reported cases + unreported cases [rom each source

For rheumatic fever, for instance, no single source was found to be satisfactory.
Here an upper limit based on data from hospital, school, and death records
provides an index. For tuberculosis an upper limit based on the reporting of
cases found in hospital, sanatorium, death certificate, and health department
data provides the most useful index.
VITAL STATISTICS 377

 

It is concluded that it is impossible to devise any final or universally ap-
plicable index since such shifting factors as the occurrence of an epidemic or
a change in the population will temporarily alter the level of reporting of
particular diseases. However, West states: “the need of the local health officer is
not for refined figures which could be developed from protracted study, but for
approximate figures which will assist him in interpreting and evaluating the
morbidity program of his own department and in planning the better utilization
of reporting sources.”

Since 1925 there have been many proposals for the establishment of a
morbidity reporting area similar to the birth and death registration areas. As
yet no definite steps have been taken. The change in title of the sixth revision
of the International List of Causes of Death to the International Statistical Classi-
fication of Diseases, Injuries, and Causes of Death (1948) should be noted, how-
ever. It has been increasingly suggested that public health agencies obtain mor-
bidity data for administrative planning by means of special detailed studies
and sample surveys rather than to depend upon routine reports which are subject
to so many limitations.® This approach to the problem has already been put
into effect in a number of instances, notable among which are the Hagerstown
Studies and, more recently, the United States National Health Survey. The
use which has already been made of the data collected in these two instances
has more than justified their cost and points to the need for further application
and development of these techniques.

Langmuir? has stated:

The morbidity survey is a particularly useful epidemiological tool in that data
on both the sick and the well are obtained concurrently. The problems arising from
underreporting of cases, from arbitrary classifications of causes of death, and from
unknown shifts of population between census years are largely eliminated. . . . Tts
unique advantage lies in the detailed information that can be collected about the
population. Frequency rates, specific for a wide variety of social and environmental
factors, can be determined. Such comparisons are not obtainable by matching routine
morbidity reports and death certificates with census figures.*

He further points out the interrelationships between the simple survey and the
special study.

The simple morbidity survey has one inherent limitation—only general data can be
obtained. The questions asked by the interviewers must be simple and understandable
to the informants. Few specific diseases can be adequately counted by this method.
Special studies are necessary to collect such definitive epidemiological information *

Administrative Uses of Vital Statistics. The collection and analysis of public
health statistics are at best costly and difficult tasks. The only real justification
for performing it is the administrative use to which the resulting information
may be put. Reports of vital and of related events, such as the services rendered
by the personnel of a health department, constitute important legal records.

*Langmuir, A. D.: The Contribution of the Survey Method to Epidemiology, Am. J. Pub.
Health 39:747, June 1949.
378 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES |

Their personal value arises in connection with proof of citizenship, the right to
attend school, to vote, to marry, to enter the armed services, and to draw benefits
ol many types. Records of births and deaths are of particular significance in the
establishment of inheritance rights and in the prevention of capital crime. Not
infrequently health department service records play an important role in litiga-
tion relating to property use and condemnation.

Of particular importance are the uses to which statistical data may be put
in the administration and management of the public health program. For statisti-
cal data to be of real value in the public health program, efforts far beyond the
strict legal responsibilities imposed upon public health agencies are required. Too
often the minimal acts ol registration and reporting have been conducted as the
sole activity in this field. Registration may be relegated to an untrained clerk
who routinely accepts, transcribes, and files the documents after a most cursory
examination. This procedure can make statistics nothing but “dead” in the
most literal sense. When, on the other hand, all of the statistics available to a
health department are correlated, they become of fourfold value in that they
make possible: (1) the definition of the problem, (2) the development of a logical
program for its control, (3) the planning ofl records and procedures for the ad-
ministration and analysis of the program as it progresses, and (4) the evaluation
ol the results of the program.

An example may serve to illustrate these points. The crude number of
deaths occurring in a community is ol relatively little value. It must be fixed
to some standard, the most convenient and useful being a unit of population.
This involves an appreciation of the adequacy of reporting and the availability
ol a dependable population count or estimate. The death rate may then be
found to be 9.5 per 1,000 inhabitants. A series of questions now arise. Is this
high or low? Comparison must be made with the rates of other communities
ol a comparable nature or adjusted for the differences. If it is decided that the
single figure is relatively low, is that true of all groups in the community? Age
is one basis for grouping. Calculation ol age-specific death rates may show a
much higher than average mortality under the age of one year. Further breakdown
may localize the problem in the neonatal period, involving particularly infants
born prematurely. What can be done to alleviate the situation? Perhaps an
analysis of certain other factors may point the way. Correlation of birth and
infant death certificates may point to premature infants born at home or in a
particular hospital as accounting for a majority of the deaths. The health de-
partment may then strive for the installation of special [acilities, incubators, and
specially trained nurses in the hospital in question. In order to include those
born at home, it is imperative that birth certificates be sent to the local health
department within twenty-four hours after birth, in which case they should
be routinely screened for prematures. A somewhat better solution would be the
arrangement of a discussion of prematurity with the local medical society and
the adoption of a policy of phoning the health department immediately upon
delivery of a premature infant in the home. In either of these ways, it becomes
possible for the health department to detail a public health nurse to the care
of the infant within the first few crucial days of life.
[81RTH]

 

 

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Fig. 23. Diagrammatic sketch of diphtheria prevention program, Detroit, Mich.

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380 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

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PHILADELPHIA PUBLIC HEALTH SERVICE AREAS
o Ye | 2 3
SCALE IN MILES
1951

Base map prepared by Philadelphia City Planning Cownission, 1951

Fig. 24. Spot map. Distribution of reported deaths from tuberculosis, Philadelphia, 1957.

Perhaps analysis of the statistical data relating to births and infant deaths
indicated a higher incidence of prematurity and premature death among cer-
tain racial or nationality groups. It then becomes the task of the public health
stall to study the habits and customs of these groups in an attempt to discover
VITAL STATISTICS 381

 

causal relationships. If such relationships are discovered, a difficult but fascinating
task is laid before the health education and public health nursing staffs.

Figure 23 presents another example, this time of the use of the crude cer-
tificate in the diphtheria prevention program of one city. It should be noted
that the birth certificates represent the key to the approach and also that for
public relations reasons a constant running check is made against reports of
infant deaths.

Of increasing importance in the planning and operation of modern public
health programs is the use of [ractionated data and of certain graphic devices.
There is nothing particularly new or difficult about the breakdown of crude
or general data into its component parts. The possible number and types of
such breakdowns are practically infinite and the public health worker must
decide which are going to be most useful. With all statistical analyses, much
depends upon the form in which the material is arranged for study and presen-
tation. A mass of figures is generally incomprehensible. It is desirable, therefore,
to depict the data in some manner which makes it possible to grasp the total
picture and all of the details. One of the most common methods is the simple
spot or pin map which gives an instant over-all answer to the question of where
the problem is located. An example is presented in Figure 24 which shows for a
large city the residences of persons who died from tuberculosis known to the
health department as of a certain date. Since the information is based upon
a constantly moving point in time, this should preferably be in the form of a
pin map. This would make possible the shifting of pins as cases are added
or dropped and would also allow for the use of different-colored pins to indicate
the present status of each case as to severity and hospitalization.

By itself, a spot map of a disease or other single item is limited in that it
does not indicate the extent to which the group is affected. One general approach
to this problem is to distribute the data on the basis of various personal character-
istics such as age, race, sex, or economic status. Figure 25 illustrates one method
of doing this. The city to which the figure relates has a low tuberculosis death
rate. Note, however, how this analysis and presentation points to this specific
disease as an important cause of death in one particular age group. A few of the
many other facts it brings to the surface are that cancer and heart disease are
important even as early as the young adult years, that the greatest risk of death
is during the first year of life particularly because of prematurity, and that acci-
dents are of great significance throughout childhood and young adulthood. Natur-
ally information of this sort will largely determine the nature of the public health
program of the area.

A very dramatic and easily comprehended method of relating specific prob-
lems to other factors and to the group is by means of transparent overlay maps.
This is particularly useful if there is available for use as a base a map such as
Figure 26 which shows the distribution of the population of the area. Thus,
if spot maps such as Figure 24 are of the same size and are made on transparent
material such as pliofilm, they may be successively superimposed on the popula-
tion map or on each other for visual correlation. Some of the earliest and most
382

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PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

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VITAL STATISTICS J&83

     
   

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Fig. 26. Distribution of total population, Philadelphia, 1955.

extensive uses of this procedure have been made in Cleveland both for problem
analysis and for community education 0.11.12

In recent years, public health administrators have come to realize that the
health programs of large cities are best administered through neighborhood
health centers. These centers are usually decentralized administrative units
ol the central health department and are usually designed to include popula-
tions of about 200,000. Merely to determine the best locations of the health
centers, it is necessary to have detailed information concerning the various
384 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

subdivisions of the jurisdiction. It is strange that while data has long been
available for small villages and towns, this has not been generally true of the
neighborhood units of large cities until the 1940 census. Too often programs
have been based upon data limited to the incidence ol cases and deaths and
have totally ignored the composition of the matrix among whom the cases and
deaths were occurring. To be of more than limited use and significance these vital
statistics must be related to the places people live, the way they live, the kinds
ol work they do, and the problems they face. Because of this, the Bureau of the
Census, during recent years, has broken down and made available much of the
enormous [und of information it gathers on the basis of census tracts.

A census tract is a small area with definite and permanent boundaries, in-
cluding a population of between 3,000 and 6,000. It is fairly homogeneous with
respect to race, nativity, economic status, and general living conditions. This
has made it worth while for public health administrators in turn to tabulate
the vital statistical data of their jurisdictions on the basis of smaller administra-
tive areas. The correlation of these two sources of information has two great
advantages: (1) health statistics compiled on a census tract basis serve to show
the geographic distribution of health problems, and (2) health statistics com-
piled on a census tract basis may be related to other social and economic factors
also available by census tracts. As Dunn'® has well stated, the ability to spot births,
deaths, communicable disease cases, nurse's visits, and other pertinent data on
a tract map shows the health administrator where his business is. Classes for
mothers should be organized in areas where births are most frequent. There
should be special effort and specific preventive measures in areas where still-
births and infant deaths predominate. Well-baby clinics should be located in the
areas where the babies live. Venereal disease and tuberculosis clinics should
be located in the areas where veneral disease and tuberculosis cases are con-
centrated. Similarly, public health education programs on venereal disease and
tuberculosis should be stressed in these areas. Special preventive measures should
be taken in areas where certain other communicable diseases occur. Accident
prevention programs should be stressed in areas where most accidents occur and
where persons who are involved in accidents reside. Outpatient hospital clinics
should be located in areas where the people who use them reside. Nurses’ areas
should be designed according to the distribution of demand for nurses’ services.
Housing inspections and inspections of food establishments are presumably made
on a city-wide basis. It is a good idea to design inspectors’ areas by census tracts
and to keep inspection records on this basis. Problem areas may be easily
spotted and special attention can be given these areas.

It is not practical, of course, to establish a health center or clinic in each
census tract. Furthermore, because of the small numbers of births, deaths, and
cases of disease occurring in each tract, any rates computed in this relatively
small population base are of doubtful significance. In using the information,
therefore, the health officer usually finds it desirable to recombine the census
tract data in a manner most convenient and best suited to his needs. The usual
practice is to form health or sanitary districts, the boundaries of which coincide
with those of a number of census tracts. It is then possible to compute statistically
VITAL STATISTICS 385

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SCALE IN MILES
1951

Base map prepared by Philadelphia City Planning Commission, 1951

Fig. 27. Estimated population, birth rate, death rate, infant mortality rate, maternal mortal-
ity rate, and death from diseases of early infancy by health district, Philadelphia, 1957. P, popu-
lation; BR, birth rate; DR, death rate; IMR, infant mortality rate; MMR, maternal mortality
rate; DEI, diseases of early infancy, Philadelphia, 1957.
386 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

significant rates and ratios which may be presented in one or several of a number
ol ways as has been done in Figure 27.

A particularly valuable and illustrative method of presentation of frac-
tionated data for administrative purposes is in the form of what has been called
the epidemiological master chart.'* This type of chart makes possible the presen-
tation, at one time, of the most complex yet comprehensible pictures of the
total public health situation. An example is shown in Figure 28, which presents
a detailed and interrelated analysis of a great many important factors bearing
on the public health program of the city of Philadelphia. It presents vital data
in a form which makes it possible to compare the health districts of the city
with one another and to gain a composite view of a large number of factors within
each district. The total width of the bars represents 100 per cent of the popula-
tion of Philadelphia. The width of the ten subdivisions in each bar indicates
the percentage of the total population residing in each district. The numerical
percentage is indicated for each district, at the top of the first bar. The height of
the two bars for race and age groups represents 100 per cent of the population
that resides in each district, the subdivisions indicating the percentage ol per-
sons in cach age and race group. In the remaining bars are shown rates of birth,
infant deaths, and deaths from important causes, with the scale placed at the lelt
of each bar. Under the title of each bar is noted the rate for the city as a whole,
this being shown further by a horizontal line drawn through each bar.

While it is in no sense the purpose of this chapter to discuss statistical
methodology, there are several computations that public health workers have
found particularly useful in judging their programs and in gauging their prob-
lems. The simplest of these is the crude death rate. This commonly used rate
is merely the number of deaths occurring within a certain time period, usually
one year, relative to a convenient unit of population, usually 1,000 persons.
Thus a community of 23,460 persons which experiences 220 deaths during a
year has a crude death rate of 220 x 1000

23,460
This figure has obvious limitations, all of which arise from the many factors
its innate crudeness may conceal. It is easily possible, for example, for a com-
munity to have a low crude death rate and yet experience serious mortality
from certain particular diseases. Similarly, one community may have a lower
death rate than another, merely by virtue of a greater proportion of young
adults in its population. Despite these handicaps, however, the crude death rate
is still the single most commonly used basis for comparison by time and place.

Less commonly used is the vital index or birth-death ratio. This is ob-
tained by dividing the number of births by the number of deaths occurring
during a year and multiplying by 100 as a base. If this ratio exceeds 100, the
population is growing; if it is less than 100, the population is decreasing due
to biological factors alone. One limitation ol the figure is that a prolific com-
munity may have a vital index of more than 100 in the face of unhealthy con-
ditions and many deaths, while the index of another and perhaps healthier
community may be low merely because of small families or an older average
age of the population.

- = 9.4 deaths per 1,000 population.
VITAL STATISTICS 387

 

A useful rate not commonly used in most countries is the discratic index.
It presents the relationship between the infant mortality rate and the mean
age at death. It is considered a good measure of the state of well-being of a
community since it takes into consideration both the tendency of death during
the sensitive first year of life in relation to the total number born, and the
average length of life of the total dynamic population which is necessarily in-
fluenced by all sanitary measures and preventable causes of death along each
phase of life. The population under one year of age is subject to all of the
conditions that tend to raise or lower the infant mortality. If the mean age at
death is low, it indicates that diseases are destroying life in the younger age
groups of childhood and early adulthood where preventive medicine and public
health measures offer the greatest benefits up to the present time. The discratic
index is defined by de Shelley-Hernandez'» as “the reflection of the sanitary
condition of the community as seen through the observed relation between the
mean age at death of the inhabitants, and the force of infant mortality. It is
obtained by dividing for a given year the coefficient in terms of 1,000 live births
of the infant deaths, by the mean age at death or average duration of life of
the inhabitants of the same community.” For the practical application of this
interesting and useful index, de Shelley-Hernandez has suggested the following
standards:

Discratic Index Sanitary and Health Conditions

1 very good
good
almost good
almost bad
bad

very bad

Ct 0 ND

Another type of statistical index of fundamental importance to health
officer is the endemic index. This may be developed in several ways. If one
wishes to compare the current frequency of a disease with some standard for
the community in the recent past, the experience for several years might be
averaged to obtain a mean. If for the previous five years the experience of each
calendar week is averaged, there results a five-year moving mean. If a disease
demonstrates cyclicity, as does measles, an endemic and epidemic moving mean
may be calculated and graphed for comparison with the current experience and
for estimating to a certain limited degree the probable anticipated incidence.
Similarly an endemic median and a three-, five-, or seven-year moving median
may be obtained, Figure 32 on page 558 presents several charts of this type.

An increasingly important use of vital statistics is in connection with the
allocation of Federal funds to state health departments and of state funds to
local health departments. Various aspects of this subject have been discussed
in Chapter 7. It will suffice here to call attention to the bases upon which such
grants-in-aid are made. Just as population serves as the basic factor in the com-
putation of incidence and death rates, population or per capita data form
the most significant single factor in the allocation of public health funds. Be-
yond this, many fiscal formulas include provisions for supplemental grants,
388 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Health District | 2

Percent of
Total Population 54 9.8 10.4 9.2 9.9 9.5 12.2 12.3 1.9 9.5

rr rr rr |
458 oer | | | | | |
; ry

 

(Maturity)

 

 

15-44
(Reproductive)

AGE GROUP

5-14 | | . — 1
(School Age) | | | Percent

| — L re 1 red — 10
Under 5 | | [ yr a ; Hi i ol

(Pre-School)

 

 

 

 

 

Non-White Ln

Percent

o]

 

 

 

|
|
White Co .

Fig. 28. Epidemiological master chart, Philadelphia, 1957.
VITAL STATISTICS 389

 

 

40

- | |
| |
Co

Birth
Rate : City
pm 212

 

 

 

 

 

City
1.4

Death
Rate

 

 

 

 

80 |

100 | — |
|
|

Infant
Mortality |
Rate
City
20 31.6

 

 

 

 

 

100

City

Diseases
f 47.1

0
Early 40
Infancy

 

 

 

 

 

 

Fig. 28 (cont'd). Epidemiological master chart, Philadelphia, 1957.
390 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

25

20

 

Infective & 15
Parasitic

Disease 10

 

 

 

 

 

 

 

 

 

 

 

 

100
80
60 |
Pneumonia Hi
40 . | Ld

fr

20 Ln .

 

 

 

 

 

 

 

0

 

 

 

 

50

40

 

 

30

Tuberculosis

 

 

 

 

 

 

 

 

 

 

500

400

 

 

Tuberculosis °°

Morbidity
Rate 200

 

 

100

 

 

 

 

0

Fig. 28 (cont'd). Epidemiological master chart, Philadelphia, 1957.

City
7.6

City
37.8

City
15.8

City
101.0
VITAL STATISTICS 391

 

 

10CO

800

600
Diseases
of
Heart 400

 

City
474.1

 

 

 

200 |

 

 

 

 

 

500

400

300

 

 

Cancer

 

 

 

 

 

200 | : oo IR | city
Ea : 197.5

 

 

 

 

100 |

 

 

250 a

200

Vascular 150

Lesions i

of CNS LL
100 |

 

 

 

JT City
Fre ; Tre 107.9

 

 

 

 

 

 

50

 

oL

 

 

50

 

40

 

30

 

 

 

Diabetes City

22.2

 

 

 

 

 

 

Fig. 28 (cont'd). Epidemiological master chart, Philadelphia, 1957.
392 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

beyond the per capita grants, based upon special problems. The existence of
these is determined by morbidity data, prevalence rates, facilities available or
needed, mortality, natality, and rate of population increase.

Statistical data are of further administrative importance in the sense that
they provide a measure of the degree of compliance of local health departments
with established standards, and a means for the evaluation and comparison of
the programs of health departments. The periodic completion of the evaluation
schedule of the American Public Health Association is becoming accepted practice
in an increasing number of health departments. This extremely valuable ad-
ministrative tool or yardstick depends almost entirely upon accurate statistical
information.

Elsewhere it has been stated that every progressive health department has
a responsibility to accept research as one of its functions. The word research
almost automatically makes one think of statistics. They are mutually inter-
dependent. Unfortunately, too few official health departments on either the
state or local level engage in special statistical research projects. The potentiali-
ties here are very great. To conduct such investigations obviously requires highly
trained statistical personnel. When they are available and engaged by the health
department, a problem arises as to their relationship with the rest of the personnel
of the vital statistics unit. This logically calls attention to the question of the or-
ganization of statistical services in public health agencies.

Organization of Statistical Activities. While detailed information is not
available concerning the organizational patterns of statistical activities in small
local health departments, such as rural counties and small cities, certain general
statements may be made. In these situations, as mentioned earlier, the local
health officer is usually designated as the registrar of vital statistics. Ordinarily
he in turn delegates this responsibility to some member of his office staff who,
although seldom specifically trained, in some instances is referred to as a statistical
clerk. This person acts as a sort of combination record clerk and clearing house
for the reports that come to the health department. Certificates of birth and
death are received, checked, transcribed, indexed, and filed. His analytic activities
are usually confined to the compilation of simple tabulations for the annual
report. He also receives the reports of cases of morbidity which are transmitted
to the health officer or whatever person is responsible for their control. In con-
nection with this, he often maintains files and registers of active and closed
cases. In most instances, he has no responsibility for the service and activity
records of the health department personnel who usually take care of their own.
Where systems such as the family or household folder are used, however, he is
often put in charge. The general picture, therefore, is one of simplicity and
almost informality, brought about by the combination of small staff, proximity
to problems, and lack of statistically trained personnel and of funds to employ
them.

When the public health departments of large cities and states are con-
sidered, one would expect to find a more or less uniform plan of statistical organ-
ization since the needs and problems are essentially similar in such situations.
VITAL STATISTICS J393

 

Interestingly enough, this is not the case. From the viewpoint of organizational
principles, the statistical activities of these larger units are ol two types: func-
tional or line in the sense of the routine collection, preservation and transcrip-
tion of vital statistical documents, and stall, in the sense of the activities related
to studies, research, consultation, fiscal and program control. Herein lies the
origin of most of the organizational problems and variations.

The patterns found on the state level may be used for purposes of illustra-
tion since data concerning them is conveniently available and since the state is
ultimately responsible. An analysis by Swinney! indicated five basic patterns
of organization of state health department statistical activities: (1) no central
statistical organization, (2) a division of vital statistics with some central statistical
services, (3) a division of vital statistics with an independent central tabulating
unit, (4) a central statistical division, with an independent division of vital
records, (5) a central statistical division covering all registration and statistical
activities.

In the eighteen states in the first category, the collection, preservation, and
tabulation of the routine vital records was a function of a separate line division
or bureau of vital statistics. Beyond this, each major subdivision of the health
department was individually responsible for all of its own record keeping, re-
porting, and statistical functions. Several unusual situations were found in
this group. In Nevada, the vital statistical and the personnel functions were
merged, in South Dakota, vital statistics and health education were in one di-
vision, while in Massachusetts, vital statistics was the responsibility of the Secre-
tary of State although a cooperative relationship with the State Health De-
partment was maintained.

In the second category were fourteen state health departments in which
certain limited statistical services to other divisions were rendered by the line
division or bureau of vital statistics. In most instances this had resulted from
attempts at economy and efficiency by pooling all mechanical tabulating equip-
ment and specialized statistical personnel. The usual pattern was for the func-
tional divisions to collect and edit data and to plan tabulations. The vital
statistics division then punched cards and tabulated the data, following which
the completed tables were returned to the program divisions for analysis and
release.

The six state health departments in the third category had what amounted
to an adaptation ol the foregoing in that they maintained a division of vital
statistics and a central tabulating unit, which, however, were not united. The
typical pattern here was a line division of vital statistics and a central tabulating
unit as a staff agency in the division of administration.

Four state health departments had established independent units for statisti-
cal services in addition to line divisions responsible for vital records. Again, as
in the case of the third category, the central statistical service was organized as a
staff agency responsible to the commissioner of health. The difference, however,
lay in the purpose ofl the central statistical unit. In this instance it had no
routine administrative or operating responsibilities. Rather, it existed to pro-
vide staff services and technical assistance to all parts of the department and
394 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

 

to local health departments in the state. As in Tennessee, which had the first
and most highly developed unit of this type, it existed for the purpose of “think-
ing the program through” and for planning, analysis, and interpretation. Need-
less to say, this necessitates highly qualified leadership and a well-trained staff.

The remaining six states, which formed the fifth category, had relatively
recently centralized all statistical services in one unit. The pattern that was ap-
parently emerging was to form subdivisions or sections dealing with vital records,
tabulation, analysis and reports, and consultation service.

In connection with the analysis summarized above, Swinney found adminis-
trators divided into two groups with regard to centralization of statistical services.
One group felt strongly that except for routine activities, such as vital records
and tabulating, all statistical functions should be left in the various [unctional
divisions. The primary reason given was the fear that centralization of statistical
records and activities would detract from their adequacy and usefulness. The
majority, however, felt that some form ol centralized statistical unit was needed
in large public health organizations to ensure efficiency, correlation of data and
activities, and more profitable use of statistical personnel.

It is probably desirable that so much variation exists. Among other things,
variation indicates ingenuity and experimentation, two characteristics that con-
tinue to be greatly needed in this as well as many other fields of public health.

REFERENCES

1. Shapiro, S., and Schachter, J.: Birth Registration Completeness, United States, 1950, Pub.
Health Rep. 67:513, June 1952.
2. Bailey, A. E.: Some Recent Trends in Vital Statistics Registration Practices, Am. J. Pub.
Health 38:253, Feb. 1948.
3. Mountin, J. W., and Flook, Evelyn: Central States Services Affecting All Branches of Public
Health Work, Pub. Health Rep. 58:262, Feb. 12, 1943.
4. DecPorte, J. V.: Effectiveness of Different Systems of Collecting Vital Statistics Data, Am. J.
Pub. Health 29:857, Aug. 1939.
Fowler, W.: Diseases and Conditions Required to Be Reported in the Several States, Pub.
Health Rep. 59:317, March 10, 1944.
6. Ciocco, A., West, M. D., and Altenderfer, M. E.: State Variation in the Collection of Report-
able Disease Statistics, Am. J. Pub. Health 36:384, April 1946.
West, M. D.: Morbidity Reporting in Local Arcas, Pub. Health Rep. 63:329, March 12, 1948;
and 63:1187, Sept. 10, 1948.
8. Morbidity Surveys—A Symposium, Am. J. Pub. Health 39:737, June 1949.
9. Langmuir, A. D.: The Contribution of the Survey Method to Epidemiology, Am. J. Pub.
Health 39:747, June 1949.
10. Green, H. W.: Population Characteristics by Census Tracts, Cleveland, Ohio, 1930, Cleveland,
1931, Plain Dealer Publishing Co.
11. Green, H. W.: Tuberculosis and Economic Strata, Cleveland’s Five City Area, 1928-1931,
Cleveland, 1932, Cleveland Health Council.
12. Green, H. W.: Infant Mortality and Economic Status, Cleveland's Five City Area, 1919-1937,
Cleveland, 1939, Cleveland Health Council.
13. Dunn, H. L., Health and Social Statistics for the City, Am. J. Pub. Health 37:740, June, 1947.
14. Darling, G. B.: Epidemiological Master Chart, Am. J. Pub. Health 21:665, June 1931.
15. de Shelley-Hernandez, R.: Statistics Applied to Biological Science, Caracas, Venezuela, 1939,
El Comercio, Ministerio de Hacienda.
16. Swinney, D. D.: Current Organizational Patterns of Statistical Activities in State Health De-
partments, Pub. Health Rep. 64:621, May 20, 1949.

ot

~1
chapter 1 5

Laboratory services

 

Development of Public Health Laboratories. Early recognition was given to
the important role played by laboratory procedures in the public health program.
This may be attributed to the need for scientific guidance in an era rife with
epidemic disease. It is not surprising, therefore, that most of the older public
health laboratories owed their inception to some catastrophe such as an epidemic
and that, generally speaking, they were developed in congested cities and towns
before they became common on the state level. For example, the first municipal
laboratory in the United States began operation in 1892 when New York City
suffered a severe outbreak of cholera. At about the same time the first state
laboratory was established in Michigan, followed by Rhode Island in 1894.
Other state laboratories, however, were slow in their formation. This relatively
early resort to laboratory procedure by health departments was perhaps more
fortunate than is ordinarily realized. In a sense, it established a philosophy or
point of view and encouraged a constantly inquiring attitude. Without it,
many of our programs up to recent times would have been based upon sheer
guesswork. The benefits that accrued from this relationship between laboratory
and program were stated by William H. Welch! in the following terms:

The development of laboratories connected with boards of health is one which is
peculiarly American. The appreciation of the need of such laboratories, of what can
be accomplished by them and of the benefits which the general public derive from
them, has been greater in this country than elsewhere. We have led in this particular
direction . . . . The foundation of such laboratories has had a very important stimulat-
ing influence upon boards of health, both local and state. It has introduced a scientific
spirit into the work; it has brought into connection with executive officers the younger
men who are full of enthusiasm with reference to studies along these lines, and I think
that we may say that the general tone of boards of health has been elevated and stim-
ulated by the foundation of laboratories of this character.*

Functions of Public Health Laboratories. While it is true that public
health laboratories originally were and to a considerable degree still are primarily
concerned with problems of sanitation and epidemiology, the scope of their

*Welch, William H.: (Lecture) Relations of Laboratories to Public Health.

395

ed
396 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

work has been greatly broadened in recent years. Within the health department
itself, the laboratory serves as a guide and tool for each of the other activities.
It furnishes the clue to the types and extensiveness of the communicable disease
problems. It not only indicates the effectiveness of the sanitation program but
even provides the basis of design of engineering structures in that field. It is
of great importance in certain phases of the maternal and infant health pro-
grams. In the final analysis it might be said with good reason that by itself
laboratory service is of little value and that of necessity it must be used as an
adjunct or in relation to other programs and activities. Beyond the component
parts of the health department, while individual medical management is primarily
the concern of the private practitioner, the modern public health laboratory
finds it of utmost importance to assist him by ascertaining, inasmuch as pos-
sible, the availability of essential aids to diagnosis, prevention, and treatment.

At the present time, therefore, many of the larger public health laboratories
are engaged in the following types of activities:

I. Provision of diagnostic facilities (often for noncommunicable as well
as for communicable diseases) for physicians and hospitals, as well as
for public health workers

2. Consultation service for private physicians as well as for public health
workers

3. Chemical and bacteriological examination of food, milk, water, air,
streams, narcotics, drugs, liquors, and other substances

4. Manufacture and distribution of sera, toxins, antitoxins, vaccines and
other biological materials for diagnosis, prevention, and therapy; a few
laboratories also determine standards of quality and potency of such
substances

5. Supervision by state laboratories of the practices, procedures, personnel,
and products of local and private laboratories

6. Research

The following discussion is limited chiefly to the larger laboratories of
major cities and particularly of state health departments which, because of the
populations they serve, are in a position or find it necessary to engage in a wide
variety of activities. In a sense, the laboratories of smaller communities with
limited facilities and resources may be considered subsidiaries or local outposts
of the more extensive laboratories of larger governmental units.

All states assume responsibility for providing laboratory services for the
diagnosis and control of communicable diseases. Ordinarily the spectrum of
diseases for which such services are available is broad. Because of the magnitude
of specimens, and because of state legislation pertaining to it, serologic tests for
syphilis account for a significant proportion of the examinations performed by
state public health laboratories. An additional reason is the inability of most
laboratories in smaller jurisdictions to perform the tests and their tendency
to transfer the responsibility to the larger state unit.

To a more limited but increasing degree, state laboratories provide services
relating to certain noncommunicable conditions. Thus, Mountin and Flook?
 

LABORATORY SERVICES 397

found that, in 1950, thirty-six state health departments routinely made various
pathological and biochemical tests as part of their regularly scheduled work.
About one third provide tissue examination services, usually for cancer.

Because of the magnitude of the work and because of the customary re-
sponsibility of the state for supervision, most state health department laboratories
carry on routine bacteriological and chemical analyses of public supplies of
drinking water. Private water supplies are usually tested upon special request
by private citizens as well as physicians and public health workers. Frequently
a fee is charged for this service. A charge for testing private water supplies is
more common than for any other type of public health laboratory service; in fact,
it is rare for any other charges to be made. In several instances, state universities
also make analyses of drinking water, either independently or cooperatively with
the health department.

Interestingly, facilities and procedures for the testing of food, milk, and
drugs are much more varied than those relating to disease diagnosis and water
examination. This is indicative of the differences ol opinion hence the complex
patterns which have developed throughout the United States with regard to re-
sponsibility for surveillance over [ood, milk, and drugs. Although the state health
department laboratories are most commonly charged with this responsibility, in
twenty four states, two or more agencies are involved. Most [requently the other
agency is the department of agriculture, and in three instances it has exclusive
jurisdiction over all aspects of milk and food laboratory control. In addition, in
about a dozen instances, independent state laboratories or laboratory departments,
state chemists, agricultural experiment stations, livestock sanitary boards, state
university laboratories, or boards of pharmacy analyze milk, foods, and drugs
from standpoints of significance to public health.

Altogether, thirty states have established facilities for the laboratory study
and control of industrial dusts, gases, fumes, and other toxic substances to which
workers may be exposed. In twenty-five of these the work is done by the public
health laboratory; in three states the department of labor performs this function
alone; and in the other two, the departments ol health and labor share re-
sponsibility.

At the present time one of the major functions of state health department
laboratories is the distribution of biologicals and other materials for diagnosis,
prevention, and therapy to local health departments and through them to hos-
pitals and private physicians. About one half of the state laboratories manu-
facture at least a few of the materials they distribute. The most common of
these are typhoid fever vaccine and silver nitrate for the prevention of ophthalmia
neonatorum. About six states prepare rabies vaccine, diphtheria toxoid and
toxin lor Schick tests. Other products occasionally manufactured in state labora-
tories include smallpox vaccine, diphtheria antitoxin, scarlet fever antitoxin,
tuberculin, pneumonia serum, antimeningitis serum, and convalescent sera for
measles, scarlet fever, and several other diseases. A few manufacture multiple
antigens, particularly diphtheria-tetanus-pertussis combined antigens. Several
southern states have distributed antimalarial and antihelminthic drugs and some
provide supplies of sulfonamides and antibiotics such as penicillin to local health
398 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
departments. In the majority of instances, no charge is levied for materials
distributed.

Technical procedures, methods of transporting specimens, and reports of
findings have been quite well standardized. Much of the credit for this may be
given to the American Public Health Association, and particularly to its lab-
oratory section. This section is composed of a number of committees among
which are those relating to diagnostic procedures and reagents, examination of
water and sewage, examination of dairy products, analysis of frozen desserts,
examination of shellfish, biology of laboratory animals, and biological products.
Each committee studies procedures and recommends those most practical for
use by public health laboratories.

The development of standard methods and the great increase in various
legally required serologic tests have served to place responsibility upon state
health department laboratories for the supervision and control of techniques
used by local public and private laboratories. This is done by inspections, the
analysis in the state laboratory of duplicate test specimens from the local lab-
oratory, the licensing of local laboratories, and by setting qualifications for
and approval of locally employed laboratory personnel. One third of the states,
for example, specifically require by law that laboratories performing serologic
tests for syphilis be approved and periodically checked by the state laboratory.
Nine states extend this supervision to include all types ol diagnostic tests having
public health significance. Increasingly, even in states with no such provisions
for regulation, approval by state laboratories is being voluntarily sought by
private laboratories as a mark of recognition.

No public health agency can remain progressive and effective without con-
stantly seeking ways of improving its work, services, and methods. While re-
search is needed and possible in all phases of public health, one place where
particularly fruitful investigations may be carried out is in the laboratory.
An opportunity exists here both for pure laboratory research and for investiga-
tions carried on in conjunction with other functional divisions of the health
department. Thus, the majority of state laboratories engage in special research
projects in addition to their routine activities. Usually such investigations are
engaged in either because of the development or discovery of a particular new
problem or because of the personal interest of the laboratory worker or director.
Occasionally special local funds are appropriated for particular research projects
and special personnel are assigned or employed full time to carry them out.
Increasingly, however, Federal and private research funds are being placed at
the disposal of the large, well-equipped and well-staffed public health laboratories.
Frequently, investigations are designed to improve currently used techniques
or to compare them with new procedures. Much also has been done by public
health laboratories in the development and production of new products and
techniques. In addition, an increasing amount of pure research is being done.
Of particular note are investigations concerned with diagnostic tests for cancer
and with various aspects of influenza, rabies, pneumonia, diphtheria, pertussis,
brucellosis, poliomyelitis, staphylococcic and streptococcic infections, and histo-
plasmosis.
LABORATORY SERVICES 399

 

 

Laboratory Organization. Despite the fact that the public health laboratory
is essentially an auxiliary agency existing to augment the programs of the other
units in the public health organization, one seldom finds it structurally located
in the manner theoretically recommended for auxiliary agencies. The very
practical reasons for this are the unusually technical nature of its activities
and its frequently large size. No comment is needed with regard to the first of
these reasons. As for the second, it may be pointed out that in a number of
states, notably Michigan, New York, and Massachusetts, the laboratory itself is
of about the same magnitude in budget, physical size, and number of employees
as the rest of the organization. The pattern, therefore, has been for the lab-
oratories of state and large city health departments to be set up as major func-
tional line units in the organization. Among the states only a few exceptions
are found to this rule. In two states, more than one bureau has laboratory func-
tions; in one state the laboratory is in the bureau of local health services. In
Arizona the state laboratory is an entirely independent agency. A minor but
peculiar exception is found in Wisconsin where, although a bureau of laboratory
services exists in the state health department, all serologic tests for syphilis are
done by the psychiatric institute.

In attempting to make adequate laboratory services readily available where
they are most needed, an interesting administrative and organizational paradox
is found in connection with the laboratory services of states and large cities.
The apparent lack of attention to the development of local facilities has been
due to the fact that laboratory services, because of their high technical nature
and cost, have tended to become more or less centralized. Yet, having centralized
all but the simplest procedures in the state health department laboratory, there
is now observed some tendency toward decentralization. This decentralization,
however, takes the form of branch or regional counterparts of the state laboratory
rather than returning to dependence upon small local laboratories.

More than half of the state health departments maintain branch laboratories
at strategic points throughout their area. Usually such branch laboratories serve
as localized points for the distribution of biologicals and specimen equipment
received from the central state laboratory and for the collection of specimens
to be transmitted to the central laboratory. In addition, certain analyses which
are within the competency of the local laboratory are performed there, whereas
others are performed in the central laboratory for reasons of competency or
efficiency.

A number of states make additional use of their supervisory authority by
designating certain local public health and even private laboratories as branches
or agents. This procedure has much merit in that it encourages those laboratories
to maintain their standards and stimulates others to improve theirs. Some few
states emphasize the development and use of local public health laboratories
by subsidizing laboratories in local health departments. The subsidy may take
the form of funds, personnel, or equipment.

In a few places, notably some rural counties of Maryland, the use of a
joint hospital-health department laboratory has been found to be advantageous,
since the additional financial resources allow the utilization of better trained
400 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

personnel. In small cities with more than one hospital, for example Jamestown,
New York, it has been found effective to have a single director administer the
health department laboratory as well as the several hospital laboratories. This
arrangement provides a well-integrated laboratory service and enables the com-
munity to obtain a director of higher caliber.

A similar problem that has occasionally arisen is concerned with the extent
to which laboratory services should be centralized or decentralized within the
structure of the health department itself. In the past it was not too rare to
find several divisions within a health department, each with its own laboratory
service. Thus, the division of communicable disease control might operate its
own small laboratory in addition to the main laboratory, as might perhaps
the venereal disease division, the sanitary engineering division, the food and
milk division, and so on. The organization chart of State “B”, Figure 6, Chap-
ter 9, provides an illustration. There are many objections to this. It involves the
problem of vertical in contrast to horizontal organization and administration.
The inefficiency, resulting from duplication of materials, equipment, and per-
sonnel, is obvious. It is difficult enough to find competent laboratory directors
without multiplying the problem and usually settling for persons with lower
qualifications and less ability than is needed. Often, the directors of the various
units involved, such as engineering, have attempted personally to supervise the
work of their laboratories. However, the proper direction of a laboratory is
a specialized full-time responsibility and an engineer or epidemiologist rarely
makes a good laboratory director. Furthermore, a multiplicity of smaller unit
laboratories tends to divide the total work of the organization into tight little
compartments, no one of which is aware of the others or how they might act
to mutual benefit.

Three different arrangements therefore are possible. The first, and by far
the most desirable, is the organization ol a single central division or bureau of
laboratory services, operating as a major unit of the health department and
providing all laboratory services to all programs of the department. The second,
and least desirable, is the operation of a series of smaller, specialized laboratories
within each of a number of the functional units of the department. The third
approach, which is a compromise and is sometimes made necessary out of de-
ference to convenience, tradition, or personality, is maintenance of certain small
departmental facilities [or the performance of certain relatively simple procedures,
in addition to a large central laboratory.

In Chapter 9 which dealt with the organizational aspects of public health,
decentralization of programs and services, especially in larger cities, was dis-
cussed. Where programs are decentralized by means of health districts with
district health centers, it is frequently useful to provide a small amount of
space and personnel for the immediate on-the-spot performance of certain ele-
mentary but important laboratory tests. The decision depends, of course, upon
the nature of the programs being carried out in the district. Especially as public
health agencies become more involved in programs of chronic noncommuni-
cable disease and adult health maintenance, the provision of basic laboratory
facilities in health centers will become more practical and necessary.
LABORATORY SERVICES 401

During recent years a number of states have experimented with the use
ol mobile laboratories as a substitute for or in addition to branch laboratories.
Some have expressed doubt as to the usefulness of these laboratories and a few
have discontinued them. It is possible that dissatisfaction might be attributed
to failure to appreciate their essential purpose and therefore to use them im-
properly or inefficiently. Their use involves certain considerations, however.
They should always be considered an adjunct to, rather than a substitute for,
the central and branch laboratories. Their effective function requires good
working relationships between the staffs of the mobile laboratory, ol the central
laboratory, and of the local health department or local governmental officials.
It is desirable that they be kept flexible in nature rather than geared for only
one particular function or activity. In this way the mobile laboratory can be
made to serve a multitude of purposes. In an age of good roads and rapid transit
it would seem as if the mobile laboratory might occupy a significant place in
the over-all public health program, particularly in certain areas and for certain
purposes. This is certainly true of ficld epidemiological investigations, stream
pollution studies and control, resort sanitation, industrial hygiene activities,
and some aspects of food and milk control.

The distribution of biological products and the collection and transmission
ol biological specimens requires careful planning and timing on the part of
the health department laboratory. Arrangements must be made for temporary
storage and for prompt pick-up. Delivery and pick-up services for materials
going to and from the state laboratory must be coordinated with the time sched-
ules of public carriers such as railroad and bus lines. Containers [or specimens
and for their sale shipment must be designed and distributed. Furthermore,
provision must be made for twenty-four-hour availability of certain products,
particularly antitoxins and antisera, for use in cases of emergency. In small
communities reliance is usually placed upon the cooperative nature and concern
of the local health officer or pharmacist.

In large cities it has been possible for health departments to make very
satisfactory arrangements for the provision of collection and distribution sta-
tions throughout their areas. Some are located in fire or police stations and
others are in pharmacies where refrigerators are placed at the disposal of the
health department. All large city health departments provide for their own
messenger service for the collection of specimens and for the daily replenishment
of supplies at the distribution stations. It is worth while to include report forms
in or with the supplies made available, and many communities require that
identifying data concerning cases be given at the time biological materials are
obtained from distribution stations.

REFERENCES

1. Welch, William H.: (Lecture) Relations of Laboratories to Public Health.
2. Mountin, J. W., Flook, Evelyn, and Mullins, R. F.: Distribution of Health Services in

Structure of State Government, Washington, 1952, Public Health Service Publ. No. 184,
Part II.
chapter 1 6

Health education

 

Health education has long been an important activity of all public health
personnel. Only relatively recently, however, has it come to be considered a
major function in public health. The transition has been gradual. In the earlier
eras of public health which dealt with the sanitation of the environment and
the control of communicable disease, public health activity was interpreted to
consist largely of doing things to and for people, with reliance upon legal force
whenever necessary. With the development of the newer interpretation of public
health as the sum total of personal health, there has come about an appreciation
of the need to do things with people and to get people to do things about their
own health. This change in point of view was summarized by Governor Franklin
Roosevelt in the foreword to “The Report on Public Health in New York State
by the State Health Commission of 1931.” He compared the report with that
of 1913 as depicting “. . . the transition of the public health movement from
the single problem of attaining mass health to the double task of maintaining
mass health and controlling preventable disease in the individual.

“This is a more difficult task than that of establishing wholesale preventive
measures in which the people themselves are not required to take an initiative.
If involves the fullest use of public health education, so that citizens may un-
derstand and cooperate with activities necessary for their own welfare. Important
as are the laws which the Commission has recommended, of far greater im-
portance is intelligent action on the part of the individual and of the community.”

Scope of Health Education. There have been innumerable attempts to
define health education. One of the best-known definitions is that written by
Wood! in 1926 which described health education as “the sum of experiences
which favorably influence habits, attitudes, and knowledge relating to individual,
community, and racial health.” The term usually includes at least four phases
or types of activities. These, as will be seen, are in no sense mutually exclusive
but overlap generously and are greatly dependent each upon the others. The
most elementary phase is that which might be termed sensitization. Here, the
intent and expected result is not addition to the health knowledge or change
in the health habits of a person or a community; rather, it is a process by which
the individual and the community are made aware of the existence of certain

402
HEALTH EDUCATION 403

 

things: a health department, a disease, a service. Sensitizing procedures such
as slogans, spot radio announcements, and the like are not expected to give the
public more knowledge about a subject or make them do something they other-
wise might not do. The best analogy is found in the field of commercial ad-
vertising in which a manufacturer attempts to make potential customers aware
of the existence of his product in competition with those of other manufacturers.
He may accomplish this by bombarding the publics eyes and ears, and, in some
recent instances even the olfactory sense, with simple reminders of his product.
The techniques used are manifold, and include everything from spot radio an-
nouncements urging one to eat “Oaties,” to sky writing, huge billboards, and
even the perfuming of newspaper advertisements. In doing this the manufacturer
and his advertising agent do not expect the public to rush to the nearest store to
buy his product. What he does hope for is that when the individuals compris-
ing the public are in a situation which requires them to make an immediate deci-
sion, “Shall I buy or not?” or “Shall I buy this brand or that?” they will choose the
product to the existence of which they have been sensitized. Therefore, when
a health department, by any of the audiovisual methods asks, “Is this baby pro-
tected against diphtheria?” or states, “Diphtheria kills children,” it is merely
sensitizing the listeners or readers so that they will be receptive to further and
more detailed information.

The second phase of health education is publicity, which is closely related
to the foregoing and, like it, is of considerable importance in the public re-
lations program of the organization. In one sense publicity might be considered
an elaboration of sensitizing procedures, presenting more details about the items
mentioned in the simple concise statements. Examples of activities that might
be included in this category are press releases relating to the program of the
health department, announcements of clinics available for various purposes,
and statements considering the seriousness of certain conditions in the community.

The third phase of health education is education in its most exact sense.
In the final analysis this is really accomplished only in a rather intimate manner
and involves personal contact between the one who imparts the information
and those who receive it. It must be realized that education in health or in
anything else is never something given by one person to another. The mere act
of presenting information and knowledge accomplishes nothing. To use an
extreme example, a gibbon might be exposed to the constant expostulations
of the world’s greatest philosophers, but it is doubtful that he would learn any-
thing, simply because of inability to absorb and interpret the sounds he hears.
For a large segment of the human race, the word inability may well be changed
to unwillingness. In other words, learning takes place only through the efforts
of the learner. In order to impart information to increase the knowledge of
others or to change concepts, personal discussions carried out in terms familiar
to the listener and related to his personality and circumstances are required.
Derryberry? has described a demonstration of the truth of this in the experience
of the United States Government in selling war bonds. “The most extensive
use possible was made of all known information media, including news articles,
billboards, radio exhibits, pamphlets, motion pictures, etc., in an effort to induce
404 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
people to buy bonds, not only for financing the war but also [or curbing in-
flation. When final tabulation was made, it was found that over 80 per cent of
individual purchases were made on personal solicitation, which shows the need
for intimate and personal contact in order to induce overt action in a large
proportion of the population.”*

A similar experience was observed in Detroit in 1936 in connection with
a program to control tuberculosis.? Unusual publicity facilities were placed at
the disposal of the health department. For weeks, front page space and occa-
sionally even headlines were made available for the purpose. News stories were
written by one of the country’s outstanding popular writers. Free radio time
was made available for the presentation of excellent dramas, professionally pre-
pared, produced, and enacted. The city was exposed to a prolusion ol posters,
streetcar advertisements, pamphlets, and other similar material. A sizable special
appropriation made possible the employment of a large number of additional
public health nurses to engage primarily in home visits for the promotion of
examinations for tuberculosis. After all this had gone on for a while, a study
of those who were examined was made to determine which approach prompted
them to go to their physician or to a clinic. Despite the almost ideal publicity
methods, it was found that the visits of the public health nurses and the back-
fence discussions between neighbors accounted for most of the positive responses.

In a study of the utilization of commercial advertising for health education,
conducted during 1947 by the Health Education Section of the American Public
Health Association, 4,182 persons from 1,215 different households were ques-
tioned concerning their health knowledge and practices. Only 29.9 per cent
gave newspapers and magazines as the sources of their information. Friends and
relatives were mentioned by 27.5 per cent, physicians by 33.7 per cent, almanacs
by 1.8 per cent, and other sources by 7.1 per cent.

The final phase in the health education program is that of motivation.
The mere transmission of information or knowledge, even il it is accepted, is
not the final step, since in itself it does not imply action or a change in habit
or conduct. Among those who die each year from preventable diseases are many
who have been exposed to much publicity relating to them and have even ac-
quired considerable knowledge about them. Only a fraction of the parents of
children who needlessly die from diphtheria are either ignorant of the availability
of protective measures or opposed to them. In other words, the acquisition of
knowledge in itself is not an accomplishment; it is what is done with that knowl-
edge that makes the difference. In order to motivate people to use the health
knowledge imparted to them, they must be confronted by a basic human emo-
tional urge to taken action. As Bauer! has pointed out, the urge may be based
upon fear, ambition, jealousy, determination, pride, malice, or any combination
of these.

In the study of commercial advertising referred to above, inquiry was made
with regard to the use of patent medicines. Of those interviewed 60 per cent

*Derryberry, Mayhew: The Role of Health Education in a Public Health Program, Pub.
Health Rep. 62:1633, Nov. 14, 1947.
HEALTH EDUCATION 405
said they used products of this nature before calling a physician. Although the
majority stated that the claims for the products were not substantiated in prac-
tice, the investigation indicated that the patent medicines resorted to most
often were those for which the advertising played upon emotions, fear, vanity,
and interests, and which promised cure and relief. It is because of these im-
portant considerations that the health educator is referred to as a “catalyst,” one
of whose chief functions is the provision of learning situations by means of
community organization.

Personnel in Health Education. Everyone involved in or concerned with
health in any way is a health educator. A long list of such persons could be
produced. The most important, however, are all of the members of the health
department staff, private practitioners of medicine, dentistry, and nursing, teach-
ers, the personnel of many voluntary and community organizations and, last
but not least, parents. These are the people who in effect are on the “firing
line” of health education. It is they who in their daily person-to-person con-
tacts are responsible for the actual transmission of knowledge relating to health.
In addition, in recent years there has developed a specialized worker, the health
educator, who is trained to act as a combined correlator, coordinator, instigator,
implementor, and catalyst for all of the potential abilities and activities of those
in the front line. Beginning in 1943, training programs were set up in several
of the schools of public health to provide training for this new type of personnel.
Graduates of these curricula have been found increasingly useful by official and
voluntary health agencies on all levels and in school health programs. Both
the present actual and the potential demand for this new professional group
is great, and it would appear that within a remarkably short period of time
they have carved a definite niche for themselves in the health programs of the
communities and states of the nation.

Functions in Health Education. As in all other phases of the public health
program, the functions in health education vary in the different levels of govern-
ment. In their Proposed Report on Educational Qualifications and Functions
of Health Educators the Committee on Professional Education of the American
Public Health Association listed the functions of the health educator on the
community level in the following categories:

A. Program planning and evaluation

I. Study, survey, and research in assessing health education needs and
possibilities
2. Analysis of present knowledge, interests, beliefs, and practices of
the people in terms of aids or barriers to the educational process
B. Organization and promotion of health education activities

I. Development of groups for health action

2. Assistance in establishing and maintaining close cooperative working
relationships between those agencies and groups of citizens which
contribute to the health education of the public; in this the public
health educator often serves as a liaison person among public, civic,
professional, official, and voluntary organizations
406 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

3. Assistance in planning preservice education for public health, school,
or other personnel

4. The stimulation, organization, or guidance of inservice education
for employed personnel in health departments, schools, or other
agencies

5. Provision of technical assistance and service as a resource person in
the development and guidance of health education programs in schools,
parent-teacher associations, clubs, adult education services, exten-
sion services, study groups, and libraries

6. Assistance in interpreting the value of health activities to the com-
munity in the development of community interest and support

7. Leadership in the use of various educational teaching or group work
procedures as applied to public health activities

C. Extension of health education through communication

1. Development, preparation, and use of mass media of communication

2. Establishment of health library facilities

3. Organization of a speaker’s bureau, conferences, and meetings

4. Organization and operation of an information service

Functions in health education on the state level, by virtue of removal from
the immediate scene of action, are similar in purpose and design to those of
many other activities of a state health department. Derryberry® has suggested
the following functions and activities in which a division of health education
in a state health department might engage, depending upon the size of the state,
its resources, the extent of its coverage with local health units, and the presence
or absence of trained health educators in local areas:

1. Planning, developing, and administering a state-wide program in public
health education

2. Encouraging and promoting the development of programs in local

health departments, utilizing trained personnel who are capable of

working in all phases of the public health program and are also suffi-

ciently competent in education to work with the schools

Recruiting personnel and arranging for their training and assignment

4. Assisting the medical, nursing, and sanitation personnel in their educa-
tional work by providing them with an educational mechanism and
advice on effective techniques of education in various local situations

5. Consulting with local health departments and local health educators
on all matters pertaining to health education

6. Maintaining relations with the press and the public, preparing articles
and approving special stories and speeches by department personnel

7. Preparing or securing public health education material and distributing
it through useful channels

8. Correlating the educational endeavors of the other divisions or bureaus
in the state health department

9. Coordinating the activities of all agencies in the state interested in health
education

eo
HEALTH EDUCATION 407

 

10. Developing and maintaining a continuing inservice program of training
for public health personnel

11. Evaluating continually the materials and methods being used both in
the state and in the local departments

Health education on the Federal level has been a particular interest of the
Public Health Service. Necessarily its attention is focused upon the national
approach to problems and situations, and the encouragement of the state and,
through them, local health agencies in activities in this field. Coffey” has pre-
sented the following particular responsibilities of the Public Health Service in
health education:

1. To focus attention on health problems of national scope as they arise

2. To give consultation service and assistance in program planning and
execution and in the preparation of materials when such assistance is
requested

3. To stimulate the training of personnel and hold high the standards for
their training and accomplishment

4. To serve as a clearing house for new ideas, methods, and materials

5. To summarize new developments in science and show its applicability to
the subject matter of health education

6. To prepare high quality materials that have national application

To conduct an information service for the many inquiries received

8. To conduct research on methods and materials of health education and
evaluate programs with the purpose of making all our efforts more
effective

~

It is not within the province of this book to discuss the many and various
techniques in health education. Attention is called, however, to Chapter 12
dealing with public relations, much of which has a direct bearing on the sub-
ject of the moment. A few additional words are indicated to emphasize several
general considerations. The term “community organization” is one of the most
commonly encountered at the present time, especially in connection with health
education programs. Its exact meaning often appears elusive to many. Perhaps
the simplest manner of restating it would be to say, “Find out everything you
can about your community, its inhabitants, interests, prejudices, facilities, sub-
divisions and the like and proceed to work through them.” The first prerequisite
to a sound health education program, and therefore a sound public health pro-
gram, is a thorough-going community survey, diagnosis, or analysis. Every or-
ganized group and every influential person or agency must be noted with their
particular interests and potentialities. They must be approached in so far as
they represent segments of the population. The method of approach must be
carefully considered.

An excellent example of careful planning for community health educa-
tion is that followed by Morgan and Horning® in Hartford. Short-range and long-
range objectives were established, the community was very completely analyzed,
and the public was approached through their already organized groups and
with their participation. The work was decentralized into education districts
408 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

formed by grouping census tracts, which automatically provided extensive in-
formation regarding the characteristics of the people and each area. Perhaps
most important was the coordination of the efforts of all individuals and agencies
in the community.

One of the easiest mistakes that may be made is to speak a language [oreign
to that of one’s listeners. Too many long, technical, and complicated words and
phrases may be used. Public health workers have been taken severely to task
in this respect in an editorial® entitled, “By His Tongue Shall Ye Know Him,”
which appeared in the American Journal of Public Health. Its contents should
be read and reread by everyone engaged in work in this field. A few of the
concluding statements are worthy of repetition. “The use of jargon becomes
a bad habit with public health workers. They come to depend upon it to con-
fuse and mystify the public and to help create a favorable impression of their
work. . . . But perhaps the main reason that public health workers use jargon
is that it makes them feel important. It impresses the public and it adds to
their own feeling of well-being to hear the long and musical words rolling
from their lips. After all, it takes a pretty smart fellow to be able just to make
the sounds, to say nothing of knowing what they mean and less of knowing
how to translate them into appropriate and effective action.” *

School and Health Department Relations. The school represents a most
important learning situation for a large and significant group ol the population.
What is learned by a child tends to have a deep and lasting influence on his
happiness, opinions, and behavior throughout his life. The child is reached
and influenced primarily through two channels, his parents and his teachers.
Unfortunately the influence ol some parents, chiefly because ol limitations in
their childhood, is not always ol the best. As a result, the importance of the
teacher in the development of desirable health knowledge and practices is doubly
magnified and serves to emphasize the importance of teacher training in health
and the maintenance ol the personal well-being of those in this important re-
lationship to children. A certain amount of friction between public health
agencies and departments of education seems to have resulted [rom their mutual
interest in the development of health knowledge and instruction of children.
It is strongly felt that no real cause for conflict exists. In some areas both the
health department and the school department reach [or the school health educa-
tion program with airs of equal proprietorship. The fact is that it belongs to
both of them, or more correctly, that both belong to it. Each organization has
its place and its function. The personnel of health departments must always
remember that teaching is a professional specialty in itsell and that in the final
analysis it is the classroom teacher who does the teaching of the children. On
the other hand, school personnel should bear in mind that the school health
program and its educational component are merely parts of the larger total
community health program. This does not necessarily imply a right for the official
health department to usurp the activities of the schools in this field any more
than this over-all responsibility and concern entitles the health department

*Editorial: By His Tongue Shall Ye Know Him, Am. J. Pub. Health 38:264, Feb. 1948.
HEALTH EDUCATION 409

to take over the private practice of medicine or the management of food in-
dustries. The need is obvious. What is indicated is the coordination, in friendly,
professional, and cooperative terms, of the contributions and abilities of those
interested in health education, whether employed in a health agency, a school
system, or elsewhere. Many communities employ a person referred to as a school
health coordinator. Usually this person is on the staff of the school system,
occasionally on the staff of health departments, and sometimes employed jointly.
There is an increasing tendency to require that they obtain training in a school
of public health. Such professional persons in company with the health educator
of the health department may accomplish wonders in the improvement of the
program. Similar trends are observable on the state and Federal levels where
joint planning committees and interagency consultations are frequent.

Organization of Activities For Health Education. Within public health
departments, the organization of activities for health education poses problems
quite similar to those arising in relation to public health statistics. While each
functional unit of the agency should be engaged in health education to some
degree, there are certain over-all aspects of the field that must be dealt with
in a more central manner. The questions arise, therefore, whether or not the
work should be completely centralized in one health education unit and whether
such a unit should be a line or a staff agency. Every possible variation may be
observed both in state and local health departments. Centralized health edu-
cation units are commonly found, organized sometimes as a separate line unit
and sometimes as a staff agency in close proximity to the health officer. Not
infrequently, on the other hand, all activities for health education are completely
decentralized and dispersed throughout the various parts of the organization.
Beyond these are numerous illogical arrangements, usually arising from expedi-
ency, wherein health education is placed in a division of vital statistics, of maternal
and child health, or of communicable disease control. This has little to recom-
mend it since it usually results in provincialization of the service.

Certain general conclusions may be drawn. It would seem manifestly im-
possible to centralize completely the activities for health education. Even if
this could be accomplished, the rest of the health department would lose the
major part ol its effectiveness. Therefore, the functional units, augmented and
supported by a central unit of health education staffed by specialists in that
field, should be encouraged to engage freely in these activities. These per-
sons, among other ways, should function as consultants and advisors to the
line divisions of the agency. It would probably be best, in most circumstances,
for the central health education unit to be a staff unit closely associated with
the administrator, with whom over-all community planning and programming
may be effected.

REFERENCES

1. Wood, T. D.: In Fourth Yearbook of the Department of Superintendent of the National
Educational Association, Washington, D. C., 1926.

2. Derryberry, Mayhew: The Role of Health Education in a Public Health Program, Pub.
Health Rep. 62:1633, Nov. 14, 1947.
410 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

3. Vaughan, H. F., Harmon, G. E., and Molner, J. G.: Results of Mass Education for Tuber-
culosis Prevention in Detroit, Am. J. Pub. Health 27:1116, Nov. 1937.

4. Bauer, W. W.: What is Health Education? Am. J. Pub. Health 37:641, June 1947.

Committee on Professional Education, Proposed Report on Educational Qualifications and

Functions of Health Educators, Am. J. Pub. Health 47:114, Jan. 1957.

6. Derryberry, Mayhew: Health Education in the Public Health Program, Pub. Health Rep.
60:7, Nov. 23, 1945.

7. Coffey, E. R.: Planning for Health Education in War and Post-War Periods—The National
Program, Pub. Health Rep. 59:904, July 14, 1944.

8. Morgan, L. S., and Horning, B. J.: The Community Health Education Program, Am. J.
Pub. Health 30:1323, Nov. 1940.

9. Editorial: By His Tongue Shall Ye Know Him, Am. J. Pub. Health 38:264, Feb. 1948.
chapter 1 7

Environmental health

 

Background. In terms of both ancient and modern history, sanitation activi-
ties aimed at the promotion of environmental health represent a major phase of
community health programs. In Chapter 2 mention was made of the many
sanitary installations that remain as evidences of the degree of civilization at-
tained by Minoan, Grecian, Roman, and other early societies. Similar reference
has been made to the problems with which the early public health organiza-
tions of this nation were concerned. It will be recalled that most of them dealt
with attempts to promote the salubrity of the physical environment, particularly
of the growing urban communities. The essential similarities between the sanitary
concerns of ancient civilizations, those of our founding fathers, and those of the
present time, are striking. This has prompted Hollis"? to summarize:

The need for a healthful environment is common to all peoples; it cuts across
boundaries of occupations, race, class, and politics. If it differs from neighborhood to
neighborhood, and from region to region, it differs not in fundamentals but only in
complexity. *

It is in this setting that we are beginning to perceive the framework of the new
concept of environmental health. Its foundation rests on the essentials of existence—
man’s need for and man’s use of air, water, food, and shelter. The protective lining
of this foundation is sanitation . . . . Since sanitation is basic to community existence,
it is understandable that the pioneers in public health gave primary attention to clean-
liness. Water supply, waste disposal, and food and milk received top consideration.t

Whatever the reason may be, activities in environmental health tend to be
most firmly established, most readily supported, and most vigorously demanded
of the many constituent parts of the community health programs. Because of
this, it has often been the pattern for newly established local health departments
to begin operation with various phases of a sanitation program before pro-
ceeding to some of the other aspects of a well-rounded health program which
might be less readily understood, less evident in results, or more controversial.

*Hollis, Mark: Environmental Health Needs in a Dynamic Society, Pub. Health Rep. 67:903,
Sept. 1952.

THollis, Mark: Aims and Objectives in Environmental Health, Am. J. Pub. Health, 41:264,
March 1951.

411
412 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Few nations of the world can match the hygienic record attained by the
United States and much of the accomplishment can be attributed to the sanitary
measures which have been instituted. To them can be attributed the spectacular
reductions in typhoid fever, cholera, dysenteries, summer diarrheas, the control
of many of the milk-borne and food-borne infections, the control of malaria,
and the elimination of yellow fever. It was not until the beginning of the pres-
ent century that the chains of events involved in the transmission and perpetua-
tion of these diseases became unraveled. Prompt steps were taken to break links
in these chains. At first, activities in the field ol sanitation were concerned pri-
marily with the abatement of noisome nuisances. Gradually the provision and
supervision of sanitary water supplies and sewage disposal facilities were added
as the first well-defined and scientific measures. Meanwhile, the Rockefeller
Sanitary Commission, established in 1909 to combat hookworm disease, led shortly
to programs by state health departments with emphasis upon the eradication ol
enteric infections as well as hookworm infestation in the rural population.
These activities laid the foundation for the eventual establishment and spread
of full-time county health departments.

In this regard, the noteworthy surveys, demonstrations, and epidemiological
investigations of the Public Health Service, particularly those ol Lumsden,
should not go unmentioned. Throughout this formative era of the modern
sanitation and public health program much emphasis was placed upon the
construction and use of sanitary privies as a practical means of disease preven-
tion, and it was one of the chief functions of public health workers of that
period to assure the sanitary disposal ol human excreta. This has prompted
some to claim the sanitary privy as a primary factor in the development of
the tremendously significant public health movement. As Hollis recently aptly
phrased it, the initial phases of sanitation activities center on keeping human
excreta out of the diet. Sanitation work today covers an imposing array of ac-
tivities, for most of which sound scientific reasons may be put forward. Among
those that may be listed are the sanitation of milk, milk products, foods, meats
and shellfish as well as of food processing and handling establishments; the
control of insect and rodent vectors of disease; sanitary garbage collection and
disposal; industrial hygienic and safety measures; the prevention of stream
pollution; and the sanitary supervision of recreational areas including parks,
camps, picnic grounds, swimming pools and beaches. Recently, interest in at-
mospheric sanitation has been renewed, but now on a scientific basis with
consideration given to temperature, humidity, dust, smoke, and bacterial con-
tent and to means of control by smoke abatement, air conditioning, and air
sterilization. Another recent venture has been the fluoridation of public water
supplies for the prevention of dental caries.

Current activities in the fields of housing and community planning illustrate
an interesting and significant shift in the fundamental point of departure for
sanitary planning and action. Here the trend is to draw away as soon as possible
from activities which involve repair or even prevention of potential undersirable
effects toward programs of a positive or promotive nature. In other words, until
relatively recently public health activities have been based upon negative con-
ENVIRONMENTAL HEALTH 413

 

cepts, upon definitions of ills, which has resulted in programs designed to at-
tack things that have gone wrong, i.e., the isolation of the infected case, the
filling of the decayed tooth, the purification of the polluted water. We have
now reached the point in many areas where we can begin to think in positive
terms. We can begin to base our planning on the definition of good health
rather than of illness, on maintenance of cleanliness and salubrity instead of
cleaning up insanitation.

In general, then, perhaps the best summary statement of the present day
content of the field of environmental health is that of Holmquist and Dappert?
in their discussion of the expanding scope of public health engineering.

Public health work deals with the application of science to the problems of man’s
relation to his environment. The task of the public health engineer is to assure
necessary favorable conditions and to prevent or minimize the unfavorable. The air

we breathe, the water we drink, the food we eat, the light by which we see, the people

with whom we come in contact—in fact, any of the conditions of competitive life

under which we live—are all a part of our environment. And just as long and broad

as you can conceive environment to be, just that long and broad is the field of public

health. *

Regional Differences. Although the basic objectives are universal, the details
of the environmental health program have not developed uniformly through-
out the communities and states of the nation. Furthermore, as will be discussed
later, activities in this field have not necessarily in all instances been centered
in the health department. The rural agricultural South and West are faced
with rather different problems than the urban industrialized Northeast. As a
result, certain activities are stressed more in one area than in the other, and
dependence is placed upon somewhat different categories of personnel. The
congregation of large numbers of people in the many cities of the northeastern,
western coastal, and Great Lakes states necessarily has led to their emphasis
on the construction and operation of sanitary engineering facilities and to the
employment of many sanitary and public health engineers.

In other more rural parts of the country, particularly in the southern states,
the opportunity for centralized sanitary control has been limited essentially to
a few moderate-sized towns and a handful of larger cities. Chief emphasis in
this area, therefore, is placed upon a somewhat simpler and more individualized
approach. Here, patient and persistent attention must be given to such matters
as privy and well location and construction, dairy barn sanitation, screening,
and the like. To many, these may appear prosaic, elementary, and nontechnical.
However, a background of technical knowledge of no small degree is necessary
for the solution of such environmental problems. Furthermore, they provide a
measure of community health protection quite comparable to that resulting
from the more complex and interesting structures of municipal sanitary engineer-
ing. For example, during the period from December 1933 to July 1942, a total
of about 3 million sanitary privies were constructed in thirty-eight states and in
Puerto Rico through the cooperative efforts of the Federal work-projects agencies,

*Holmquist, C. A., and Dappert, A. F.: Expanding Scope of Engineering in State Health
Departments, Municipal Sanitation, 10:530, Oct. 1937.
414 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

the state health departments and the Public Health Service. This figure does
not include the many others constructed privately or under the sponsorship of
the agricultural and farm agencies.

A further point to be remembered here is that while the turning of a valve
in a water treatment plant or the flushing of a toilet in the urban or surburban
areas involves no particular educational impact for the individual citizen, this
is not true on the rural scene. This has been dramatically emphasized by Mustard
in a meaningful statement that it is fortunate that sanitary safety is more easily
attained in warm, comfortable indoor bathrooms than in drafty, outdoor privies.
Tisdale and Atkins, commenting on the Federal Community Sanitation Pro-
gram, have pointed out that in view of the many persons employed in “selling”
3 million privies, it was necessary to explain to at least 15 million persons the
reasons for sanitary disposal of excreta. It cannot be doubted that this program
contributed significantly to the public understanding of this and in fact of a
number of other important phases of environmental sanitation and public health.

One of the great difficulties of course is found in the differences in means,
abilities, and willingness to finance sanitary improvements. Thus, as Hollis’
points out:

Government is ordinarily held responsible for financing public health services in
the city. This is not so in the country. Sanitation of food and premises is clearly a
public problem in the village and other rural centers such as the school, church,
and grange or community hall. But in most rural areas in the United States, sanitation

is ordinarily regarded as an individual or private concern, even though many individual

rural families cannot finance sanitation by themselves. If there is the will to bring
rural demands for environmental improvement into balance with the demand for cars
and electricity, however, the economic devices that provide cars, telephones, and power
are capable of financing pipes and drains as well.

In the city, the danger of contagion has created awareness of community responsi-
bility. In rural areas, the danger of contagion is less apparent. It is recognized mainly

in the enforcement of sanitation on dairy farms, in the effort to protect the safety

of fluid milk produced for the urban market. Hygienic milk production is probably
the heaviest single contribution of its kind to rural environmental health in the United

States. *

He concludes therefore:

Three major factors in the lag in rural sanitation are the relatively high cost of
water and sewerage systems for isolated structures, the usual necessity to finance each
installation individually at relatively high rates, and the absence in many rural areas
of a strong public health authority. These factors have less force in the village than
on the farm.*

An important variation with regard to the foregoing is found in the relation-
ship between the environmental health problems and programs of decentralized
suburban and fringe areas as against centralized urban areas. Indeed, it is per-
haps here that a solution may be found to some of the differences which exist
between rural and urban opportunities for environmental health. Board and
Dunsmore$ have carried out a particularly interesting analysis of this increasingly

*Hollis, Mark: Environmental Health in a Rural Economy, Pub. Health Rep. 68:1108,
Nov. 1953.
ENVIRONMENTAL HEALTH 415

 

frequent type of situation in which they have indicated many of the similarities
and differences among urban, suburban, transitional, and rural problems, as
well as the many agencies which may contribute to their adequate solution.

An administrative benefit for which the rural sanitation program may be
given credit has been the development of a spirit of cooperation between the
officials of the health agencies on the various levels of government. Thus, it may
be said with little exaggeration that it was in this field that the state health
departments and the Public Health Service first learned to work together as did,
to a considerable degree, the state and local health organizations. Furthermore,
the successful pursuance of the program necessitated the integration of activities
and therefore cooperation between public health departments and other agencies
on the same governmental level such as the agricultural and farm organizations.

Sanitation Needs. Although the United States is already the most sanitized
nation in the world, much unfinished business remains. On reviewing the past
and examining the present in order to enunciate aims and objectives for the
future, Hollis concludes:

As we look back on environmental health over the past fifty years, we see that
despite our great achievement there lies before us a whole continent of unfinished
business. To our credit, we have shown some intelligence about clearing a few health
barriers ahead of orderly national growth. This was true to a great degree of municipal
water supply and liquid waste collection. It is true also of certain aggressive actions
in the past ten years against insect-borne diseases. *

However, he continues:

We cannot be smug or comfortable about the history of milk sanitation, shellfish
sanitation, and sanitation of bathing waters. There are no grounds for congratulations
on the national record on controlling water pollution, on school and institutional
sanitation, and unsolved questions of food sanitation. What, one may ask, is the national
health plan on air pollution including control of irritating pollens, the hygiene of
housing, and home accident prevention? What do we know about unhealthful aspects
of faulty community planning, substandard recreational facilities, and abnormal noise?
Most certainly we cannot view with pride our progress in rural sanitation—more than
25 million of our rural population who have been able to obtain electric power are
still without running water and water-carried waste systems. These are but examples.*

Periodic evaluations of the needs have been made by several agencies, par-
ticularly the Public Health Service. One such evaluation™ was conducted in 1947
and has served as the basis of an inventory of national sanitation needs.t It
pointed out the following significant facts relating to the current stage of ac-
complishment:

1. More than 14,000 systems provide water to about 85 million people, and the quality of the
water furnished is generally excellent.

*Hollis, Mark: Aims and Objectives in Environmental Health, Am. J. Pub. Health 41:264,
March 1951.

iFor further information see also Water Pollution in the United States,® Environment and
Health, Statistical Summary of Water Supply and Treatment Practices in the United States,”
and Economic Report of the President
416 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

More than 70 million people are served by sewerage systems, and more than 5,500 treatment
plants have been installed, which serves about 42 million people.

More than 70 per cent of our market-milk supply is pasteurized.

Practically all of our larger cities, and a constantly increasing number of the smaller ones,
provide regular collection service of garbage and refuse, and disposal methods have been
improved. *

On the other side of the ledger, unmet needs of great proportions were

found to exist and are summarized here for their interest and pertinence:

6.

~1

10.

Approximately 2,360,000 people in 5,710 communities with no public waterworks systems
need such facilities. Almost 15,000 communities with over 79 million people have waterworks
which need improvements or extensions. In rural areas where community systems are im-
practicable, 27 million people need either new or improved water supplies.

More than 9,100 towns with 6,360,000 people need complete sewerage systems. Some 9,900
additional communities with almost 80 million people have systems which need improve-
ments. In rural areas, more than 33 million people lack satisfactory sewage or excreta dis-
posal facilities of even the simplest type.

In 8,300 communities with 70 million people, there are needs for better facilities for
collecting and disposing of garbage and other municipal refuse.

More than 36 per cent of the community needs are either ready for construction or in the
planning stage. Two-thirds of the work which is ready for construction, and more than
half which is being definitely planned, is in cities of 100,000 or more. In cities of over
5,000 population almost half of the needed work is at least at the planning stage. In the
smaller towns much less advance planning has been done.

Much of this needed construction is a backlog of work which developed during and after
the war. Materials shortages, rapidly rising construction costs, and an unwillingness of local
governments to enter into competition for materials and labor necessary to meet the acute
housing shortage, have made most communities continue to defer all except emergency
work. As conditions in the construction industry return to more nearly normal, this backlog
of needed work should proceed at an increasingly rapid rate.

The cost of needed water supply and waste disposal facilities for the United States is esti-
mated at $7,834,581,000 (Table 30).

The per capita cost of needs varies from $23 in Rhode Island to $107 in New York State and
averages about $60 for the nation as a whole.

The per capita cost of needs is greatest in the smallest communities and in the largest
ones. In towns of less than 1,000 population, needs exceed $100 per capita, while in cities of
over 1,000,000 they approach $120 per capita. However, a much larger proportion of income
will be required in the smaller towns than in the wealthier big cities.

In the fringes of most of our metropolitan areas, houses with inadequate sanitary facilities
are being built which promise to become the slums of tomorrow. State legislation to enable
counties to adopt and enforce suitable zoning laws are badly needed, as well as additional
personnel in the local and State health departments who can deal with the sanitation
problems of these rapidly growing areas.

Educational work and technical advice are needed to assist the small communities in ob-
taining the water and sewerage facilities they should have. This will require additional
personnel in the State health departments. In some States improved laws are necessary
to facilitate the formation of sanitary districts. In other States the laws providing for
revenue financing of sanitation facilities need revision to make them more usable. Financial
assistance in the form of low-interest loans would give impetus to the installation of needed
community facilities. These small towns and the rural areas deserve special attention since
it is in them that the incidence of the filth-borne diseases is highest and serve as focal
points of infection from which these diseases can spread.

*Information taken from Nation-wide Inventory of Sanitation Needs, Pub. Health Rep.

(suppl. 204) April 1948.
ENVIRONMENTAL HEALTH 417

 

11. It is in the rural areas beyond the reach of any practicable community facilities that the
greatest shortage of sanitation facilities exists. Although this is due to some extent to a lack
of money, it is also due to a lack of realization of the dangers involved. Local health de-
partments are lacking in many of these areas and are understaffed in most of them. Exten-
sion of adequate local health services to these areas is a prime necessity.*

Table 28. National Cost Estimates for Needed Sanitation Facilities, 1947
(Cost In Thousands of Dollars)

 

 

 

Ready for Planning in Projects for
Type of Facility Construction Progress Future Total
Water $385,591 $608,349 $1,275,042 $2,268,982
Sewerage 360,509 908,048 2,480,296 3,748,853
Garbage and refuse disposal 166,526 166,526
Rural sanitation 1,650,220 1,650,220
Total $746,100 $1,516,397 $5,572,084 $7,834,581

 

 

 

 

In the light of recent developments in public health dentistry there should
be added to the foregoing the fluoridation needs ol the nation. By 1954 there
were approximately 16,800 public water supplies in the United States of which
about 15,000 contained no natural fluorides. As of September 1957, only 798 of
these have controlled fluoridation programs serving about 32 million people.
According to Knutson,'® Chief of the Public Health Service’s Dental Health
Division, “At the present rate of progress in the fluoridation of public drinking
water supplies it will take 150 years to complete the task ahead.” However,
the pattern ofl development of chlorination of water supplies indicates that,
once established in the public mind as a measure of unquestioned value, fluori-
dation of water supplies will proceed much more rapidly.

On the basis of the general background that has been presented and the
statement of sanitation needs, let us pass to a brief consideration of the most
important concerns of the present-day field of environmental health.

Water Supplies. Water is one of the prime necessities of human existence,
so much so that, given dire enough circumstances, even the most educated in-
dividual will resort to the consumption of water from grossly polluted or
dangerous sources. Beyond its iniportance for human consumption, water serves
many purposes, i.e., as a source of fluid for animals; as a medium of transporta-
tion; as an agent for cleansing and cooling the body, objects, or the environ-
ment; as a means of recreation for swimming, boating, and fishing; as an agri-
cultural irrigant; as an adjunct to innumerable industrial processes; as a conveyor
for the disposal of human and industrial wastes; as a means of air conditioning;
as a fire extinguisher. The per capita domestic use of water from public supplies

*Information taken from Nation-wide Inventory of Sanitation Needs, Pub. Health Rep.
(suppl. 204) April 1948,
418 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

has grown from about 90 gallons per day in 1890 to more than 150 gallons
per day at the present time. With regard to total use, the United States Geological
Survey in 1948 estimated that municipal water consumers used 12 billion gallons
of water each day, rural consumers used 3 billion gallons, private industry about
70 billion gallons, and about 95 billion gallons were used for irrigation.

Our chief concern here is with the consumption of water by humans for
domestic purposes. At the moment, most of the other uses of water are of in-
terest to us in so far as they effect the salubrity of the water which humans
drink. Water supply systems may be classified as public and private. About
100 million people in the United States, about two thirds of the population,
are served by public water systems. However, about 10 per cent of the families
living in about 7 million homes in communities so served do not have water
outlets readily available. In addition, there are still 2,500,000 people living
in 5,700 communities of 200 to 500 population without a public water system.
In rural areas, about 27 million people need improved pure water facilities.

Public water supplies are derived [rom various sources, i.e., streams, lakes,
cisterns, deep wells and springs, and their nature differs according to their
source. Atmospheric waters which are caught in cisterns are by far the most
pure, both bacteriologically and chemically. However, they constitute only a
very minor proportion of all public water supplies and only in very small com-
munities. Surface waters such as streams and lakes which depend for replenish-
ment upon repeated run-offs, under most circumstances do not have as high a
chemical content as do ground waters from deep wells and springs. However,
while the latter tend to be more pure bacteriologically, surface waters, because
of their more extensive exposure, are more apt to become bacteriologically
polluted. Similarly, underground waters in general are clear, while surface waters
ordinarily contain considerable amounts of suspended matter which must be
removed before they can be considered suitable for human consumption. These
differences in source, hence composition, necessarily give rise to differences in
approach to administrative control. Streams and lakes in general do not lend
themselves to adequate control of the watershed. On the other hand, some im-
pounding reservoirs are subject to control from the standpoint of prevention of
further pollution of the water. Increasing public pressure [or recreational facilities
is resulting in more liberal access to both the reservoir and the surrounding
watershed. In any case, in view of the high factor of safety in relation to cost,
surface waters should probably always be subjected to filtration, chlorination,
and fluoridation. Rapid sand filtration is the usual method of choice. Recent
improvements in sanitary engineering have resulted in filters with rates up
to four gallons per square foot per minute, about double the previous usual
rate, without any sacrifice of safety.

The provision of a safe and satisfactory public water supply to a community
involves the following procedures:

1. If a surface water, the watershed should be protected and controlled in

so far as is practical.

2. The intake should be located properly with regard to all possible sources

of contamination and pollution.
ENVIRONMENTAL HEALTH 419

3. If necessary and practical, provision should be made for primary sedi-
mentation and purification by means of storage reservoirs and exposure
to air and light.

4. Bacteria, algae, and any residual turbidity should be removed by the
addition of a coagulant (usually alum) and settling out of the coagulated
particles, and then passage through a rapid sand filter.

5. Residual and subsequent bacterial contaminants are combatted by the
addition of a disinfectant, usually chlorine, to a concentration of from
2 to .5b p.p.m. This is a most important procedure.

6. A concentration up to from .7 to 1.5 p.p.m. of fluoride should be achieved

by the addition of sodium fluoride, sodium silicofluoride, or hydro-

fluosilicic acid for the prevention of dental caries. The ultimate con-
centration will depend upon the average water consumption per indi-

vidual 14

Use of the water by all the population of the community should be as-

sured by low water rates, adequate distribution systems, and housing

requirements.

8. Contamination of the purified water should be prevented by initial dis-
infection of the distribution system pipes and by prevention of cross-
connections and back siphonage.

~1

In order to achieve these ends the cooperative action of a number of com-
munity agencies is necessary. Among these are the health department, the de-
partment of public works or the water department, the tax or finance office,
possibly the park police, the plumbing department, the housing commission, the
dental society, and possibly others.

The assurance of safe water to the rural population poses a completely
different set of problems. The sources are usually relatively simple and primi-
tive wells, often shallow and unprotected. Hence they are easily subject to pollu-
tion not only from the surface, but also through seepage from poorly placed
privies, improperly constructed septic tanks, or nearby barnyards. Contamina-
tion over greater distances may occur if fissures or other subterranean passages
exist in the substrata. Offsetting these hazards is the fact that the use of each
small rural water supply is characteristically limited to a very small group of
people, often only one family.

The solution of this difficult problem lies essentially in persistent rural
health education programs coupled with sanitary consultation from the local
health department. The objectives of these efforts should be encouragement of
proper locating of wells and excreta disposal facilities, proper construction of wells
and installation of a pump in a tightly sealed, curbed, and drained well top.1?

Stream Pollution Control. Although pure water for drinking purposes is of
paramount public health concern, the many other uses of this precious com-
modity make it desirable to regard the development, protection, and use of
water resources as a unit. By now 65 per cent of our population lives and works
in cities with resultant concentration of tremendous burdens of human and in-
dustrial wastes on the bodies of water to which they are related. The magnitude
420 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

of this water pollution was brought out by the recent series of studies covering
226 river basins in the United States, of which 146 are interstate. The summary
of these studies'® indicates that in 1950 there were more than 22,000 sources
of stream pollution in the country, including 11,800 municipal sewer systems
and 10,400 industrial waste outlets. Of the latter, one half produces organic
wastes which markedly increase the biochemical oxygen demand, and others
discharge wastes that are toxic or give rise to tastes and odors which detract from
the subsequent usefulness of the water by humans. It was further indicated
that despite the reduction of pollution by 9,300 treatment plants, 6,700 municipal
and 2,600 industrial, the wastes still being discharged into rivers and lakes are
equivalent in Biological Oxygen Demand to those from over 150 million people.
It estimated that to solve this problem adequately, 6,600 more municipal sewage
treatment plants or additions to present plants and 3,500 more industrial waste
treatment plants or additions will be necessary at a cost of from 9 billion to
12 billion dollars of public and private funds.

The increasing concern with the problem resulted in the enactment of the
Water Pollution Control Act of 1948." While Congress recognized the primary
responsibilities of the states in the matter, the Water Pollution Control Act
authorized and directed the Public Health Service to “take the initiative in
developing or adopting comprehensive programs for the solution of water pollu-
tion problems in cooperation with the States, interstate agencies, municipalities,
and industries. The Act stated that comprehensive programs were to be devel-
oped for surface and underground waters, giving due consideration to all water
uses—public water supply, propagation of fish and aquatic life, recreation, and
agricultural, industrial, and other legitimate uses. It provided for Federal grants
to the States and interstate agencies to help them carry out industrial waste
studies, and for loans to municipalities to assist in the construction of needed
abatement work . . .. The Act further provided for Federal research and techni-
cal and consultative assistance to State and interstate agencies, municipalities
and industries, and for the encouragement of uniform State laws, interstate
compacts, and cooperative State activities in the field of water pollution control.
Initial responsibility for enforcement of pollution control measures was left with
the States; Federal authority was to be exercised only on interstate waters, only
after the efforts of the States had been exhausted, and only with the consent
of the States.” *

To carry out its responsibilities, the Public Health Service set up a water
pollution control program with field units in each of the ten large drainage
basin areas. Each unit is staffed with engineers and scientists with extensive
experience in water pollution control who work closely with officials of the
various state governments. The Taft Sanitary Engineering Center in Cincinnati
serves as the research center for the work.

There are two particularly important conditions for successful control of
stream pollution. The first is the necessity of planning on a regional basis since
relatively few of the situations involve only one state. While it is important

*Schwob, C. E., and Dworsky, L. B.: Progress in Water Pollution Control, Pub. Health
Rep. 67:1080, Nov. 1952.
SN

ENVIRONMENTAL HEALTH 421

that each state develop its own programs based upon its own legislation, it is
fundamental, as Klassen!'® has described, to plan and coordinate the various
state water pollution control programs and in so far as it is possible the laws
upon which they are based, in order to bring about a practical program which
will serve the needs of the drainage basin in question.

The second condition is a recogntiion of the fact that while the chemical
and physical characteristics of human wastes do not vary significantly, it is rare
that industrial wastes, even those from similar enterprises, are the same. Hence
each stream pollution problem, especially if it involves industrial wastes, is a
case study in itself. Therefore, as Eliassen!® says, while the sanitary engineer
is most adequately fitted in education and experience for water pollution con-
trol work, “The sanitary engineer cannot go it alone. He must have qualified
sanitary chemists and sanitary biologists as members of his team. With the
right combination of talents in these three major realms of sanitary engineering,
this team can give distinguished service to industry and government in the abate-
ment of stream pollution by the control and treatment ol industrial wastes.”

Waste Disposal. Closely related to the problems of water sanitation and
stream sanitation is that of safe waste disposal. The waste materials of present-
day households consist of human excreta, garbage, and refuse. In urban areas,
there are also added an increasing amount of industrial wastes. Until recently
each of these was considered to be a somewhat separate problem. In urban com-
munities, however, they have become increasingly interrelated. In some instances,
garbage and refuse are collected and disposed of together. Also, there is a trend
toward the grinding of garbage in the household and disposal along with excreta
and other household wastes through the plumbing and sewerage system. In-
dustrial wastes may also be discharged into the sewerage system or directly into
bodies of water which also receive raw or treated sewage.

There are various methods of disposal of waste products of human societies.
These may be listed as: (1) discharge into bodies of water, with or without
treatment, (2) discharge onto the surface of the ground, (3) burial in the ground,
and (4) incineration. No one of these offers the perfect solution since each has
some disadvantages or hazards and each may be more applicable than the others
in specific situations. Ehlers and Steel?’ have listed the following goals or re-
quirements which should be applied to the choice of satisfactory disposal methods:

1. There should be no contamination of ground water that may enter springs or wells.
2. There should be no contamination of surface water.

3. The surface soil should not be contaminated.

4. Excreta should not be accessible to flies or animals.

5. There should be freedom from odors or unsightly conditions.

6. The method used should be simple and inexpensive as to construction and operation;

this applies particularly to rural areas where the farmer may construct his own
facilities. *

It is not within the province of this book to describe and assess the various
methods of waste disposal since those details are readily available in a number

*Ehlers, V. M., and Steel, E. W.: Municipal and Rural Sanitation, ed. 4, New York, 1950,
McGraw-Hill Book Co., p. 28.
422 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

of excellent books devoted specifically to the field of sanitation and sanitary
engineering. The intent here is to present merely a general background picture
of certain factors which must be considered with regard to a public health agency's
interest and responsibility in the problem.

Social and environmental circumstances are ol particular significance with
regard to the disposal of human excreta which is by far the potentially most
dangerous type of waste material. The pertinent situations, hence the methods
of approach, are three in kind. The simplest situation is that in which no water
carriage is possible; this applies particularly to rural areas. Under such circum-
stances resort may be made to the pit privy, the bored hole latrine, the vault
privy, the chemical toilet, the septic privy, or the box and can toilet. A second
situation is that found most commonly in suburban areas and some small com-
munities where a supply of running water is available thereby making water
carriage of excreta possible, but where no public sewerage system exists. Under
such circumstances, individual cesspools or septic tanks are commonly used.
Finally, there is the situation where both a public water supply and a public
sewerage system make possible not only water carriage but also water disposal
of human excreta. Here, new problems arise in that there is a concentration of
tremendous amounts of human wastes, the complication of plumbing hazards
in the form of possible cross-connections and back siphonage, and the frequent
addition of garbage and industrial wastes. Some attempts have been made to
dispose of sewage by making use of it for irrigation purposes in so-called sewage
farms. The success and practicability of this approach has been very limited
in the United States.2! 22

Generally speaking, therefore, and because of the large amount of water
it contains, sewage is usually disposed of in a body of water. This may be done
with or without treatment. The dangers of the discharge ol raw sewage into
streams or lakes are obvious, and increasingly it is becoming important and
necessary to treat sewage for the following reasons:

1. Public health reasons—to prevent the pollution of drinking water, fish
and mollusks, and bathing places.

2. Aesthetic reasons—to prevent the formation of foul odors, and the develop-
ment of streams and shorelines made unsightly by solid or suspended
waste matter.

3. Economic reasons— to prevent the killing of commercially valuable fish
life, the infection of livestock and other animal life, and the deteriora-
tion of land values.

4. Salvage reasons—to make possible the recovery of commercially valuable
fertilizer, grease, gases, and other products.

Prescott and Horwood** describe the objectives of the various methods of
sewage treatment to be fourfold:

1. To diminish the amount of solid materials discharged into a stream, in order to lessen
the demands on its purifying properties, and to prevent the formation of sludge
banks and the appearance of objectionable floating materials.
ENVIRONMENTAL HEALTH 423

 

2. To decompose, through the agency of biological methods, the organic matter in
sewage, and to transform it into simpler organic compounds, and into gases and
liquids. In this way, the burden of the final purification which takes place in a
stream will be greatly diminished.

3. To stabilize the organic matter in sewage through the agency of biological methods
operating under aerobic conditions, so that the purifying properties of a stream
into which the treated sewage is ultimately discharged will be taxed to a minimum.

4. To diminish or destroy the bacteria present in sewage, particularly the pathogenic
varieties capable of producing disease.*

These objectives are accomplished in different situations by combinations
ol the following procedures: (1) screening and/or sedimentation, (2) anaerobic
digestion of settleable solids in a septic tank, Imhoff tank, or separate sludge
digestion tank, (3) oxidation of nonsettleable organic matter by filtration, ac-
tivated sludge, or irrigation methods, (4) disinfection with chlorine or other
disinfectants.

While the operation of public sewerage as well as water systems is a local
responsibility, the over-all routine control of these matters is largely a state
concern. The state health department is the official agency with major responsi-
bility, but in nearly three fourths of the states the responsibility is shared with
other departments or special commissions. Among these are departments of
public works, labor, education and industry; special state sewage, stream pollu-
tion or sanitary boards or commissions; state universities and laboratories.
Among the functions for which the state commonly has responsibility are the
promulgation and enforcement of laws, rules, and regulations; approval of
plans and installations; examination and licensure of treatment plant operators;
periodic inspection of installations; provision of consultation services to localities;
provision of grants-in-aid to local sanitation units; and the promotion of satis-
factory local facilities.

Authority for the supervision ol semipublic waste disposal systems is more
apt to be shared among several agencies than in the case of public supplies.
Thus, if the system involves educational institutions, parks, or industries, as
examples, the departments of education, parks, industry or labor are almost
certain to be involved in practically all instances. This shared responsibility
and authority, however, does not alter the fact that the state health depart
ment must play the primary regulatory and supervisory role with respect to
the sanitary aspects of the situation. Often, of course, these responsibilities are
met in collaboration with or through the local public health structure if it
is adequately staffed.

The weakest link exists in relation to supervision and control of individual
private waste disposal systems in rural areas. Where a local public health de-
partment exists, it almost invariably includes some form of activity in the field
of human excreta control. The basis of the activity usually consists of a persistent
health educational approach on a personal basis augmented by general educa-
tional measures, consultation from the state health department, and sometimes

*Prescott, S. C., and Horwood, M. P.: Sedgwick’s Principles of Sanitary Science and Public
Health, New York, 1935, Macmillian Co., p. 103.
424 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

actual assistance in the financing and construction of private sanitary privies
or septic tank systems.

Food and Milk Sanitation. The majority of the cases of epidemic gastro-
intestinal infections which occurred up through the first quarter of this century
were attributable to impure water. Because of the remarkable strides which have
been made since that time in providing safe water to the majority of the people,
water no longer plays an outstanding role as a transmitter of disease in the
United States. Since 1923, the Public Health Service has compiled and analyzed
reports of milk-borne epidemics from data submitted by state health depart-
ments. Since 1938, these analyses have also included outbreaks traced to water
and to other foods. An analysis of these data (Table 29) presents an interesting
and significant picture. As recent as the period 1938 to 1942, not only was water
the cause of a significant number of outbreaks, but in terms of persons affected
it was still the most important.

k
Table 29. Changes in Food-Borne and Water-Borne Disease Outbreaks,
U. S. 1938-195725.26

 

 

 

 

 

 

Milk and Milk
Water Products Other Foods
Time Period _—
Outbreaks Cases Outbreaks Cases Outbreaks | Cases
1938-1942—Number 247 | 103,441 208 9,114 902 29,095
Annual average 49 20,688 42 1,823 181 5,819
1943-1951—Number 208 32,342 205 7,259 2,769 | 101,466
Annual average 23 3,594 23 806 308 11,274
1953-1957—Number 33 3,043 55 1,539 1,081 | 53,469
Annual average - 7 609 11 308 216 | 10,694

 

 

 

While the average annual number of outbreaks caused by water and milk
was roughly the same and in each case only about one fourth of the number
caused by other foods, the number of persons affected by water-borne epidemics
was about three and one half times the number affected by other foods and
about eleven times the number affected by milk and milk products.

However, when the data for the period since 1942 are considered, a marked
shift is found to have occurred. Comparing the two periods, it is seen that al-
though the average annual numbers of epidemics attributable to water and
to milk and milk products have been cut in half, those due to other foods have
doubled in number. Furthermore, while the average annual number of persons
affected in the recent years by milk and milk products was one half of what it
had been and for water only one sixth of what it had been, with regard to
outbreaks due to other foods, the number of persons affected doubled. The more
ENVIRONMENTAL HEALTH 425

 

recent period, 1953 to 1957, has witnessed a decline in all three types of epidemics.
However, the decline is most marked in the instances of water-borne and milk-
borne epidemics which declined both in number of epidemics and number
of persons affected. Indeed, although the average annual number of epidemics
borne by foods was about one third less in the period from 1953 to 1957 than
in the period from 1943 to 1951, the number of persons affected remained es-
sentially the same.

These figures illustrate two facts with regard to the present time. Foods
are easily the most important and an increasing cause of gastrointestinal infec-
tions in the United States. While milk and milk products are potentially the
most perishable and most dangerous foods and despite their ever-increasing
use, they now are a relatively unimportant cause of disease when compared
with other foods. This is explainable on the basis that their very perishability
has focused so much attention upon means of ensuring their salety. In order
to promote scientifically sound standards and uniform legislation, the Public
Health Service in 1924 developed a standard milk ordinance. Since then, there
have been nine revised editions ol the Milk Ordinance and Code Recommended
by the United States Public Health Service. Each one represents the pooled
opinions and experience of public health officials, the milk and dairy industry,
veterinarians, agriculturists, scientists, consumer representatives, and others.>?
By 1952, it formed the basis for regulation and practice in 32 states and is en-
forced state-wide in 13 states. Adopted by 386 counties and 1,519 municipalities
in 38 states on a voluntary basis, the ordinance and its accompanying code now
protect about 65 million people. It is recognized as the only fluid milk regula-
tion approaching a national standard and has been accepted by many states
as the basic regulation for an interstate certification program and an industry-
wide education program. More recently there has been developed a Frozen
Desserts Ordinance and Code Recommended by the Public Health Service. Of
particular effect on the maintenance of the safety of milk and milk products is
the widespread application of the pasteurization process. Pasteurization of all
market milk is compulsory in 5 states, 15 counties, and 152 municipalities. In
addition, 346 towns and cities require pasteurization of all except certified raw
milk. As a result, about 90 per cent of the fluid milk sold in the United States
is protected by pasteurization.

Effective supervision and control of the many complex factors involved in
the production, processing and sale of milk and milk products has resulted from
cooperative action on the part of public health agencies, departments of agri-
culture, and the responsible representatives of the milk and dairy industry. The
actual control programs are administered by sanitarians and veterinarians on
the local level supported by the state departments of health and agriculture and
by the industry. On the state level, authority may be vested in either the state
health department or the department of agriculture, and sometimes in both.

From the analysis of epidemics presented, it is obvious that foods other than
milk are a matter of considerable concern to public health agencies as an in-
creasing source of preventable disease. Dauer® has presented an analysis of the
food-borne outbreaks of 1957 which gives a more complete picture of the
426 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

problem. Of the 250 food-borne outbreaks reported during that year, the diseases
involved were: gastroenteritis, 132; staphylococci food poisoning, 58; salmonellosis,
30; shigellosis, 11; botulism, 6; streptococcal infection, 4; typhoid, 3; trichinosis, 3;
and chemicals, 3. The types of establishments involved were: public restaurants,
58; schools and colleges, 21; food shops, 17; hospitals and institutions, 11; recrea-
tion camps, 6; labor camps, 10; trains, 4; private homes, 55; private clubs, 15;
social gatherings, 84. Dauer points out that the last three types of establish-
ments, involved in 104 outbreaks, are of a private character, but the remaining
127 (60 per cent of the total) are public or semipublic food places which should
be subject to control by health authorities.

. The first efforts of the Federal government to bring about control and
supervision of the quality of foods occurred in 1879 when a bill was introduced
in Congress to prohibit the adulteration of articles of food and drink. This
and a number of subsequent efforts came to naught, and twenty-seven years
passed before June 30, 1906 when Theodore Roosevelt signed a bill which pro-
hibited the manufacture and sale of adulterated and misbranded food. For
twenty years it was administered by the Bureau of Chemistry of the Department
of Agriculture. During this period several other acts were passed relating to
proper weights, packaging, labeling, food purity, meats, and standards for butter.
In 1927 the Secretary of Agriculture recommended the establishment of a Food
and Drug Administration to administer all of these various acts. Between 1927
and 1933 additional legislation was passed dealing with canned foods and in-
spection of seafood plants on invitation. Meanwhile attempts were made to
revise and bring up to date the original Food and Drug Act of 1906. Eventually,
on June 25, 1938, President Franklin D. Roosevelt signed a bill which established
the present Federal Food, Drug and Cosmetic Act. Two years later, under the
Reorganization Act, the Food and Drug Administration was transferred from
the Department of Agriculture to the Federal Security Agency, where it formed
a separate unit under a Commissioner of Food and Drugs.

The situation on the Federal level is somewhat complicated by the retention
ol meat inspection responsibilities by the Department of Agriculture, and by
the obvious concern of the Public Health Service for all matters dealing with
the salubrity of foods. In general, all three Federal agencies concerned with
different aspects of the food problem work in close collaboration, each fulfilling
certain responsibilities. On the state and territorial level the situation is even
more confused. All but four states have some [ood control agency, but there
is no uniformity among them. The agencies involved are: departments of agri-
culture in twenty-three states; departments of health in twenty states; food or
food and drug commissions in two states; state chemist in one state; and public
service department in one state. Since 1939 efforts have been underway to revise
state laws to bring them into conformity with the Federal Food, Drug and Cos-
metic Act. This has been more or less accomplished in about one third of the
states.

Practically all municipalities and a great many counties carry out some form
of food control activities, usually by personnel of the local public health agency.
The personnel vary in quality from untrained inspectors to well-qualified sani-
ENVIRONMENTAL HEALTH 427

tarians and veterinarians. In general, the activities consist of inspection, rating,
and certification of food processing and dispensing establishments, sampling and
analysis of foodstuffs, physical examination and training of food handlers, and
local prosecution of infringements of food ordinances and laws. In carrying out
these activities, the local personnel work closely with and are supported by person-
nel of the various interested state and Federal agencies.

Particular attention is given by local public health authorities to sanitary con-
ditions in restaurants and taverns and bars. Many different types of inspectional
and rating forms have been developed and many types of action such as cer-
tification, licensing, and awards of merit have been used. In order to bring about
some reasonable and sound basis for uniform action, the Public Health Service
in 1934 began the development of a suggested procedure. After several ex-
perimental editions, the Ordinance and Code Regulating Eating and Drinking
Establishments Recommended by the Public Health Service was published in
1943. By 1952 it had been adopted by 674 municipalities and 322 counties, and
applied state-wide in 19 states. It now protects over 95 million people. Fuchs?
who has played a major role in its development and use explains: “The ques-
tion of enforcement methods was settled by offering two different forms of the
ordinance, one a grading type which permits enforcement by degrading or permit
revocation or both, the other a nongrading minimum-requirements type en-
forceable by permit revocation only. In the grading type, the competitive effect
of grading on public patronage tends to improve conditions in eating establish-
ments, thereby aiding in enforcement.” *

In a number of fields, public health interests and private enterprise have
found themselves in the same arena. In some instances they have unfortunately
acted at cross-purposes. Sometimes business and industry have looked upon public
health workers as interfering, unrealistic, and restraining and have pointed, with
considerable right, to the maze of conflicting requirements, ordinances, codes, and
standards with regard to the same article or process in different communities or
states. Public health workers on the other hand have sometimes accused private
enterprise of being completely mercenary and without social conscience. Fortu-
nately, in recent years industry and public health have made a number of sincere
attempts to get together in an amiable and intelligent manner to arrive at mut-
ually satisfactory conclusions and recommendations. In the field of environmental
health, and especially with regard to food sanitation, this led to the establish-
ment in 1944 of the National Sanitation Foundation. This is an independent,
nonprofit corporation financed entirely by business and industry and governed
by a board of directors comprised of individuals from private enterprise and
public health. Its purposes are: (1) to bring together representative industrialists,
businessmen, and public health workers to define and outline mutual problems,
(2) to finance research in fields of mutual concern and interest, (3) to promote
a program of personal and community health to acquaint employees and the
general public with the needs for good sanitary practices and community clean-

*Fuchs, A. W.: Restaurant Sanitation Program of the United States Public Health Service,
Pub. Health Rep. 62:263, Feb. 21, 1947.
428 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

liness, and (4) to work toward the development of a testing laboratory, similar
to the Fire Underwriters Laboratory, for materials of sanitary and health
promoting value. The initial stages of the latter are now in operation.

The Foundation sponsors the Joint Committee on Food Equipment Standards
with representatives from six interested national professional organizations. “Task
committees” set up by industry prepare preliminary standards for consideration
with the Joint Committee. After repeated conferences and revisions, if agree-
ment is reached, the standards may be approved by the Joint Committee. After
final review and approval by the Foundation’s Council of Sanitation Consult-
ants, the standards are published. Equipment which meets the standards is then
awarded the Foundation’s seal of approval. The procedure, while long and
complex, assures the careful study and consideration of all aspects of the problem
at hand and when completed, concurrence of public health workers, scientists,
and industrialists is certain. So far, standards for soda fountain equipment, gen-
eral food service equipment, and dishwashing equipment have been satisfactorily
developed and adopted. In addition, the Foundation carries out significant ac-
tivities in public sanitation education and has conducted several worth-while
“sanitation clinics” and “inservice training courses” for representatives of public
health agencies, business and industrial groups, and public officials.

Somewhat similar to these efforts are the increased activities on the part of
business and industry toward “self-policing.” Among the examples of this are the
programs of the National Canners’ Association, the Ice Cream Merchandising In-
stitute, the Food Industries Sanitarian Association, and the American Institute
of Baking. These are all good signs which point toward a more fruitful and
mutually more agreeable method of cooperative action from which the public
cannot help but benefit.

Atmospheric Pollution. During recent years the public and health officials
have become increasingly aware of the atmosphere as the important medium in
which we live and of the possibility and consequences of overloading it with waste
products of human activity. Thus there has been developing in the field of en-
vironmental health a concern with atmospheric pollution somewhat similar to
the established concern with stream pollution. In fact, one investigator,*! referring
to the many contaminants of air, has said, “Because it is left to the atmosphere
to rid us of these contaminants, it is common to speak of our aerial sewage system.”
Pound for pound, man consumes at least ten times as much air as water. Although
there has been for many years concern over the purity of the water used by human
societies, little attention has been given to the quality of the air which constantly
is breathed into the lungs and absorbed into the blood stream. Historical records
do exist, however, which indicate at least momentary concern with the problem
and even related legislation. As a result of the widespread adoption of soft so-called
sea-coal in English towns and cities, a smoke abatement law was passed as early
as 1273 by Edward I. He banned the use of coal as being prejudicial to the public
health. Shortly after, Parliament in 1306 formed a smoke-abatement group whose
recommendations resulted in a royal proclamation which prohibited the use of
coal in the furnaces of artificers. Record has it that in 1307 one offender was
actually executed for violating the regulation? In 1661 a report entitled
ENVIRONMENTAL HEALTH 429

 

“Fumifugium” claimed that almost one half of the deaths in London were
“phthisical and pulmonic distempers” resulting from polluted air.?3

Even now, the most common complaints about air pollution, are in regard to
smoke content and odor. A smoky or sooty atmosphere obviously results in dirty
clothes and buildings, less sunlight, damage vegetation, and sometimes impaired
breathing. However, there are a number of other reasons [or concern, including
particular and gaseous chemicals, dusts, and irritating pollens. Recognition of this
has resulted in a change in name and emphasis of many agencies and associations
from “smoke abatement” to “atmospheric pollution control.”

The atmosphere may be polluted from many sources. Smoke results wherever
fuel or other material is incompletely burned, i.e., industrial, commercial or do-
mestic heating facilities, incinerators, brush fires, dumps, and automobile motors.
In urban areas, especially, automobile motors are a major generator of poisonous
carbon monoxide gas as well as smoke. In rural and suburban areas irritating
pollens and toxic agricultural sprays and dusts are apt to be particularly prevalent.
Industrial contaminants represent a particularly complex and important source of
atmospheric pollution. In general, they fall into two classes: (I) particulate matter
or aerosols, and (2) gases and vapors. The most common types of the former are
metallic oxides, sulfur trioxide, fumes, mists, fogs, carbon, tar, and fly-ash. Sulfur
dioxide and carbon monoxide probably are the most common of the gases and
vapors. In addition, it has been shown that ozone which may be produced by
photochemical reactions can give rise to irritating proportions as well as aid in the
development of additional irritants by its oxidizing action on other pollutants.
The complexity of industrial and other factors which may pollute air is well illus-
trated by the studies reported by Magill** and by Larson? of the qualitative con-
stitution of smog in Los Angeles. Analysis of samples of air in that area indicated
the presence of the following contaminants:

Aerosols
Ether-soluble aerosols Lead
Sulfuric acid mist Aluminum
Carbon Calcium
Silicon Iron

Gases and Vapors

Acetylene Methyl chloride
Aromatics Nitric oxide
Benzene Nitrogen dioxide
Isobutane Nitrous oxide
n-butane n-pentane
Butenes Phosgene
Carbon tetrachloride Propane

Ethane Propylene

Ethyl benzene and xylene Sulfur dioxide
Formic acid Toluene

Methyl cellosolve Trichlorethylene

Unsaturated hydrocarbons ranging from CH; to C,H,
Products of oxidation of the above unsaturated hydrocarbons
(aldehydes, peroxides, ketones, and organic acids.)
430 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

It is obvious that in addition to the discharge of contaminants into the atmos-
phere there are certain fixed or variable meteorologic and topographic factors
which may determine whether or not a nuisance will develop, the degree of its
concentration or extension, and the acuteness and severity of its result. If a com-
munity is situated within a topographic bowl, natural dispersal of atmospheric
pollutants will be somewhat limited and there may result a considerable concen-
tration of soot and noxious gases. The role of weather was summarized by the 1951
Technical Conference on Air Pollution®® as follows: “The average distribution
of contaminants in a city is governed by wind, rain, atmospheric stability, and top-
ographic features. The contaminants in their turn influence rainfall and fog
occurrence and persistence.” Baynton®! has pointed out that insufficient attention
is given to these factors until they combine under special circumstances to cause
dramatic disastrous situations such as those at Donora, the Meuse Valley, and
elsewhere. He urges that any program relating to atmospheric pollution must
take into account a study ol winds, atmospheric stability, and precipitation as they
are related to seasonal variation, diurnal variation, surface temperatures, and
many other meteorologic factors.

Pollution of the atmosphere may result in economic loss to individuals and
to the general population in a variety of ways. Losses may take the form of dam-
age to livestock and vegetation, corrosion of metals and structural materials,
damage to clothing and other fabrics, damage to the finishes of automobiles and
houses, disruption of communications and increased artificial lighting require-
ments, depreciated real estate values, and last but by no means least, the acute
and chronic harm done to humans. Not including the effect on humans, Gibson37
in 1949 estimated the over-all national economic loss due to atmospheric pollution
to be about 114 billion dollars or about $10 per capita per year. He further calls
attention to numerous examples ol industrial establishments which, by installa-
tion of control procedures, have actually netted from modest to substantial profits
[rom the recovered materials. For example, one chemical company in Los Angeles
spent $40,000 for equipment to prevent atmospheric contamination. As a result
it is now recovering filteen barrels per day of lead oxide worth $90,000 per year.
This is not meant to imply, however, that air pollution control procedures neces-
sarily result in profit because that is by no means the case.

For our purposes, of course, it is the effects upon human life that are of
greatest interest and importance. The question of the relative role of air pollution
on the health of the individual or of a community under ordinary circumstances
is so involved that an answer is as yet impossible. As Princi®$ states, “The degree to
which such atmospheric contaminants affect individual health has either been
taken for granted on the one hand or totally ignored on the other.” Base lines,
standards, and methods of measurement necessary to determine adequately the
physiologic or histologic effects of substances in the air still leave much to be de-
sired. Even when a relatively severe short-time exposure occurs, such as that at
Donora, conclusive answers are usually not obtained because the investigations
take place after the fact and not before and during the incident. Nevertheless,
much has been learned during recent years as a result of studying “epidemics” of
air pollution, continuous smog situations, long-term effects on workers constantly
exposed to certain substances, and laboratory experiments.
ENVIRONMENTAL HEALTH 43!

The “epidemic” situation, of course, is the most dramatic and a number of
facts of value have resulted from their investigation. Four of these occurrences
merit special mention. During 1930 the heavily industrialized area in and around
Liege in the Meuse Valley of Belgium was subjected to four days of continuous
fog saturated with industrial smoke and fumes. Many thousands of people became
ill and 63 died. While studies indicated significant amounts of sulfur dioxide,
sulfuric acid and other chemicals in the air, no single substance was found in a
concentration sufficiently high to have caused the damage by itself.

A similar tragedy occurred in 1948 in Donora, Pennsylvania, a small town of
about 14,000 inhabitants. Because of its location in a valley and because of its
industry, polluted fogs are very common in Donora. Usually the sun and wind
dissipate the fog during the early hours of the day. Occasionally, however, it may
remain throughout a day. On October 27, 1948, a thick fog settled down in the
valley and remained for 414 days, meanwhile becoming more and more polluted
by the smoke, fumes, and gases from the town’s industrial plants. During the
period, 20 individuals died and about 6,000 others, or 43 per cent of the popula-
tion, became ill in varying degrees. The episode and the circumstances were
studied exhaustively for a year by the Pennsylvania Department of Health assisted
by the United States Public Health Service.40.41

As in the case of the Liege disaster, while a large number of gases and fumes
were identified in the atmosphere, it was concluded that no single contaminant
was responsible. In both instances, it was felt that a combination of irritating and
toxic materials, of which sulfur dioxide undoubtedly was one, acted synergistically
to produce the illnesses and deaths. In both instances the deleterious conditions
were observed to affect the population selectively. Almost all of the victims who
were affected fatally and many of those who became ill but did not die suffered
[rom respiratory or cardiac difficulties. The prolonged and intensive pollution of
the air harmed the aged, the infirm, and enfeebled infants, earlier than it affected
the remaining more vigorous fraction of the population. Among other things, this
indicates the need for a completely different set of tolerance levels of toxic sub-
stances [or a community as a whole as against those used heretofore. Most of the
latter are based on the tolerance of industrial workers.

A third disaster of this type occurred on November 24, 1950 at Poza Rica,
Mexico, where 320 persons were hospitalized, 22 of whom died.** This case dif-
fered from the Liege and Donora episodes in that it was possible to point to a
single toxic agent. A gasoline refinery at the site discharged a number of aerial
contaminants, one of which was hydrogen sulfide. A combination of relatively
localized unusual meteorological phenomena resulted in a very high concentration
of hydrogen sulfide gas around the plant.

The City of London, England, has experienced a number of sudden increases
in the death rate due to atmospheric pollution. Its situation is somewhat different
from the others described in that unlike the others the problem is not primarily
related to industrial contaminants. Severe fogs with stasis and lethal concentration
of atmospheric pollutants occurred particularly in 1873, 1880, 1892, and 1948. In
the 1880 incident, the death rate of 896 per million was about 50 per cent above
normal expectancy. In fact, it was significantly higher than the rate of 876 re-
corded for the worst week of the great London cholera epidemic of 1866. Despite
432 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

this, the events of December 1952 and especially of the five days, December 5 to
9, were even more spectacular. It has been shown conclusively that during the
total period of the first three weeks of December about 4,000 deaths were caused
by the polluted fog. While the very young, the aged and the infirm were affected
most, it is interesting that all age groups contributed to the increased mortality.
The mortality of infants doubled, deaths of children 10 to 13 years of age in-
creased by a third, and deaths of young adults increased almost two thirds. Deaths
from bronchitis which were eight times normal and deaths from pneumonia which
were three times normal accounted for about one half of the total increase in
mortality. Other causes of death for which marked increases were observed were
pulmonary tuberculosis and cancer, coronary disease and myocardial degeneration.

The cause of the phenomenon was a prolonged absence of wind and a low
temperature which produced a low altitude inversion whereby the normal upward
air currents came to a stop. As a result the usual air contaminants of the area ac-
cumulated to unprecedented concentrations. For example, the summer daily aver-
age concentration of smoke is about 0.12 mgm. per cubic meter of air and of sulfur
dioxide about 0.07 parts per million. On December 8, 1952 these figures rose to
4.46 mgm. per cubic meter and 1,339 parts per million, respectively. 44

A challenge even more difficult than that found in “epidemic” type situations
is presented by the problem of determining the chronic effects of atmospheric
contaminants on the health of people. Some attempts have been made in the past
to study this phase of the problem, but inherent difficulties have necessitated in-
complete and inconclusive data. Some of the best work has been in relation to the
chronic smog problem of Los Angeles.® There, the outstanding effect on health
has been eye irritation, and at first it was assumed to be due to sulfur dioxide
because it is an outstanding air contaminant, because of its irritating effect, and
perhaps because of its ease of determination. However, control procedures which
significantly reduced the amount of the gas in the area did not result in appre-
ciable relief. This led to a discovery that certain hydrocarbons, including gaso-
line vapors, could be oxidized in the air to form compounds capable of produc-
ing all of the observed deleterious effects including eye irritation which had been
produced. The Detroit-Windsor International Air Pollution Study*¢ has been de-
signed to investigate the chronic effects of exposure to air pollution on a much
broader scale, taking into consideration a large number of variables of possible
significance. It may eventually provide additional scientific and epidemiologic in-
formation upon which to base more practical and effective control programs.

By its very nature, atmospheric pollution is difficult to control. Its causes are
many and complex, really adequate standards and means of measurement are still
in the process of development, and an extensive number of public and private
agencies, businesses, and industries have important interests in anything that is
done. The atmosphere surrounding a present-day community is bound to be con-
taminated. Obviously a completely pure atmosphere is unattainable. Numerous
compromises must be made. Not the least of the problems facing those interested
is where to draw the line. It would seem that control must depend upon legisla-
tion, public as well as industrial education, the further development of standards
ENVIRONMENTAL HEALTH 433

 

and measurement techniques, the further development and application of practi-
cal mechanical devices for controlling the aerial waste products of industry, and
the development and application of new sources of heat and power.

While numerous attempts have been made to bring together the various
groups concerned with air pollution, at present there is no Federal agency au-
thorized to coordinate control activities. Legislation to this end has been pro-
posed, but so far only laws relating to international problems and to the District
of Columbia have been enacted on the Federal level. Among the states, California
in 1947 enacted the most extensive legislation. In addition to having established
a control authority and having provided for continuous study and research, it has
placed a limit on the dusts, fumes and sulfur which may be discharged by industry
and requires approval of plans for any installation that might add to the pollu-
tion of the atmosphere. An increasing number of cities have enacted ordinances
dealing with various phases of air pollution. Since the mid-1940’s, Pittsburgh and
St. Louis particularly have brought about spectacular improvements. In St. Louis,
for example, the sulfur dioxide concentration in the air in 1950 had been re-
duced 83 per cent below the level of the winter of 1936-37, and the downtown
concentration was no higher in 1950 than it had been 20 miles out of the city
fifteen years before. Between 1945 and 1948 the average number of hours per
month of heavy smoke during the heating season decreased from 158 to 77, a re-
duction of more than 50 per cent. During the same period visibility at the airport
improved 75 per cent.*” These improvements were due essentially to the enforce-
ment, coupled with community education, of an ordinance which declared the
production or emission of dense smoke a nuisance to be summarily abated; made
it unlawful to import, sell, or use any solid fuel for hand-firing or surface-burning
types of equipment which did not meet the standards of a smokeless fuel; and spe-
cifically included control of smoke from locomotives.

In discussing the legislative aspects of the air pollution problem, Dyktor*s
warns against the tendency to go to extremes and by means of legislation to
“throw the whole book” at both industry and all fuel users. He advises:

Legislation must be of the ‘performance’ type without specifying the means of
attainment of the ‘performance.’ In other words, one should be concerned principally
with the discharge from the stack and the potential violator should be given a free
choice of means to avoid an actual violation. *

He concludes with particularly sound advice well worth repetition here:

Human experience teaches that a policy of adjustment and flexibility is the best
policy in the long run. This applies particularly well in air pollution control. Litigation
is to be avoided because the democratic process demands careful preparation of the
facts plus considerable time spent in court, and this energy can be used to better
advantage in a cooperative effort which will give more permanent results. Therefore,
in practice, the provisions of the legislation must be applied with a great deal of
judgment, and sight must not be lost of the fact that only a compromise can be ar-
rived at in most instances.*

*Dyktor, H. G.: The Community Problem. In Inservice Training Course in Air Pollution,
University of Michigan School of Public Health, Feb. 6-8, 1950, Ann Arbor, Michigan, pp. 13-14.
434 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Housing and City Planning. In discussing the need for public health in-
terest in housing, Winslow!? commented:

The filth epidemics of the Nineteenth Century have been conquered in civilized and
relatively prosperous lands like ours. We can now think in terms of health rather than
in terms of disease; and, from this standpoint, such problems as nutrition and housing
come to the forefront. The slum of today is no longer a hot-bed of cholera and typhus
fever as it was seventy-five years ago. It remains, however, one of the major obstacles
to that physical and emotional and social vigor and efficiency and satisfaction which
we conceive as the health objective of the future.*

Many attempts have been made to establish a conclusive relationship be-
tween unsatisfactory housing and ill health. Several of these have been referred
to earlier in the discussion of the sociological aspects of public health. How-
ever, because the dwellers in poor housing are subjected to so many other un-
desirable factors such as low economic income, malnutrition, limited education,
and the like it is impossible to determine with exactness what is cause and what
is effect. The difficulty and its proper interpretation has been summarized partic-
ularly aptly by Anderson? as follows:

Of the many newer aspects of environmental sanitation, the standards of housing
seem to rest on an especially insecure epidemiological foundation. IT would not question
the potential health significance of housing, and yet epidemiological data on which
to base this belief are virtually nonexistent for poor housing cannot be separated
from other attributes of poverty.

This inability to secure epidemiological support for housing standards should not
discourage us from attempts to improve housing conditions or even to do so by regula-
tion. Almost every community has houses that by no stretch of the imagination can be
defended as desirable for human habitation. An appreciable fraction of our population
lives under conditions that are undesirable socially, morally, and hygienically. Housing
needs no defense nor need it await epidemiological support.t

The history of the movement to provide decent housing for people has
been briefly traced by Catherine Bauer® on a basis which should not be lost
sight of by public health workers. She reminds us that the housing movement
may be viewed not only as a significant chapter in scientific and public health
history, “but also as a very lively and important chapter in political history.”
She points out that without exception, “every major step in housing progress
in the past century has involved some public action,” and suggests that “political
philosophy—the motivating forces behind public action and the application of
scientific knowledge—is not secondary or incidental, but paramount.” Of par-
ticular significance to our present consideration, she traces the gradual develop-
ment of enlightened political philosophy, dating from the English Poor Laws of
the early nineteenth century, with its expanding concepts of individual rights—
to due process of law, to health, to education—to the more recent concept of

*Winslow, C.-E. A. (Chairman): An Appraisal Method for Measuring the Quality of Hous-
ing: Part I. Nature and Uses of the Method, 1945, American Public Health Association Com-
mittee on the Hygiene of Housing, p. 1.

Anderson, G. W.: The Present Epidemiological Basis of Environmental Sanitation, Am.
J. Pub. Health 33:113, Feb. 1943.
ENVIRONMENTAL HEALTH 435

 

 

the right of individuals to a decent home. She proceeds then to provide us with
a sound basis for future thought and action in proposing that henceforth our
interest is “not just a question of ‘minimum standards’ to allay disease or prevent
divorce or save the taxpayers money, or of sporadic housing programs tied to one
emergency kite or another, to provide employment or increase the birthrate or
improve the physical qualities of soldiers or lessen the danger of revolution,
but good housing for all, to be provided by public action where private en-
terprise could not do the job, on the fundamental democratic principle of equal
opportunity.” *

The production of housing in the United States has depended essentially
on the law of supply and demand. The demand, however, has been closely linked
to the economic ability of individuals and families to afford the product. Thus,
even in the relatively prosperous year 1929, a third of American families had
incomes under $1200 and an additional third had incomes from $1200 to $2000
per year. Budget experts believe that a family should not expend more than
about one fifth of its income for housing. The inability of a considerable propor-
tion of the population to afford good housing, entirely on their own, is there-
fore obvious.?*

The slum dweller is the real problem, not the slum. The basic inescapable fact
is that a substantial part of our urban population cannot pay for decent housing.
In an Atlantic seaboard city like New York, private capital cannot possibly build and
maintain decent housing for rent at less than $30 per room per month. No family of a
size requiring a three-room apartment can afford to pay such a rent on a family income
of less than $5,000 a year. It is true that gouging landlords are, in some instances,
obtaining huge incomes from subdivided tenements and cellar dwellings. To expect,
however, the private landlord to be able to meet the housing needs of the $2,000-income
families with children is a fantastic dream. The submerged one-tenth of the population
of New York and of other large cities, who have incomes of $2,000 or less, can pay only
$30 per month for the whole dwelling unit.

It was for this very reason that our federally subsidized low-rent housing program
was initiated; it can provide a most economical type of basically decent housing and
provide it to the needy tenant for a price of $30 per month for an average household.
The far more extensive development of this program is an essential precedent to the
elimination of the slum dwelling. . . .¥

An important consideration is that private housing is constructed largely
during periods of economic upswing when building costs are also going up.
Furthermore, during periods of economic depression, the cost of houses does not
go down to the extent that salaries and incomes decline. During the depression
years of the 1930's, despite ever growing needs due to population increase and
continued movement toward cities, construction of homes lagged considerably.
The postdepression spurt was then thrown off balance by the exigencies of the
war effort. By the end of the war, a tremendous backlog of housing needs had
developed. Since that time we have observed the greatest building boom in our
history. Despite this, about one third of the nation’s 46 million dwellings are

*Bauer, C.: The Provision of Good Housing, Am. J. Pub. Health 39:462, April 1949.
iEditorial: The Shame of the Slums, Am. J. Pub. Health 43:621-623, May 1953.
436 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
considered to have basic health deficiencies. A summary ol these deficiencies has
been given by Johnson” who indicates that about 6,600,000 dwelling units or
one out of seven are overcrowded, 13,800,000 or one out of three lack inside hot
and cold running water, and over 6,900,000 have no piped running water. Ap-
proximately 12,900,000 housing units lack decent toilet facilities. Suprisingly
only one half of the water deficiencies and one third of the toilet deficiencies are
in rural farm areas. A quarter of the dwellings lack a bathtub or shower, 60 per
cent of the deficiency being in urban and rural nonfarm areas. Using general
condition and plumbing facilities as criteria, the 1950 housing census indicates
approximately 16 million dwellings to have one or more basic health deficiencies.

The components of healthful housing have been studied over a number of
years by the Committee on the Hygiene of Housing which was established in
1937 by the American Public Health Association. As a result, the Committee
has issued a series of important documents which have filled a longstanding need.
These documents are: The Basic Principles of Healthful Housing, Housing for
Health, Standards for Healthful Housing, An Appraisal Method for Measuring
the Quality of Housing, and A Proposed Housing Ordinance. Under four broad
headings, the Committee has listed the following thirty basic principles which
must be considered with regard to healthful housing’:

Fundamental Physiological Needs

I. Maintenance of a thermal environment which will avoid undue heat loss from the human
body.

2. Maintenance of a thermal environment which will permit adequate heat loss from the
human body.

3. Provision of an atmosphere of reasonable chemical purity.

4. Provision of adequate daylight illumination and avoidance of undue daylight glare.

5. Provision for admission of direct sunlight.

6. Provision of adequate artificial illumination and avoidance of glare.

7. Protection against excessive noise.

8. Provision of adequate space for exercise and for play of children.

Fundamental Psychological Needs

I. Provision of adequate privacy for the individual.

2. Provision of opportunities for normal family life.

3. Provision of opportunities for normal community life.

4. Provision of facilities which make possible the performance of tasks of the household without
undue physical and mental fatigue.

5. Provision of facilities for maintenance of cleanliness of the dwelling and of the person.

6. Concordance with prevailing social standards of the local community.

Protection Against Contagion

1. Provision of a water supply of safe, sanitary quality, available to the dwelling.

2. Protection of the water supply system against pollution within the dwelling.

3. Provision of toilet facilities of such a character as to minimize the danger of transmitting
disease.

4. Protection against sewage contamination of the interior surfaces of the dwelling.

5. Avoidance of insanitary conditions in the vicinity of the dwelling.

6. Exclusion from the dwelling of vermin which may play a part in the transmission of disease.

7. Provision of facilities for keeping milk and food undecomposed.

8. Provision of sufficient space in sleeping rooms, to minimize the danger of contact infection.
ENVIRONMENTAL HEALTH 437

Protection Against Accidents

1. Erection of the dwelling with such materials and methods of construction as to minimize
danger of accidents due to collapse of any part of the structure.

Control of conditions likely to cause fires or to promote their spread.

Provision of adequate facilities for escape in case of fire.

Protection against danger of electrical shocks and burns.

Protection against falls and other mechanical injuries in the home.

Protection of the neighborhood against the hazards of automobile traffic.

ore

> =

The achievement of these goals, as Johnson indicates, involves action on
three fronts: “First, prevention of accelerated rates of deterioration of dwellings
and their environment, thereby forestalling the formation of new blighted and
slum areas; second, the rehabilitation of existing substandard housing, if salvage
is economically feasible, and its demolition—which is part of rehabilitation in
its broader sense—of substandard dwellings that are beyond repair; and third,
the production of enough new housing to provide for population increase, for
families now overcrowded, for replacement of demolished and decayed structures,
and for the normal vacancy cushion.” *

As is indicated by several of the preceding criteria, adequate housing is
now considered to involve circumstances which extend beyond the physical struc-
ture of the dwelling. Many of the objectives are unattainable if the surrounding
neighborhood or indeed the entire community is allowed to develop in a com-
pletely hit or miss fashion. It is necessary, therefore, to give consideration to
the over-all living needs of the neighborhood and to the planning of the com-
munity as a whole. This involves the development of long range programs of
improvement, land use and trafic planning, with attention to street and free-
way layout, parks and playgrounds, sites for schools and other public buildings,
shopping centers, and the location of business and industrial enterprises.

Beyond this, is the need for increased attention by public health workers
and others to fringe areas surrounding municipalities. It is here that some of the
worst housing problems exist today. O’'Harrow®® calls attention to the sizable
portion of the American population which lives under these circumstances. He
points out that, “In 1950, the census counted approximately 20,900,000 people
living in this ‘no man’s land’—more than the combined population of our five
largest cities.” While not all of these, of course, live under substandard con-
ditions, a substantial proportion of them do. Three reasons are given by O’Harrow
for subdivisions going sour and giving rise to difficulties. In the first place they
may be premature, with land subdivided before there is a real need for it. Be-
yond the economic loss which results from much of the land lying unused, the
situation invites the development of suburban squatter slums. A second reason
for failure is that subdivisions may be poorly designed by promoters butchering
the land into inadequate sized lots in an uncompromising gridiron pattern, with
no concern for recreation, parking, or other public spaces. Finally, subdivisions
and fringe areas are very apt to suffer from incompleteness with no plans for,

 

* Johnson, R. J.: Health Departments and the Housing Problem, Am. J. Pub. Health 42:1583,
Dec. 1952.
438 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

much less provision ol water, sanitary or storm sewers, street lights, fire hydrants,
or grading and surfacing of streets. Board and Dunsmore® have described the
health problems which may arise under such circumstances and emphasize the
need to think in terms of metropolitan communities irrespective of political
boundaries as far as environmental health is concerned.

Any reasonably adequate solution of the tremendous and complex problem
ol housing obviously requires the combined and coordinated efforts ol private
enterprise, the local, state and Federal governments, and various professional
and civic recreation. Governmental action on all levels involves participation by
many different agencies and departments including those concerned with health,
building inspection, plumbing, water, legal counseling, schools, recreation, traffic
engineering, fire protection, public works, tax enforcement, public welfare, public
housing and redevelopment. This is not a job to be done by the official health
agency alone.

Several administrative approaches have been tried. Traditionally, in this
country, responsibility for the quality of new housing has been vested in housing
officials who have been primarily concerned with protection against fire and
structural collapse. Of somewhat secondary interest have been requirements re-
lating to the water supply, plumbing, heating, lighting and ventilation. Once
housing is constructed and occupied, responsibility for the supervision of its
quality is usually transferred to the local health department. This is perhaps
because the health department is in the best position to use effectively the police
power and other legislative measures’ and because of the multiplicity of in-
terests of public health agencies. Thus many local health departments have
long been active in various fields directly related to housing. Among these are
the enforcement of requirements with regard to heating, lighting and ventilation,
control of atmospheric pollution, supervision of water supplies, plumbing and
sewerage systems, rodent and vermin control, nuisance abatement, accident pre-
vention, and sanitary education.

The contributions of the local health department to the solution of the
broad problem of housing may be in several fields which include:

1. The development and promotion of the acceptance of local desirable housing
standards.

2. Participation in the enactment and enforcement of proper building codes and
housing ordinances.

3. Measurement of the quality of existing housing.

4. Participation in the remedying of existing housing deficiencies, through re-
habilitation and slum clearance.

5. Participation in the proper control and direction of new housing, through
zoning, city planning, and the issuance of various permits and licenses.

6. Education of the public in the hygiene of housing.

The need for concentrating the responsibility for administering laws or regu-
lations relating to housing is emphasized by Johnson?” who advocates the for-
mation of a Housing Board responsible to the administrative head of the com-
munity. He suggests that it consist of the heads of departments directly con-
ENVIRONMENTAL HEALTH 439

 

 

cerned with the various aspects of the housing regulations, plus one or two
others who are vitally concerned. “For example, a typical board might consist
of the commissioners of the building, fire, and health departments, along with
the executive director of the Housing Agency or the slum clearance and rede-
velopment agency, and the head ol the planning department. In some com-
munities the commissioner of police and the director ol wellare may be added
to, or substituted for, one of the above representatives.” *

It must always be remembered, however, that while laws and regulations
may provide a basic background and a legal means ol requiring conformance
to housing standards, they have never in themselves provided or maintained a
decent dwelling. One of the greatest areas of neglect has been in health education
as it relates to housing. If adequately pursued, it would undoubtedly bring about
the correction of more housing deficiencies than could ever be accomplished by
laws.

Major consideration of necessity has been given to the situation and possi-
bilities on the local level. A few words should be said about the position of
the state and Federal governments. They may provide types of assistance and
service which individuals, communities, and organizations are unable to provide
for themselves. State governments may provide funds and consultation for the
planning and construction of public housing, for slum clearance and redevelop-
ment, and for regional planning. In a few instances, state-wide housing legislation
has been enacted and enforced. The Federal government through legislation may
assist by the insurance of mortgages and of deposits in home loan banks, by the
subsidization of slum clearance, redevelopment and low-rent public housing,
by rent controls, grants for farm housing, bv research, and by the collection of
statistics on housing, labor and materials.

With regard to relationships among the various levels of government, a
concluding statement by O’Harrow is worthy of particular reference.

When a local or state government continues to neglect a problem long enough,
a higher government steps in and takes over the solution of the problem . . . in
at least two of our major cities, the state has taken over the police department.
Federal activities in public housing are example enough at the next level. The review
of all subdivisions in Wisconsin, except those for Milwaukee County, has for some
time been handled by the state. Without endorsing this method of handling the problem,
one can point to such things as straws in the wind for local and state governments.f

Vector Control. As pointed out in Chapter 23 which deals with the control
of communicable diseases, those pathogenic organisms which involve nonhuman
hosts or vectors at any stage of their life cycles offer an additional point of
potential control. The number of such diseases is very large and the numbers
and types of vectors impressive. Vectors of particular public health concern are
rodents and arthropods. Of the former, rats, ground squirrels, and prairie dogs
are most important, especially in view of their role in the spread of plague.
Among the innumerable arthropods, certain mosquitoes, flies, fleas, roaches, lice,

*Johnson, R. J.: Housing Law Enforcement, Pub. Health Rep. 66:1451, Nov. 1951.
TO’Harrow, D.: Subdivision and Fringe Area Control, Am. J. Pub. Health 44:473, April 1954.
440 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

mites, and ticks are of impressive significance. It is all too easily overlooked by
residents ol the United States that insects exact a far greater toll of health and
life than any other thing. Malaria is still the world’s leading cause of illness
and death, and many other insect-borne diseases are far from rare. Furthermore,
considerable numbers of the insect vectors of many of those diseases are present
in many parts of the United States. Accordingly, the control of insect vectors of
disease is still and will long continue to be an important phase of environmental
health programs in many places.

The possibility of controlling disease-transmitting insects became a reality
at about the turn of the century. Lile cycles of many organisms and of many
vectors became known. Experiments and demonstrations of various methods
ol control of breeding places and ol protection against adult insects were carried
out. The use ol courageous administrative procedures for the widespread use
ol these methods established Havana and Panama as famous landmarks in public
health history. Destruction of mosquito breeding places was accomplished by
drainage and fillings; larvae were killed by fish and by the spreading ol oils;
adult insects were destroyed or repelled by fumigants and smudges and were
excluded [rom living and sleeping quarters by screening and bed nets. Subse-
quent decades brought cheaper and easier larviciding with Paris green, and
pyrethrum became widely used as an insect adulticide. It was not, however,
until World War II presented the terrible risk of action in far-flung disease-
ridden areas that insect control really came into its own. Some ofl the older
materials like pyrethrum were made more effective by refining their insecticidal
principles and by applying them with aerosols as the medium. Remarkably el-
ficient new repellents were also developed. It was the development of DDT and
its widespread use against mosquitoes, lice, and other disease vectors, however,
that really opened a new epidemiologic era. Its many successes against many
vectors of many diseases in many places represent a real triumph of man over
his environment. *

The control and destruction of rodents is of importance because of two
diseases in particular, i.e., plague and murine typhus. In the United States, plague-
infected wild rodents have been spreading eastward from the west coast at a
rapid rate, necessitating intensified control procedures in order to prevent epi-
demics. Murine typhus is endemic in a number of southeastern and some western
states. In this instance, rats and mice which infest households are the rodents
of consequence. Other mammalian hosts of diseases dangerous to man which
in certain areas assume importance are wild monkeys and some ruminants in
relation to yellow fever, and dogs, wolves, foxes and bats in relation to rabies.

Many urban and rural local health departments as well as state health
departments have established vector control activities, usually in conjunction
with their environmental health programs. Activities which are variously included
are educational and promotional activities, vector surveys, research with regard
to vectors, materials, and control measures, direct application of insecticides and
rodenticides, licensure and supervision of pest eradicators, studies on or super-

*For a brief summary see Advancing Frontiers in Insect Vector Control by Andrews.®
ENVIRONMENTAL HEALTH 441

 

vision of garbage disposal, rat-proofing in relation to the housing program, and
elimination of mosquito breeding by spraying, drainage, filling, or variation of
impounded water levels.” To perform these various functions adequately a
variety of types of personnel is required, i.e., sanitary engineers, laboratorians,
sanitarians, sanitary inspectors and sometimes zoologists and chemists. Of par-
ticular importance are entomologists and biologists’ to whose services and
abilities increasing attention is being given by public health agencies.

Miscellaneous Sanitation Activities. In addition to the areas of environmental
health already discussed, there is a wide and varied array of miscellaneous ac-
tivities and programs which may be carried out by health agencies. No more
than passing mention will be made of them here since most of them are of
specialized and restricted importance, interest, and responsibility.

Of specific Federal concern is the supervision of the salubrity of vehicles
of interstate and international traffic, i.e., busses, trains, boats and airplanes.
The United States Public Health Service, which is responsible for these activities,
has developed standards for each.61.62.63 The maintenance of a sanitary environ-
ment in connection with parks, recreation areas and trailer camps may be a
concern of a local, state, or Federal health agency depending upon the particular
situation. Usually the responsibility is shared with another branch of govern-
ment, such as those concerned with highways, recreation, or conservation. Re-
lated to these problems but more exclusively the responsibility of the public
health agency is the supervision of the quality of swimming pools and bathing
places.

Finally, there is the newly emerging and potentially very important field of
radiologic health. The chief concern here for the public health agency is protec-
tion against damaging radiations, either from the nuclear processes themselves
or from the waste products resulting from these processes. Already the problem
is significant. Increasing amounts of radioactive isotopes are being used for
medical diagnosis and treatment, for materials testing, and for industrial re-
searches of many kinds,%* and the first plants for production of public power
from nuclear energy are already under construction. The problem of fall-out
from nuclear weapons testing compounds the situation. Those who have particular
interest in the subject of radiologic health are referred to two recent symposia
on the subject.%5.66

Personnel in Environmental Health. Because of the regional differences
which exist with regard to types of problems, degree of urbanity, and availability
of funds, facilities and trained personnel, a certain amount of difference of
opinion has resulted concerning the types of persons needed in order to carry
on a satisfactory environmental health program. Generally speaking, the rural
areas and small towns have found it necessary to depend upon nonengineering
personnel, often with no training except perhaps for a few weeks indoctrination
and orientation provided by the state health departments. In contrast, by virtue
of the complexity of their problems, urban centers have characteristically em-
ployed persons with professional training in civil or sanitary engineering to form
the backbone of their environmental health programs.
442 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

The development and employment of these two types of personnel has given
rise to some confusion and disagreement. Some engineers decry the lack of
training of sanitarians who in turn label engineers as impractical in insisting
upon a high degree of professional training in all circumstances. It is felt that
this confusion and disagreement is best eliminated by the adoption of a broad
and more unified point of view concerning the nature and magnitude of the
total job that needs to be accomplished. Actually there is a place and a need
for both types of workers in public health. The essential problems, as so often
is the case, are concerned with training, cooperation, and supervision.

A new occupational specialty referred to as public health engineering has
emerged. It had its origin in the two somewhat different but related fields of
activity of sanitary engineering and sanitary inspection. As MortonS” has pointed
out, neither of these was primarily or originally public health in nature from the
standpoint of time and service rendered. Sanitary engineering is concerned essen-
tially with design, construction, and operation. Although benefits of great signifi-
cance to public health result from sanitary engineering, the sanitary engineer,
being primarily interested in the design and construction of a waterworks system,
a sewage treatment plant, or a garbage incinerator, focuses his attention much
more upon construction materials, hydraulics, rates of flow and heat losses rather
than upon potential morbidity decreases and other responses of those served.

Sanitary inspection, as has been pointed out, antedated sanitary engineering
by a considerable period. Its efforts have been directed toward more local and
personal environmental factors that were thought to exert a possible deleterious
or unpleasant effect upon living. Much of it was, and still is, based upon sup-
position rather than scientific knowledge and to a considerable degree it may
be regarded as largely concerned with aesthetics. Interestingly enough, the swing
of the pendulum has resulted in a renewal of interest in the aesthetic aspects
of environmental sanitation. Anderson,’ whose position as an epidemiologist of
high order would be denied by no one, has claimed that “complete disregard of
the aesthetic aspects of environmental sanitation is not only illogical but even
detrimental to public health progress. Many of these aesthetic components have
contributed immeasurably to our standard of living. The cleanliness of a com-
munity’s streets, parks, foodhandling establishments and public buildings, in-
cluding the public toilets, is a true measure of its standard of living. If we neglect
these, we sink into a neglect of measures of greater importance.” *

Public health engineering is more comprehensive than either of the foregoing
fields. Actually, it embraces the public health aspects of both sanitary engineering
and sanitary inspection. Its prestige and potentialities as a profession are based
upon the intimate dependence of human beings on their environment and the
fact that control and adjustment of the environment in all its aspects involves
the application of engineering priciples. This was brought out by a committee
of the American Public Health Association® which defined public health engi-
neering as including, “The public health aspects of all types of environmental

*Anderson, G. W.: The Present Epidemiological Basis of Environmental Sanitation, Am. J.
Pub. Health 33:114, Feb. 1943.
ENVIRONMENTAL HEALTH 443

 

conditions whose control is based upon engineering principles regardless of
the magnitude or technical difficulty of the individual problems involved.” It
was further stated that “environmental sanitation problems—whether small or
large, simple or complicated—are fundamentally engineering in character.”

The solution, therefore, would appear to involve the provision, in one
way or another, and on all levels, of planning and supervision by professionally
trained engineers. On the national and state levels this does not present a problem
since the advisory and policy-making functions on those levels imply the em-
ployment of engineers. The difficulty arises chiefly on the local level. Even here,
most municipalities of any significant size now employ engineers who may plan
and supervise the total environmental health program including its inspectional
phases as well as those of a more complex engineering nature. In rural areas,
however, as typified by the usual county health department, the employment of
engineering personnel is relatively rare. This is due to a number of factors among
which are insufficient funds for adequate salaries and lack of enough job interest
to attract and to hold well-qualified engineers in the face of personnel shortages
elsewhere. As a result, dependence for the sanitation program in rural areas
has been placed upon untrained sanitary inspectors or, what is far better, upon
sanitarians who have received formal training to qualify them for the work.

Under either rural or urban circumstances, local health departments, func-
tioning on the direct service level, must for reasons of economy and efficiency
supplement the services of professionally trained workers by assigning specific
functions to auxiliary workers who, through training and experience, have demon-
strable ability to perform those functions adequately under supervision. This
policy has been found practical and justifiable in other phases of the public
health program as well as in medicine and engineering and there is ample reason
to follow it in the field of environmental health.

In the proper utilization of the sanitarian, Kroeze™ has listed three condi-
tions necessary to ensure the proper expansion of the local sanitation program,
to make full use of our present technical knowledge, and to meet the demands
ol the public for the type and quality of services they have reason to expect.
These conditions are: (1) a clear understanding of the nature and scope of en-
vironmental sanitation, (2) a realization of the responsibility for the technical
administration and supervision ol the sanitation program, and (3) a proper
coordination of the services rendered by various types of personnel.

Where the needed professional personnel does not exist on the local level,
supervision as well as planning and direction should be provided by the state
health department. Fortunately there is an increasing appreciation by engineers
on the staffs of state health departments of their responsibility for the guidance
and supervision of the local sanitation program. This makes for a more compre-
hensive program in the field and enables the local sanitarian to assist with certain
difficult and technical activities which formerly were handled exclusively by the
state. Among these may be named the supervision of the water supplies and
sewage disposal systems of towns and small cities, the surveillance of milk sheds,
participation in programs of industrial hygiene, and the prevention of stream
pollution. When the state health department endeavors to fulfill these functions
444 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

alone, it is essentially an attempt at remote control. By bringing the local
staff into the program, the supervision and services are rendered on a day-to-day
basis rather than at monthly or yearly intervals. This acknowledgment by the
state of the responsibility to provide the local personnel with technical assistance
and direction is expanding the usefulness of the local sanitarian considerably
and is making it possible for the local health department to provide much more
adequate service to the public than would otherwise be possible.

Theoretically, some of the need for supervision of the local sanitation per-
sonnel should be met by the local health officer who, after all, is ultimately re-
sponsible for all phases of the community health program. In some instances,
however, this is neither attempted nor possible since all too many local health
officers unfortunately appear to lack the inclination, interest or ability to assist
their sanitation staffs with their problems. This provides further evidence of
the need for rather extensive postmedical training in public health for physicians
who aspire to become directors of public health programs. Recent trends in-
dicate more and more reason for closer association between the health officer
and the sanitation staff and lor mutual attack upon problems that are really
of common concern. Where formerly sanitarians may have restricted their ac-
tivities to the inspection of wells, privies, and restaurants, they now in addition
engage in many functions which cut across the direct interests ol the medical
health officer. Among these are intensive programs of school sanitation and
education, typhus fever and malaria control, and the epidemiological control
of food and milk. Attention is called in the discussion of Public Health Nursing
to the recent introduction in some schools of public health of courses for medical
health officers in the administration and supervision of public health nursing.
Under the circumstances, the development of similar courses relating to the
responsibilities of the health officer in the field of environmental health would
also appear to be indicated.

Present Organization of Environmental Health Programs. As has been
implied by previous comments, responsibilities and functions in environmental
health are ordinarily divided among the different levels of government accord-
ing to a more or less typical pattern. Generally speaking, the supervision of
public water supplies and sewage disposal systems and the prevention of stream
pollution are responsibilities of the Federal and state governments. The Federal
concern, through the United States Public Health Service, is based largely upon
responsibility for interstate sanitation and interstate and international public
carriers, although in recent years the introduction of Federal grants-in-aid to
states and localities is a factor of great potential significance. State precedence
over local communities in these matters results from legislative direction, the
potentiality of intercommunity problems, and the availability of professionally
qualified engineers in the average state health department.

In the matters of food and milk control there exists in most instances a
division of functions and responsibility between the Food and Drug Administra-
tion, the Department of Agriculture, and the departments of health. Federal
interests are concerned with research, the development of standards, and the
ENVIRONMENTAL HEALTH 445

 

promulgation and enforcement of various laws relating to pure food. The
states are concerned with the establishment of state standards, the formulation
and enforcement of state policies and regulations, and the promotion and gen-
eral supervision of local programs. In some instances, state agencies engage in
the field inspection activities necessary for the implementation of the standards
and regulations although more often this is left to the local health department.

The developmental history of local health units in a state has much to
do with the functional relationship which exists between the state and local
agencies in matters of environmental health. Those states which were slow to
promote the establishment of local health units still tend toward the centraliza-
tion of sanitation activities in the state health department, even though they
may now contain ample city and county health departments.

In contrast with public water and sewerage systems, those private facilities
which are designed to serve single or small groups of families are practically
always left to the supervision of the local health department. In many instances,
these small private facilities are inspected only upon request or complaint or
when they are related to epidemiologically significant circumstances such as
dairies or food processing or handling establishments. Between these two types
of facilities, public and private, are some which are termed semipublic. These are
found in tourist camps, roadside parks, comfort stations, rural schools, hospitals,
and other institutions. Since they serve a number of unrelated persons of diverse
origins, they constitute an obvious public health responsibility. In some areas
this is met primarily by the state, whereas in other areas the local health de-
partments provide most of the supervision.

Aside from the variations in responsibilities for environmental health which
relate to the different levels of government, the organizational and administrative
picture is further complicated by the spreading of functions throughout a num-
ber of agencies of government on each level. While true on all levels, it is most
evident in the states. Usually the state health department is designated as the
regulatory agency responsible for public water and sewerage systems, although
in some instances other departments of government, particularly state universities
and special sanitary authorities, commissions, or boards, enter into certain
phases of the program. This relatively well-defined distribution of authority,
however, does not apply to other activities in environmental health. The situa-
tion has been pictured by Mountin and Flook™ in the following terms:

The acme of complexity in sanitation activities occurs in that portion of the program
which involves food and drug control (including milk and shellfish sanitation) and res-
taurant supervision. Confusion is due to disagreement regarding what should be covered,
who should be responsible and how the desired results should be attained. As a result,
the division of authority and variation in procedures are so heterogeneous that they
almost defy classification and description in accordance with any pattern that could be
devised. Functional overlapping and interweaving apply principally to the health de-
partments and the departments of agriculture. To a lesser degree, they involve many
other State agencies among which the dairy and food commissions, hotel and restaurant
commissions, livestock sanitary boards, departments of labor, departments of conserva-
tion, boards of pharmacy, state universities and colleges, and independent state labora-
440 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

tories are outstanding. Control methods of agencies other than the health department
are usually limited to inspections, laboratory analysis of suspected products, and law
enforcement. *

Similar variability is found in connection with most other sanitary activities
including the control of steam pollution, industrial safety and hygiene, insect
and pest control, resort sanitation, and many others.

It is hoped that one of the long-term results of the various governmental
reorganizations and of the deliberations of the various professional associations
concerned with the field will be the ultimate unification of programs and the
clear-cut definition of responsibilities. Revision of current organizational struc-
tures and methods of administration will necessarily be a slow process and no
standard, universally applicable pattern can be anticipated. The end result of
stronger environmental health programs and more adequate service to the public,
however, will more than justify the time and effort.

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Sept. 1952.
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Health Rep. 67:180, Feb. 1952.
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Sanitation, 1950, Public Health Service, Department of Health, Education, and Welfare.
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Rep. 67:1080, Nov. 1952.
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ot

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State Government, Pub. Health Rep. 57:948, June 19, 1942.
ENVIRONMENTAL HEALTH 447

 

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Pub. Health Rep. 62:263, Feb. 21, 1947.

Baynton, H. W.: Environmental Studies—Meteorological Aspects, Pub. Health Rep. 67:668,
July 1952.

Isaac, P. C.: Air Pollution and Man’s Health—In Great Britain, Pub. Health Rep. 68:868,
Sept. 1953.

Environment and Health, Washington, 1951, Public Health Service Publ. No. 84.

Magill, P. L.: Techniques Employed in the Analysis of Los Angeles Smog, Proceedings of
the First National Air Pollution Symposium, Stanford Research Institute, 1951.

5. Larson, G. P.: Air Pollution and Man's Health—In Los Angeles, Pub. Health Rep. 68:873,

Sept. 1953.

Proceedings of the United States Technical Conference on Air Pollution, New York, 1952,
McGraw-Hill Book Co.

Gibson, W. B.: The Economics of Air Pollution, Proceedings of the First National Air
Pollution Symposium, Stanford Research Institute, 1951.

Princi, F.: Public Health Aspects of Atmospheric Pollution, Am. J. Pub. Health 44:206,
Feb. 1954.

. Firket, J.: Sur les causes des accidents survenus dans la valle¢ de la Meuse, lors des brouillards

de décembre 1930, Bull. Acad. roy. de méd. de Belgique 11:683, 1931.

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1949.

Townsend, J. G.: Investigation of the Smog Incident in Donora, Pennsylvania, and Vicinity,
Am. J. Pub. Health 40:183, Feb. 1950.

McCabe, L., and Clayton, G.: Air Pollution by Hydrogen Sulfide in Poza Rica, Mexico,
Arch. Indust. Hyg. & Occup. Med. 6:199, Sept. 1952.

Logan, W.: Mortality in the London Fog Incident, 1952, Lancet 7:336, 1953.

Scott, J.: Fog and Deaths in London, December, 1952, Pub. Health Rep. 68:474, May 1953.

Angeles County, 1949-1950 and 1950-1951, Air Pollution Control District, County of Los
Angeles, Calif.
Katz, M., Frederick, W., and Clayton, G.: The Detroit-Windsor International Program,
Proceedings of the Second National Air Pollution Symposium, Los Angeles, Calif., 1952.
Editorial: Smoke Control in Pittsburgh, Am. J. Pub. Health 40:1312, Oct. 1950.
Dyktor, H. G.: The Community Problem. In Inservice Training Course in Air Pollution,
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ing: Part I. Nature and Uses of the Method, 1945, American Public Health Association
Committee on the Hygiene of Housing.

Anderson, G. W.: The Present Epidemiological Basis of Environmental Sanitation, Am. J.
Pub. Health 33:113, Feb. 1943.

Bauer, C.: The Provision of Good Housing, Am. J. Pub. Health 39:462, April 1949.

Editorial: The Shame of the Slums, Am. J. Pub. Health 43:621, May 1953.

3. Johnson, R. J.: Health Departments and the Housing Problem, Am. J. Pub. Health 42:1583,

Dec. 1952.

Basic Principles of Healthful Housing, ed. 2, New York, 1941, American Public Health As-
sociation.

O’Harrow, D.: Subdivision and Fringe Area Control, Am. J. Pub. Health 44:473, April 1954.

. Ascher, C. S.: Regulation of Housing: Hints for Health Officers, Am. J. Pub. Health

37:507, May 1937.

Johnson, R. J.: Housing Law Enforcement, Pub. Health Rep. 66:1451, Nov. 1951.

Andrews, J. M.: Advancing Frontiers in Insect Vector Control, Am. J. Pub. Health 40:409,
April 1950.

Distribution of Health Services in the Structure of State Government, 1950, Public Health
Service Publ. No. 184, 1954.

Hinman, E. H.: The Medical Entomologist in Public Health, Pub. Health Rep. 67:755,
Aug. 1952.

Handbook on Sanitation of Railroad and Passenger Car Construction, Public Health Serv-
ice Publ. No. 95, 1951.

Handbook on Sanitation of Vessels in Operation, Public Health Service Publ. No. 88, 1951.

Handbook on Sanitation of Airlines, Public Health Service Publ. No. 306, 1953.

Kelly, R. E.: Health Problems Resulting from Newer Technological Developments, Am.
J. Pub. Health 38:837, June 1948.

. Inservice Training Course in Radiologic Health, Ann Arbor, Feb. 1951, University of

Michigan School of Public Health.

Concepts of Radiologic Health, Public Health Service Publ. No. 336, Jan. 1954.

Morton, R. J.: Potentiality of Public Health Engineering in Relation to the Social Security
Act, Am. J. Pub. Health 29:460, May 1939.

Anderson, G. W.: The Present Epidemiological Basis of Environmental Sanitation, Am.
J. Pub. Health 33:114, Feb. 1943.

Report of the Committee on Coordination of Public Health Engineering Activities, Ameri-
can Public Health Association, Yearbook, 1940-1941.

Kroeze, H. A.: The Expanded Role of the Sanitarian, Am. J. Pub. Health 32:611, June 1942.

Mountin, J. W., and Flook, Evelyn: Distribution of Health Services in the Structure of
State Government, Pub. Health Rep. 57:948, June 19, 1942.
chapter 1 3

Public health nursing

 

Introduction, Historical Development. Among the many types of profes-
sional persons engaged in public health work today, one group, that comprised
of public health nurses, merits particular mention. Aside from the fact that ap-
proximately one half of public health funds and positions are devoted to them,
they are of special significance in that, considered as a group, they have close
personal contact with greater numbers of the public than do the rest of the pro-
fessional staff of the health department. To many citizens, the public health nurse
is the health department. It is she who reduces the work of the organization to its
lowest common denominator, direct service to the individual. As a matter of
plain fact, a great many health departments owe their conception to communities
having become sold on the value of the services rendered by one or two, often
unsupervised, visiting nurses. As one review! of the subject has put it, “It is
precisely in the field of the application of knowledge that the public health nurse
has found her great opportunity and her greatest usefulness. In the nationwide
campaigns for the early detection of cancer and mental disorders, for the elimina-
tion of veneral disease, for the training of new mothers and the teaching of the
principles of hygiene to young and old; in short, in all measures for the preven-
tion ol disease and the raising of health standards, no agency is more valuable
than the public health nurse.”* William H. Welch stated the case more strongly
by claiming that America’s two great contributions to public health were the
Panama Canal and the public health nurse.

The public health nursing movement owes its inception to William Rath-
bone of Liverpool, who in 1859 became impressed by the care and comfort
given his wile during a fatal illness. Already a philanthropist, he promoted the
establishment of a visiting nurse service for the sick poor of his city. It is some-
what surprising to find that despite the enormous existing demand for therapeutic
nursing of the sick, the first nurse, Mrs. Mary Robinson, was directed not only
to give direct care to her patients but to instruct them and their families in
the care of the sick, the maintenance of clean, tidy homes, and the things con-

*The Public Health Nurse, New York: Department of Philanthropic Information, Central
Hanover Bank and Trust Co., Reprinted by the National Organization for Public Health
Nursing, 1938, p. 8.

449
450 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

tributing to healthful living. As the above mentioned review went on to say:
“... this went far beyond mere nursing, and the work of the visiting nurse was
thus bound up with and made part of a general health movement—the nurse
herself becoming perforce a social worker as well as a nurse. And the highly
constructive educational work all this involved put new life and vitality into the
age-old charity of visiting the sick poor, gave it enormously increased importance,
and brought about its later amazing development.” * In order that qualified nurses
would be available for the work, Rathbone enlisted the assistance of Florence
Nightingale and established a training school in affiliation with the Royal In-
firmary ol Liverpool. Interestingly, Miss Nightingale from the beginning re-
ferred to the graduates who engaged in home visiting as “health nurses.”

In the United States, as in England, the first visiting nurses were employed
by a voluntary agency, the Women’s Branch of the New York City Mission in
1877, and the idea soon spread to other communities. Meanwhile official health
organizations were being established, and it is only natural that eventually they
would have recognized the unique contribution which nurses could make to
their programs. At first, resort was made to the visiting nurses of the voluntary
agencies. Thus, the nurses of New York City Mission carried out the orders of
the school medical inspectors, visited the pupils’ homes, instructed the mothers
in general hygiene and infant care, and took sick children to the dispensary.

The first visiting nursing associations per se were established in Buffalo
in 1885 and in Boston and Philadelphia in 1886. Originally those of Buffalo and
Philadelphia were named District Nursing Societies and that of Boston was re-
ferred to as the Boston Instructive District Nursing Association. Eventually they
all changed their names to Visiting Nurse Associations. They depended for their
support upon lay contributions and small service charges where indicated. At
the beginning, not only were they administratively under the direction of lay
boards, but the actual work of the nurses themselves was supervised by lay persons.
Within a short time, however, the Philadelphia organization led the way by
providing for a supervising nurse. It is interesting that each of these three early
voluntary field nursing organizations is still active and influential in its respective
community, and in Buffalo, until recently, the organization provided practically
all of the public health nursing services for the official health department.

With the expanding concept of public health, it was inevitable that nurses
be employed directly by official health departments. The first city to do so was
Los Angeles, in 1898. Strangely enough, the basic purpose here was to provide
visiting nurse care to the sick poor rather than to engage in educational or
promotional activities. The first official public health nurse, although paid out
of tax funds and responsible to the health officer, was assigned to the Los Angeles
Settlement Association. As more nurses were added, however, there was established
in 1913 a bureau of municipal nursing in the health department. The first state
legally to approve the employment of public health nurses by local boards of
health was Alabama, in 1907.

*The Public Health Nurse, New York: Department of Philanthropic Information, Central
Hanover Bank and Trust Co., Reprinted by the National Organization for Public Health
Nursing, 1938, p. 9.
PUBLIC HEALTH NURSING 451

 

In the earlier days of public health work it was more easily possible to
focus public attention upon special individual problems and to obtain public
and private funds for their solution than it was to gain support for a broad
general program. As a result, most public health nursing programs were originally
organized on a specialized basis with nurses employed specifically as tuberculosis
nurses, school nurses, maternal and child health nurses, communicable disease
nurses, and, later, industrial nurses. This trend was given further strength by
the activities of the National Tuberculosis Association and the passage of the
Sheppard-Towner Maternity and Infancy Act and by the growing interest of
school officials in the health of the school child. On the other hand, the demon-
stration of the value of county health units sponsored by the United States Public
Health Service and the Rockefeller Foundation and the Town and Country Nurs-
ing Service sponsored in many parts of the nation by the American Red Cross
indicated distinct advantages to the generalization of nursing activities.

Over a number of years, therefore, one of the outstanding controversies in
public health nursing administration centered around the question of specializa-
tion versus generalization of nursing services. It was argued on the one hand,
particularly by clinicians, that a nurse specially trained for tuberculosis work,
for example, was equipped to render much more adequate care and service to
the tuberculous than was a generalized nurse. Similarly, school administrators,
wishing complete administrative control over the nurses working with school
children, have argued strongly for specialized school nurses. On the other hand,
those favoring the generalization of nursing services had several strong arguments
to put forth. One of these was the fact that it was people and families who
were to be served rather than diseases or conditions. Furthermore, it was pointed
out, it is seldom that only one problem exists in a family, and a specialized
nurse tends to close her eyes to all but one. A very practical objection to special-
ized nursing was the frequency with which a family with several health problems
would be overwhelmed by the successive visits of a series of specialized nurses
where a single, well-trained public health nurse, working on a generalized basis,
would be in a position to cope with all situations that might arise. Eventually
the concensus developed in favor of generalized public health nursing programs
with a few exceptions such as industrial nursing and full-time specialized clinic
activities.

Number of Public Health Nurses. Among the standards that have been
developed throughout the years have been some dealing with the number of
nurses needed in order to satisfactorily fulfill the needs of the average community.
At the present time it is recommended that there be at least one public health
nurse for each 5,000 of the population and that, if bedside nursing services are
included, the population base should be reduced to 2,000. Taken as a whole,
the nation is still far below these minimal standards despite the phenomenal
increase in the number of public health nurses. The figures available indicate
a growth from 130 in 1901 to 29,396 in 1957, an average of 16.5 nurses per 100,000
persons in 1957. Until the early 1920’s the majority of field nurses were em-
ployed by voluntary agencies. Since that time the distribution has changed con-
siderably, and the latest increase in total employment is due in large part to
452 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

a gain in the number of nurses employed by local boards of education where
over the years the rise has been both constant and substantial. A steady and
continuing decline is seen in the number of nurses employed by voluntary
agencies. Table 30 presents the numbers of public health nurses employed in
1957 in different types of agencies exclusive of industry.?

Indicative of the shortage that exists throughout the entire field of public
health nursing is a comparison of those employed in local official agencies in
1957 with the minimum suggested in the report “Local Health Units for the
Nation.” From Table 30 it is seen that in 1957 there were 12,605 nurses actively
engaged in local health work. This is less than hall the number (26,390) recom-
mended by Emerson in his widely accepted report. In fact, at the time the
report was written, only three states and the District ol Columbia were able
to report public health nurses in the ratio of 1 to 5,000 population, and the
national average was only about one public health nurse to each 8,900 per-
sons. At the time of this writing, the national average is 1 to 6,064 with eleven
states (including five New England States, New York, New Jersey, Delaware,
Arizona, California and Pennsylvania) having a sufficient number of nurses to
meet the standards of the American Public Health Association. It should be
noted, however, that only 29.7 per cent ol those staff nurses working in public
health nursing have received one or more years of academic training in public
health nursing, although at supervisory level and above, 83 per cent have had
one or more academic years of public health training. To further illustrate the
nursing personnel shortage, 1,062 vacant budgeted positions for public health
nurses were reported in 1951 by state and local health departments. Actually
this figure is low since several states and large cities did not report and their
nursing vacancies therefore were not included in the count. It is estimated

Table 30. Nurses Employed for Public Health Work in the United States,
Hawaii, Alaska, Puerto Rico, and the Virgin Islands, 1957*

Type of Agency Total Number

 

States agencies 1,615
Local official agencies 12,605
Local combination services 967
Local boards of education 9,378
Local nonofficial agencies 4,122
Schools of nursing 217%
Colleges and universities (non-nursing) 871

Federal agencies, national organizations, and universities (schools of public health
and universities offering programs in public health nursing approved by the
National League of Nursing) 709

Grand total 29,700

 

*Information taken from 1957 Facts about Nursing, New York, 1959, American Nurses’
Association, p. 25.

tFigure for year 1953.
PUBLIC HEALTH NURSING 453

 

that about 11,800 additional public health nurses are needed in the United
States in order to meet minimum desirable standards.*

Field Nursing Agencies. In the evolution of community health programs,
the contribution of nurses has been increasingly recognized on all levels.

National Level. Generally speaking, field nurses today may be placed into
two general categories—those employed by official health agencies primarily to
carry out preventive and promotive health functions, and those engaged almost
always by voluntary agencies primarily to render home nursing care to the sick.
Despite some differences of opinion regarding terminology, it is convenient for
our purposes to refer to the first group as public health nurses and to the second
group as visiting nurses. It should be pointed out, however, that neither of these
terms can be interpreted strictly any longer. The functional differences between
the two groups are becoming increasingly obscured. They both visit homes and
they both perform what are considered public health functions. Furthermore,
there are many indications of a trend toward the inclusion of bedside nursing
care of the sick in the functions of the publicly or officially employed field nurse.
In other words, the distinction between the two groups of nurses, if indeed a
real distinction exists, depends merely upon the manner of their employment
and compensation—in one case by government, in the other by a private, yet
publicly supported, agency.

Two agencies of the Federal government, i.e., the United States Public Health
Service and the Children’s Bureau, conduct activities in public health nursing.
They operate essentially by providing grants-in-aid and consultation service to
the states and through them to local health departments, and by participating
in the development of proper standards and qualifications. The Office of Indian
Affairs until recently provided direct nursing service to its wards by means of
public health field nurses stationed on the various reservations. In 1953 this
activity was transferred to the Public Health Service. In general the work is the
same as that performed by public health nurses employed in local health de-
partments. Three nonofficial agencies which are active on the national level are
the National League for Nursing, the American Nurses’ Association, and the
American Red Cross Town and Country Nursing Service, to which reference
has already been made.

State Level. By 1937 all of the states employed public health nurses in their
state health organizations. The manner of their placement in the organization
varies. The majority of state health departments have separate bureaus or
divisions of public health nursing, while a few place it under maternal and
child health, preventive medicine or local health administration. Individual
nurses may be assigned to functional units of the department by the nursing
unit and in a few instances are employed directly by the specialized service.
The functions and responsibilities of nurses in state health departments depend
upon the legislative basis ol the department. In the majority of instances, their
function is largely advisory to local health departments, boards of education
and voluntary health agencies, and to other state agencies. In a few state health
departments which have been given broader responsibilities and powers, the
nurses may actually supervise and administer certain direct services, local as
+454 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
well as state, and may have some inspectional powers such as are related to
midwives, nurseries, and baby boarding homes. Other important activities of
state health department nurses include demonstrations, either of particular serv-
ices or of total public health nursing programs, and the conducting of inservice
training courses.

All state health departments are active in the promotion of home public
health nursing services for prenatal and postnatal cases, for infants and for
preschool children. In order to do so, they function either through the direct
assignment of state nurses to local areas, through emergency loan of state nurses
to specially selected local communities, or through subsidy ol local nursing pro-
grams. In recent years, a number of state health departments, often in con-
junction with philanthropic foundations, have experimented with the provision
ol nursing service for home deliveries. This is discussed in more detail in the
chapter which deals with Maternal and Child Health Activities.

Local Level. On the local level nurses are employed by a number of different
agencies. Outstanding, of course, is the official local health department, the
nurses of which, by direct contact, render service to the individuals and families
of the communities. In addition, the boards of education of a great many com-
munities employ special school nurses. Of a quasi-official nature is the nursing
program of the American Red Cross, which began in Ohio in 1912 and has
since spread to many parts of the country, particularly in rural areas. From
the beginning, its policy has been to promote and assist in the establishment
of local public health nursing programs and of full-time local health departments
to which it eventually turns over its work. Incidentally, the American Red Cross
has played an active and important role in the promotion of public health
nursing units in state health departments.

The majority of public health nurses employed in a nonofficial capacity are
found in the many local visiting or voluntary nursing associations. These organiza-
tions are primarily concerned with bedside care of the sick. It should not be
assumed, however, that their interest is limited to this, since the typical home
call includes much public health education and promotion as well as bedside
nursing service activities. An important consideration in this respect is the
fact that, increasingly, nurses of both visiting nursing associations and official
health departments receive similar training and frequently interchange positions.

Two other groups which provide public health and visiting nursing services
should be mentioned. Some of the large insurance companies, particularly Metro-
politan Life and John Hancock, have for many years offered home nursing service
to persons holding certain types of policies. The manner in which this is done
varies, depending upon the size of communities, the number of policyholders,
and the existence of other qualified nursing agencies in the community. In
some areas nurses are employed directly by the insurance companies, while in
others the service is purchased on a cost per visit or on a contract basis from
local private nursing agencies. The other source of nursing service which plays
an important role in certain parts of the country is the large private industrial
medical and health programs, many of which employ not only industrial clinic
455

PUBLIC HEALTH NURSING

nurses but also nurses whose function it is to attend sick employees and some-
times members of their families in their homes. With the broadening scope of
industrial hygiene, this not infrequently is found to include health protection
and promotion activities.

Before leaving the subject of public health nursing agencies, reference should
be made to the National Organization for Public Health Nursing. While it did
not render direct service to the public, it has played a dominant role in the ad-
vancement of this field. The NOPHN was organized in 1912 as the national pro-
fessional society for those engaged or interested in this work and became recog-
nized as the spokesman for the profession. No other single agency contributed
so much to the improvement of educational and service standards and to the
promotion of the public acceptance of and respect for the work of the public
health nurse. By 1952, however, it and several other agencies had become con-
cerned about the growing number of nursing agencies and the need for coordina-
tion. As a result, in that year the NOPHN joined the National League of Nurs-
ing Education, and the Association of Collegiate Schools of Nursing to form
the National League for Nursing. At the same time, the by-laws of the American
Nurses” Association were changed to provide for cooperation between it and
the new National League for Nursing. Meanwhile, the National Association of
Colored Graduate Nurses also went out of existence and its functions were
integrated into the other organizations. As a result, there are now only three
national nursing organizations: the American Nurses’ Association, the National
League for Nursing, and the American Association of Industrial Nurses.”

Functions and Responsibilities. The following statement is accepted as the
definition of public health nursing.

Public health nursing is a field of specialization within both professional nursing
and the broad area of organized public health practice. It utilizes the philosophy,
content, and methods of public health and the knowledges and skills of professional
nursing. It is responsible for the provision of nursing service on a family centered basis
for individuals and groups, at home, at work, at school, and in public health centers.
Public health nursing interweaves its services with those of other health and allied
workers and participates in the planning and implementation of community health
programs.*

The functions, standards, and qualifications for public health nurses, first
prepared in 1931 by the Subcommittee on Functions of the National Organization
for Public Health Nursing, has undergone several revisions. The most recent
statements of functions, standards, and qualifications was prepared by a com-
mittee of the Public Health Nurses Section of the American Nurses’ Association
in 1955. They represent the combined thinking of practitioners of public health
nursing from every state and territory of the United States. These statements are
grouped by classification and include functions, standards and qualifications for
public health nurses in staff positions, and administrative, supervisory, and
consultative positions listed separately.

*Statement presented and adopted at the National League for Nursing Biennial Con-
vention, May 1959.
456 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

The following are the functions of public health nurses in staff positions
employed by departments of health, boards of education, and voluntary agencies:

A. Functions relating to public health nursing care to individuals, families, and groups.

Gives, arranges for, teaches or supervises nursing care of the sick and injured.
Carries out nursing skills contributing to treatment and rehabilitation. Plans for co-
ordinated nursing service for individuals and families under her care. Appraises
individual and family health needs and hazards—existing or potential. Provides
health counseling, including emotional support, to individuals, families and groups.
Jonsults with and refers families to appropriate personnel within the agency, school,
or other community services. Treatments and, when required, diagnostic and pre-
ventive procedures are carried out under medical direction.

1. Gives skilled care to patients requiring part-time professional nursing service.

2. Teaches and supervises family members, auxiliary nursing personnel, mid-
wives, or others giving nursing care.

3. Gives prescribed treatments or emergency care, teaches and supervises patients,
family members, school personnel, or others who give such treatments.

4. Initiates nursing measures to prevent complications or to minimize disabling
effects of disease or injury.

5. Assists the physician and dentist with examinations and treatments.
Observes, evaluates, and reports to physician patient’s physical and emotional
condition, reaction to drugs or treatments. Interprets to him social and physical
factors in the environment that affect patient care.

7. Interprets to the patient and family the implications of the diagnosis and the
nature of treatment consistent with the action and wishes of the physician.

8. Plans with the family and physician for care which is feasible within the

physicial, financial and emotional resources of the family.

Helps the family accept responsibility for providing care.

10. Provides or encourages others in the community to provide group instruction
in home care of the sick, or supervises others giving such instruction.

11. Performs diagnostic tests as authorized and interprets findings of tests to in-
dividuals or families. Obtains laboratory specimens when indicated. Gives
preventive immunization or treatments under medical direction.

12. Plans for coordinated nursing service for individuals and families under her
care. Maintains necessary records for analysis and planning of service and for
the establishment of priorities for care.

=

13. Uncovers health problems through observation, interviews, and analysis of
records. Teaches others to recognize and report deviations from optimum health.

14. Studies the environment in the home, school, and community to identify
elements conducive to accident, fatigue, or emotional strain. When possible,
effects changes in the environment or in the organization of activities that elimi-
nate or modify the hazards.

15. Focuses observation on individuals, families, or groups where age, culture, oc-
cupation, economic status, geographic location, or type of health condition
increases incidence of deviations. Evaluates the urgency and complexity of the
need as a basis for action or referral.

16. Teaches basic principles of healthful living in relation to changing needs of
individuals in all age groups. Adapts and applies information from related
fields, such as nutrition, safety education, psychiatry, and dentistry.

17. Guides families toward self-help in recognition and solution of physical, emo-
tional, and environmental health problems.

18. Recognizes attitudes and cultural patterns that are detrimental to health.
Helps families to develop attitudes that permit them to make optimum use
of available health facilities.
PUBLIC HEALTH NURSING 457

19. Provides families with information, support and encouragement which may
help them to adopt attitudes and practices that promote health and reduce
anxiety, tension and fatigue.

20. Recognizes and interprets behavior patterns as influenced by basic needs for
security, love, belonging to and receiving recognition from the group.

21. Interprets patterns of growth and development and encourages attitudes and
action that will promote optimum development for each individual.

22. Helps individuals and families to accept and adjust positively to physical,
mental, and social limitations.

23. Consults about individual or family health problems with other professional
workers.

24. Helps the family to accept appropriate medical, hospital, nursing home, wel-
fare or other care as necessary. Interprets extent and limitations of service
available. Arranges referral and communicates pertinent family information
to the agency.

Functions relating to the development and operation of the Agency, the school and
the community health program.

Plans with appropriate medical and administrative personnel within the agency
or school regarding nursing participation in the health program and carries out
the nursing phases. Contributes to the public relations activities of the agency.
Furthers observation of health laws and regulation. Participates in planning, con-
ducting, and evaluating inservice educational programs for public health nurses
and for other workers in the agency or school. Participates in community planning
and action for health and welfare and contributes to professional education in nurs-
ing, medicine, social work, education and allied fields.

1. Participates in planning and carrying out nursing phases of the agency or
school program such as maternal, child, and adult health; control and preven-
tion of acute, chronic, and communicable diseases; mental health, including
psychiatric care; rehabilitation; accident prevention; and occupational health.
Helps arrange for and manage clinics and conferences. In very small agencies,
prepares simple nursing budgets and administers the office.

2. Supervises work of the non-nursing personnel and auxiliary workers participat-
ing in the nursing program. Recruits, trains, and supervises volunteer workers.

3. Participates in planning and carrying out epidemiologic investigations and other
field studies.

4. Compiles and uses records, reports, and statistical information for appraisal
and planning of the assigned program.

5. Participates in studies of nursing methods, procedures, service accomplishments
and costs.

6. Interprets community health and social needs and resources to administrative

and planning groups.

Interprets agency and school program and policies in daily activities. Interprets

agency services and fees charged to patients, families and community.

8. Maintains contact with physicians and community agencies to plan with them
for care of families and to interpret available services.

9. Participates in the public information and promotion activities of the agency.
Represents the agency in her professional organizations and in community
groups when so designated.

10. Interprets to the community the need for and meaning of health laws and
regulations. Refers violations to appropriate authorities.

11. Provides consultant service to convalescent and nursing homes, foster homes,
and similar institutions and, in selected instances, carries out inspections when
delegated by the licensing authority. Makes referrals to other sources of con-
sultant help.

~T
458 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

12. Studies and evaluates own job performance and plans for continuing profes-
sional growth.

13. Assists with orientation, instruction, and guidance of new staff and of members
of citizen committees and boards.

14. Participates in planning and conducting inservice education program of the
agency or school.

15. Plans with other agencies for continuity of patient care in hospital, clinic,
school, industry, and home.

16. Participates in the work of health, welfare and safety committees.

17. Creates awareness in the community of its health and welfare needs through
interpretation to appropriate community groups.

18. Serves as advisor to community groups planning programs related to nursing
and health. Participates in curriculum development in the school and serves
as resource person to teachers and other personnel.

19. Participates in classroom and field instruction of selected students and instruc-
tors in nursing and allied fields; such as medicine, education and social work.

20. Work through professional organizations and civic groups for the advancement
and improvement of nursing and public health.*

Qualifications of Public Health Nurses. The recommended qualifications
for public health nurses in staff positions include:

A. Preparation in Basic Nursing
I. Graduation from a school of professional nursing with state accreditation at
time of graduation.
2. Holds a current license to practice as a registered professional nurse.
B. Preparation in Public Health Nursing as evidenced by
A degree from a university program in nursing approved by the National League
for Nursing for public health nursing preparation
or
Completion of the public health content in an educational program approved by
the National League for Nursing. In this case the university may certify that the
credits earned by the applicant meet the requirements— (viz, completion of the
public health nursing content of the program).*

Qualifications for nurses in supervisory, administrative and consultative
positions call for a master’s degree with a major in administration, supervision
or consultation or in a special field; or a master’s degree in public health from a
university approved by the American Public Health Association.

Administrative Relationships. An important administrative consideration
influencing the value and efficiency ol public health nursing programs is the
nature of the relationships which exist among the various nursing and social
agencies in the community, the public, and the members of other healing pro-
fessions. The demand for public health nursing services is so great that if all
available personnel were employed in a single ideally efficient agency, it would
still fall far short of what is needed. This being the case, it is all the more im-
portant and necessary that the agencies engaged in this work cooperate to the

*Functions, Standards and Qualifications for Public Health Nurses, New York, 1955,
Public Health Nurses Section, American Nurses’ Association.
PUBLIC HEALTH NURSING 459
utmost in order to correlate and coordinate their respective programs as much
as possible.

Relationships Within the Health Department. The professional relation-
ships of public health nurses take place in two areas: first, within the health
department itself; second, in contacts with other agencies and individuals in the
community. Within the health department, the relationship between the public
health nursing staff and the administrative health officer is of paramount im-
portance. All too often, adequate and satisfactory relationships and understand-
ing between the nursing staff and the health officer are falsely assumed to exist.
It is not unknown for health officers merely to support the nursing program
quantitatively according to standards such as one nurse per 5,000 population,
but, once obtaining nursing personnel, to neglect to participate in the planning
and administration of the public health nursing program and activities. Ap-
parently some health officers, feeling that they know nothing about nursing
problems, follow the path of least resistance by allowing the nursing division
to proceed almost as if it were an independent agency. Inevitably this policy leads
to difficulty, both within and without the department. The health officer, by
virtue of his position, is ultimately responsible for all phases of the health pro-
gram of the department, and for that matter of the community as a whole.
With respect to the nursing aspects of the program, the health officer should
carefully select a well-qualified director or supervisor, provide her with adequate
administrative support, and see that general policies and interagency relation-
ships are cleared at the top ol the organization by him rather than perhaps
haphazardly and inadequately lower down by his staff nurses and the staff workers
of other agencies. He should maintain constant interest in the nursing program
and endeavor to learn enough about it to assist the nurses to see how their
activities really fit into the total community health picture. It is significant that
within the past few years several of the schools of public health have established
courses in public health nursing supervision and administration specifically for
medical health officers.

Ross? has said that “no division of nursing can rise above the level of
performance set by its health officer and that no division of nursing will get
far without his active and understanding support. The quality of the public
health nursing program in official agencies country-wide is, in the last analysis,
in the hands of health officers; if it is to become grade A only they can decide.”
In contrast with the foregoing are the occasional situations in which members
of a nursing staff circumvent their nursing supervisor or director and approach
the health officer with their problems and complaints. This practice should never
be condoned, for obvious administrative reasons. If permitted to come about
and continue, it can result only in disastrous damage to the morale of the or-
ganization. Again it is up to the health officer and his nursing director to see
that organizational channels are understood and followed by the staff nurses.

The public health nurse and the staff working in environmental health
may seem professionally worlds apart. However, they are part of the same organ-
ization and should work in a helpful as well as cordial relationship, one with
the other. In the course of her daily field visits, the alert public health nurse
460 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

is certain to become aware ol many insanitary situations. Often they have a
direct or indirect bearing upon her own professional problems. A policy of
prompt and effective interagency referral should be developed to handle these
situations. Needless to say, the same applies to the engineer and sanitarian.

Relationships With Other Nursing Agencies. One of the most important
extra-agency relationships of public health nurses is with the staffs ol other agen-
cies which render nursing services in the community. In view of the necessity of
maintaining desirable interagency relationships and in view of the considerable
scarcity of nursing personnel at the present time, it is important that public health
nursing functions be carelully analyzed in order to make the most efficient use
of the time of those employed. One writerS on this subject has stated: “The
discriminating review of our nursing functions which was forced upon us as a
war expediency helped us to set up standards of priority in our home visiting
programs which should continue to be of assistance to us in our present and
future planning. However, this review also exposed the fact that the qualities
of ready adaptability which have made public health nurses such a valuable
adjunct to public health staffs have also resulted in wasteful use of our nurses’
professional skills. We found that many of the time-consuming duties our nurses
had carried did not require highly technical skill. However, they absorbed so
much of the time of our well-prepared nurses that the teaching and other skills
they had acquired were not utilized to the best advantage.”*

Among the sound recommendations that have recently been made are those
for the elimination of public health nurses in strictly clinical activities, the use
of nurses without public health training, practical nurses, and lay volunteers
for certain activities, and the elimination in so far as possible of strictly clerical
activities of public health nurses by the employment of an adequate office staff
and the constant scrutiny of record requirements. By means of such steps the
strictly public health pursing activities of many agencies may be increased
considerably.

Consolidation of Nursing Services. There is little if any indication for more
than two field nursing groups in any given community: (1) the public health
nurses working as employees of the official health department, and (2) the staff
of the nonofficial visiting nursing association. Regardless of the number in-
volved, the correlation and coordination of the work of all agencies providing
nursing services in a community are obviously necessary and desirable in order
best to serve the needs and interests of the public. Since there is no one answer
to how this may be accomplished, each community must work out a solution
best suited to its particular needs and backgrounds. The number and variety of
possible arrangements in a given community may be somewhat as follows: If
there are several voluntary or nonofficial agencies such as a visiting nursing
association, cancer societies, tuberculosis societies, and industrial health organiza-
tions which render nursing services in the community, they may (I) remain
completely independent of each other, in an inefficient uncoordinated manner,

*Johnson, M. L.: Public Health Nursing Administration in the Changing Order, Pub.
Health Nursing 39:333, July 1947.
PUBLIC HEALTH NURSING 401

(2) retain their individual identities but coordinate their programs by means of
a central nursing advisory committee in which each agency participates, or (3)
combine their programs to form a single community public health nursing
agency. The voluntary agencies singly or together may limit their activities to
bedside care, leaving most or all educational, promotional, and legal control
measures to the nurses of the official health department. On the other hand, the
health department may delegate some or even all of its public health nursing
responsibilities to the voluntary nursing agency. In the few communities where
this procedure is followed, it is usually attributable to two influences, i.e., the
existence of a long-established, well-supported and accepted visiting nursing as-
sociation, and a weak official health department or one of relatively recent origin
and tenuous support.

The completely satisfactory consolidation of community nursing services
is as yet relatively rare, usually strongly resisted, and in some situations still
premature. One of the most successful solutions developed up to the present
time is that effected in Seattle. Here the official and voluntary nursing agencies
agreed upon a cooperative, completely generalized public health nursing pro-
gram, including all preventive, promotive, educational, and bedside services,
but retained the board of directors of the voluntary nursing agency as an ad-
visory committee which controlled its own contribution to the total cost of
the program by means of an annual contract with the official health depart-
ment. Where carefully prepared for and put into effect, this plan has worked
well and has brought about an increased efficiency and economy, and both
groups of nurses have found more professional job-appeal and stimulation from it.

As a general guide, The Association of State and Territorial Health Officers,
at their annual meeting in Washington, D. C., December, 1916, adopted a resolu-
tion which included the following recommendations:

The community should adopt one of three patterns of organization that will
provide the type of coordinated public health service most feasible under local con-
ditions and that will best fit into the general plan advocated by the state department
of health in each state. The organization patterns are:

a. All public health nursing service, including care of the sick at home, administered
and supported by the health department. This is the most satisfactory pattern for
rural communities.

b. Preventive services carried by the health department, with one voluntary agency
working in close coordination with the health department, carrying responsibility for
bedside nursing and some special fields. At present this type of organization is the
most usual one in large cities.

c. A combination service jointly administered and jointly financed by official and
voluntary agencies with all field service rendered by a single group of public health
nurses. Such a combination of services is especially desirable in smaller cities because
it provides more and better service for each dollar expended.

Medical Relationships. The nurse in public health work as elsewhere has
traditionally served on the right hand of the physician. Therefore, the relation-
ships of the public health nurse with physicians practicing in her community
become ol great importance. Repeatedly in most of her daily work, the public
health nurse comes in contact with people who either are already or should
be under the care of physicians. She must always realize that private physicians

 
462 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

as a group constitute the most powerful and most important weapon against
ill health. Accordingly, the public health nurse, working in the field with families
and individuals, must assume as one of her primary functions the interpretation
of medical service to the community. She must act as a sort ol implementer,
seeking out those who need the care of physicians, helping them to obtain it,
and assisting them in putting the advice of their physician into effect.

It is highly advantageous to a health department and particularly to its
nursing staff that there be a medical advisory committee with which to discuss,
clear, and implement matters of medical policy. The members of the committee
should be appointed by the local medical society. Frequently the public health
committee of the medical society serves the purpose adequately. A committee
of this nature is particularly helpful in planning new projects or programs in
which the public health nursing staff may be engaged. Another valuable service
of the medical advisory committee is the formulation of written policies for
the nurses of the health department. It is obviously of mutual benefit for the
director of nurses as well as the health officer to meet with the medical ad-
visory committee.

On entering a home, the public health nurse, whenever possible, should
relate her visit to the wishes of the family physician. In order to do this success-
fully, the astute public health nurse will acquaint herself with the wishes and
policies of each physician in her area and constantly keep him apprised con-
cerning the status of his patients. This she may do by means of personal in-
terviews, telephone conversations, or written reports. Some agencies have a policy
that the first contact with a physician must be through an interview or at least
by phone. These policies are basic to good relationships and are appreciated by
medical practitioners.

It is important that public health nurses observe professional ethics as they
do in the hospital situation. In the typical American community, everyone who
receives nursing care, particularly of a bedside nature, should be under medical
supervision. Permission and instructions should be obtained from the attending
physician beforehand in order to make the nursing services of greatest value,
to maintain desirable patient-physician relationships, and to develop a feeling
ol professional partnership between the public health nurse and the private
physician. Diagnoses and treatments must never be criticized or contradicted.
If the nurse feels that she possesses information which might alter the medical
management of the case, she should discuss it in a cordial, respectful manner
with the medical attendant and never with the patient or his [amily.

The selection of a physician should be the prerogative of the patient to
be served. Frequently the nurse, and for that matter other health department
employees, are asked to name an acceptable medical attendant. If possible, no
single physician should ever be suggested. The person making the request should
be given the names and addresses of several capable and creditable practitioners,
preferably from a list agreed upon by the local medical society. The complaint
is sometimes heard that public health nurses take patients away [rom private
physicians by referring them to health department and other free clinics. Un-
fortunately, this claim occasionally may have been justified. The amount of
PUBLIC HEALTH NURSING 403

the services for which private physicians are uncompensated is fairly common
knowledge. Many prefer to maintain contact with their families through poor
times as well as good. This being true and in the interests of good professional
relationships, it is important that no such referral ever be made except after
the signed release of the patient by his physician.

Community Nursing Council. Somewhat similar in nature and purpose to
the medical advisory committee which has been recommended is a community
nursing council. This advisory group should assist in studying, planning, im-
proving, and coordinating all of the nursing activities in the community. Its
membership is usually fairly large, including representatives from all official
and nonofficial agencies which render nursing services, from organized professional
groups such as medicine, dentistry, nursing and social work, and from the public
at large.

At the present time, a great many communities have a council of social
agencies, often in close affiliation with a community chest or fund. The council
plays a most important role in the development of joint analyses, planning
and implementation by all of the many social agencies which exist in the typical
American community. It usually functions by means of a number of standing
and ad hoc committees with representatives of various interested and pertinent
agencies. The health committee, which is almost universally one of the standing
committees, often has a subcommittee on public health nursing. Occasionally, this
subcommittee serves effectively in the absence of a community nursing council.

Public Health Nursing and Social Work. The association of the official health
nursing program with the other social agencies in the community brings out the
fact that in a certain sense the public health nurse is essentially a specialized type
of social worker. Her approach to individual and family problems, however, must
of necessity be from a somewhat different basic point of view from that of the
usual professional social case worker. Nevertheless, because of the complex nature
of all social problems, of which illness and its prevention are one, mutual under-
standing and cooperation between the two groups is ol great importance. The
public health nurse should first be familiar with each of the social agencies in her
community and second should know what each does, where its interests and con-
tributions cut across, supplement, or complement those of the public health nurs-
ing program. She should have available for ready reference a directory or a card
file indicating the interests, resources, location, and leadership of each one.

Usually, the social welfare programs consist of six basic community services:
child welfare services, family services, medical social services, psychiatric social
work, public assistance, and recreation. Occasionally, most or all of these are found
in a single agency. However, the usual pattern is for a number of official and non-
official agencies to be involved. Some of the types of programs in which they are
variously concerned with administering are those dealing with aid to dependent
children, the care of neglected and delinquent children, child guidance, mental
hygiene clinics, old-age assistance, unemployment insurance, aid to the blind,
vocational rehabilitation, and retirement.

One of the important practical reasons for familiarity with the social agencies
of a community is for purposes of referral. A case of tuberculosis, for example,
 

464 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

may appear to be primarily the concern of the health department through its
public health nurse. However, problems of hospitalization and its costs, family
support in the absence of the breadwinner, the placement of dependent children,
and rehabilitation, to mention but a few, will usually arise. The public health
nurse cannot solve all of these singlehandedly. She must therefore refer certain as-
pects of the total family problem, which has been crystallized by the appearance of
tuberculosis, to other appropriate community resources.

Of great value to the nurse in such instances is the existence of a social service
exchange. This is in the nature of a clearing house wherein is registered identify-
ing data regarding cases on the registers of the various community agencies. Its
purpose is to enable all community agencies to serve the needs of the distressed in-
dividual or family more satisfactorily. The following types of patients or families
should usually be registered by public health nurses: (1) those with pressing or
complex social problems, (2) those to be referred to social agencies or other health
agencies, (3) those having long-time health problems such as tuberculosis, (4)
those receiving free services for which a charge is usually made, (5) readmissions
which were previously registered with the exchange. These patients or families
are cleared again as a means of obtaining new data about them.?

Administrative Aids in Public Health Nursing. As in other prolessional
areas, public health nursing has found it practical to apply certain well-proved
administrative aids.

Supervision. Unquestionably the most valuable administrative aid is the su-
pervision provided at each level within a public health nursing agency. Super-
vision is necessary for the properly balanced development of the nursing service to
public health programs and for the maintenance of its standards. Total responsi-
bility for such supervision rests upon the nurse administrator and, depending
upon the size of the agency, assistants and one or more supervisors. At the staft
level supervision ensures the quality and quantity ol the service through both ad-
ministrative and educational processes. With a ratio of one supervisor to every
eight to ten staff nurses, it should be possible for the supervisor to offer sufficient
guidance and counsel to the field or staff nurses in order to maintain the standard
of the service offered and individually develop each staff nurse to the maximum of
her ability to serve the patient and his family. The nursing supervisor is, in fact,
also a liaison person who serves as a two-way link between the staff nurses and the
administrative officers of the agency. The supervisor interpretes policies and
methods of application and may also transmit the impressions of the staff together
with suggestions for additions or changes in policies upward to the administration
centers of the agency. In this way, it is possible for the field staff to play an im-
portant role in the formation or modification of policies and program.

Standard Procedures. In any situation where a number of persons carry on
similar work toward a common purpose, it is desirable that they each follow the
same procedures with regard to certain aspects of their work. In order to avoid
misunderstanding and confusion, it is helpful, even in the smaller agencies, to
have available manuals which set forth clearly the policies of the agency and de-
tails of technical procedure. These should include statements of the exact respon-
sibilities and authority of the personnel, standing orders used by the agency, and
PUBLIC HEALTH NURSING 465

 

descriptions of techniques which are considered safe, effective, and ethically ac-
ceptable. While each agency will find it necessary to develop its own manual, at-
tention is called to the Manual of Public Health Nursing, which has been pre-
pared and is periodically revised by the National League for Nursing (formerly
the NOPHN). Many state health departments have also prepared excellent nurs-
ing manuals for use by local health departments. There also should be a record
manual in which the purpose and proper use of each record used by the public
health nursing staff is explained and illustrated. It should be needless to mention
that valuable as are these administrative manuals, they quickly become useless
unless continually kept up to date.

Clerical Staff. Although much of the recording, particularly that relating to
details of field visits, must of necessity be done by the nurses themselves, there is
much clerical work that is most efficiently carried on by an office clerical staff.
Despite this, it is by no means uncommon to find the professional nurses of many
organizations devoting large proportions of their work time to details of record
keeping and analysis in the office. This is particularly unfortunate in the face of
significant shortages in nursing personnel. The [alse reasoning appears to be prev-
alent that, as long as nurses must be employed in the public health nursing pro-
gram, they might as well do all or most ol the clerical work involved. It should
always be realized that the records are also a necessary part of the program and
that proper personnel for their handling is wholly justified. Furthermore, it is well
to remember that the use of the relatively expensive time of a professionally
trained public health nurse for office work, which may more efficiently and ef-
fectively be turned over to lesser trained employees in lower salary scales, is poor
administration.

REFERENCES

1. The Public Health Nurse, New York: Department of Philanthropic Information, Central Han-
over Bank and Trust Co., Reprinted by the National Organization for Public Health
Nursing, 1938.

2. Waters, Y.: Visiting Nursing in the United States, New York, 1909, Charities Publication Com-
mittee.

3. 1957 Facts About Nursing, New York, 1959, American Nurses’ Association.

4. Report of Local Public Health Resources, 1951, Washington, 1953, Public Health Service Publ.
No. 278.

5. New Structure of Nursing Organizations, Pub. Health Rep. 67:1258, Dec. 1952.

6. Functions, Standards, and Qualifications for Public Health Nurses, New York, 1955, Public
Health Nurses Section, American Nurses’ Association.

7. Ross, G.: Is the Health Officer Fulfilling His Responsibility in Relation to the Nursing Pro-
gram? Am. J. Pub. Health 29:305, April 1939.

8. Johnson, M. L.: Public Health Nursing Administration in the Changing Order, Pub. Health
Nursing 39:333, July 1947.

9. Manual of Public Health Nursing, National Organization for Public Health Nursing, ed. 3,
New York, 1939, The Macmillan Co.
chapter 1 9

Social services and public health

Introduction. At several points in this book, attention has been called to the
fact that public health deals with people. Especially in the chapter on social path-
ology, attention has been called to the complex nature of the problems of people.
For example, all public health problems have components that involve economics,
education, cultural attitudes, and many other factors.

In the normal conduct of their activities, public health workers involve them-
selves to some degree in the solution of these aspects of the problems with which
they deal. Public health nurses have been particularly notable and successful in
this regard. However, it must be realized that the recognition and adequate han-
dling of such problems and the dealing with certain types of individuals and
agencies require special training and skills with which the professional public
health worker has been only partially provided. It is only relatively recently that
official public health agencies have realized the potential value and contribution
of the social service worker, especially the medical social worker, to the public
health program.

Actually, it is very natural that public health workers and social service
workers understand and relate to each other with relative ease and to mutual ad-
vantage, since they both are concerned with the multifaceted problems of indi-
viduals and families. To be successful, each must be “family oriented” rather than
“individual oriented.” This is much more true in public health and social service
work than in the private practice of medicine. To a certain extent, private prac-
tice of medicine and social service work tend to be inherently antipathetic. Private
medical practice is essentially “individual oriented” and traditionally has de-
pended upon a certain amount of dogmatism and mysticism on the part of the
practitioner and upon unquestioning acceptance on the part of the patient. In
contrast, social case work, public health nursing and, in fact, public health ac-
tivities in general attempt to aid the problemed individual or group, to under-
stand its problems, to rationalize, and to explain. As public health problems be-
come more and more involved in questions of adult health and the solution of
chronic disease problems, this is certain to become more and more true.

Background. Medical social work had is beginnings early in the twentieth
century when Dr. Richard Cabot introduced the concept at the Massachusetts

466
SOCIAL SERVICES AND PUBLIC HEALTH 407
General Hospital. He based his action on the philosophy that the patient's un-
derstanding and cooperation were needed to overcome illness, over and above any-
thing the physician and the hospital might do. Furthermore, he recognized that
there were many other factors involved in recovery, among them the family
economy, the living conditions in the home, social relationships, and the like.
Also, there are usually available in the community numerous resources that might
be tapped for the best ultimate solution of all aspects of the case, if the physician
had time to seek them out or if he had someone to do it for him and the patient.
The success of the idea in medical and hospital practice is well known. Subse-
quently numerous voluntary health agencies began using medical social workers
and more recently, because of the increasing emphasis on the social and com-
munity aspects of health as well as the tendency to integrate preventive and pro-
motive health activities with medical care, some public health departments have
begun to include them on their staffs.

The range of the medical social worker's activities is determined by the size,
scope, and vision of the health agency's program and organization. Two basic
questions to be answered with respect to their function in public health depart-
ments are the extent of their personal contact with individuals of the public and
their relationships with the rest of the staff, especially the public health nurses.
In most instances where they have been brought into the programs of county
health departments, many personal patient and family contacts were anticipated
and stressed. Repeatedly, however, it has been found that the most efficient and
fruitful use of the medical social worker’s limited time is as a staff consultant, a
program planning consultant, and for liaison with the many other pertinent com-
munity agencies. *

By 1950 there were over 400 positions for qualified social workers in health
agencies in the United States, exclusive of positions in hospitals, clinics, and other
medical institutions. The largest number is on the staffs of official state, county,
and city health departments and of other agencies concerned with crippled chil-
dren or vocational rehabilitation services. Other positions are on the staffs ol
voluntary health agencies operating on national, state, and local levels.

Role of the Social Worker in Public Health. The increased employment and
use of social workers in public health programs has led to the establishment in
the Committee on Professional Education of the American Public Health Associa-
tion of a subcommittee on educational qualifications of medical social workers in
health agencies. This subcommittee, working with the American Association of
Medical Social Workers, in addition to the establishment of personnel qualifica-
tions, has developed the following summary of the functions of medical social
workers in a large health agency:

The medical social worker in a public health agency is responsible for planning,
developing, and directing social services within the framework of the agency's function.

The social services provided by the health agency are those deemed necessary to
meet social problems influencing the effectiveness of the health and medical programs

*Sce for example Social Service in a Health Department by Grant! The Use of Medical-Social
Service by a County Health Department by French and Wiser? and The Medical Social Worker
in a County Health Department by Spiclholz and Brakel.?
468

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

which are the agency's primary concern. The social services are directed toward strength-
ening the agency’s program through increased understanding of the relationship of social
and emotional factors related to health and medical care.

The range of the medical social worker's activity is determined by the scope of the
agency's program and its organization. The medical social worker's activity may also be
limited by administrative decision to certain divisions or bureaus of the agency or health
department, particularly when the service is being initiated.

In a large health agency responsible for health and medical services, the social service
activities will include most, if not all, of the following:

I. Determination of need for social service in the agency's total program.

(a) Continued study and evaluation of needs for social services in existing pro-
grams of the agency and determination of resources within agency and com-
munity to meet these needs.

(b) Interpretation of these needs to administrator and staff.

(c) Participation in early planning for new programs with respect to essential
social services.

2. Planning and directing the scope and focus of social services which will include
the following:

(a) Consultation on the social aspects of health and medical care of individuals
and groups.

‘This service is directed toward increased understanding of the meaning
to the individual of health and physical disability and toward joint
efforts to meet related health and social needs. It may be provided to the
health officer or administrator and staff of the agency and to social and
health workers in cooperating agencies.

(b) Providing service through social case work.

This service to the individual will frequently be for a brief period and
directed toward transfer of responsibility to other community agencies,
when continuing case work is indicated. It may be intermittent, associ-
ated with periods when the individual's social and personal situation
affects his ability to accept and carry out recommendations for his health
and well-being. It is often given in clinics, through interviews with pa-
tients and families at time of diagnosis or at the time hospitalization is
recommended. This service may also be initiated at any time by request
of physicians and nurses who recognize the patient's need for help in
planning to meet special problems. These brief services facilitate and
strengthen consulation, enabling the medical social worker to discover
and evaluate social and emotional problems. The worker shares the eval-
uation of the social situation with other professional personnel who have
a continuing relationship with the individual or family.
Continuing case work services are provided on a selective basis in in-
stances of special need, in the absence of family or children’s agencies to
which referral can be made, or for demonstration purposes.

3. Participation in program planning and policy formulation of the agency, with

special emphasis on:

(a) Assistance in the development of policies and procedures of the agency such
as those related to eligibility for service and appropriate referral for services
not provided through the program. This contributes to continuity of care
and facilitates coordination of community activities for meeting social as well
as medical needs of the individual.

(b) Evaluation and reconsideration of policies in light of urgent and recurrent
problems among individuals receiving service.

(c) Discussion of gaps in program and difficulties of families and individuals
in utilizing services fully and effectively. The medical social worker's close
contact with social and health agencies in the state and community affords
SOCIAL SERVICES AND PUBLIC HEALTH

a unique opportunity to bring understanding of these problems to the
program.

4. Participation in community organization through:

(a)

(b)

Establishment and maintenance of a liaison with welfare departments, social
agencies and social service departments of hospitals in order to bring about
a better use of the health department's services by these agencies, and vice
versa.

Interpretation of social needs which cannot be met by the health department
alone, where community planning and participation are essential for re-
habilitation of the patient.

(c) Assistance to the administrator in identifying gaps or overlapping in com-

munity services and in integrating the services of official and voluntary
agencies (social, educational, vocational, etc.), so that all may work together
for the ultimate rehabilitation of the patient.

5. Participation in staff development and in-service education program of the

agency, and in orientation of new staff.

The objective of this participation is to increase the awareness and under-
standing of all personnel with respect to environmental, economic, and
emotional factors as these are related to medical and health needs, the
provision of health and medical services, and the utilization of these services
by individuals and groups.

6. Participation in studies and surveys.

(a) Studies directed toward evaluation of current programs or expansion of

(b)

REFERENCES

services in areas of unmet needs.

Studies of social and emotional factors in child growth and development and
in medical and surgical treatment, particularly related to programs and
services for which the agency has responsibility. *

469

1. Grant, M.: Social Service in a Health Department, Am. J. Pub. Health 43:1545, Dec. 1953.
2. French, W. J, and Wiser, G.: The Use of Medical-Social Service by a County Health Depart-
ment, Am. J. Pub. Health 38:1555, Nov. 1948.
3. Spielholz, J. B., and Brakel, I. V.: The Medical Social Worker in a County Health De-
partment, Am. J. Pub. Health 37:733, June 1947.
4. Proposed Report on Educational Qualifications of Medical Social Workers in Public Health
Programs, Am. J. Pub. Health 40:994, Aug. 1950.

*Proposed Report on Educational Qualifications of Medical Social Workers in Public
Health Programs, Am. J. Pub. Health, 40:994, Aug. 1950.
chapter 2 0

Maternal and child health activities

Introduction. Ordinarily public health activities are concerned with the
well-being of all people, whatever their age, sex, race, or other characteristics.
Traditionally, however, there have been two groups in society to whom particular
attention has been given: women during the periods of their pregnancies, and
young children, particularly in their infancy. There are sound administrative
reasons for this. Special attention given to a pregnant woman brings double
health benefits: first, to her as an adult member of society, and, second, to the
product of her pregnancy. Other reasons for placing special emphasis on the
period of pregnancy are that this is a period of particular physical stress during
which time the woman, who ordinarily may have no difficulties, must face the
possibilities of unusual risk. Undesirable influences during the prenatal period
may affect the subsequent quality of health of both the mother and the expected
infant and may even jeopardize their lives. Short of fatalities, these effects may
take the form of health and economic disadvantages for the woman and child
directly concerned and even for the rest of the family if the mother’s health is
permanently impaired.

Remarkable progress has been made in the saving of lives ol expectant
mothers and their infants. In the United States, during the forty years since
World War I, maternal mortality declined about 95 per cent and infant mortality
about 74 per cent. This may be attributed to many factors of which public
health progress is only one. Hospital and medical standards have improved,
as have the national state ol nutrition and the general standard of living. Also,
many new preventive and therapeutic agents have been introduced. Further-
more, while maternal and child health activities are usually given special attention
organizationally and program-wise, it must be realized that every aspect of
the public health program has had a marked effect upon the health and welfare
of expectant mothers and particularly of infants and young children. In areas
undeveloped in a sanitary sense, the institution of an effective program of en-
vironmental sanitation, involving the purification of water, the sanitation of milk
and food, and the promotion of satisfactory facilities for the disposal of human
wastes, will show its first effects in a reduction in infant morbidity and mortality.
Vital statistics are intimately related to the maternal and child health program

470
MATERNAL AND CHILD HEALTH ACTIVITIES 471

in both a causal and a direct manner. The public health laboratory is an essential
too, particularly in prenatal management where tests must be performed to
indicate the presence of syphilis, the Rh reaction, eclamptic tendencies, diabetes,
tuberculosis, and other ailments which considerably increase the risk incurred
by pregnancy, and to determine the path of medical management which must be
followed. Throughout the entire antenatal, natal, and postnatal period there
must be woven a strong thread of health education. The expectant mother must
be constantly guarded [rom communicable diseases, particularly of a strepto-
coccal and influenzal nature, and early attempts must be made to protect the
new child against gonorrheal ophthalmia, smallpox, whooping cough, diphtheria,
and occasionally other communicable infections. It is obvious, therefore, that the
maternal and child health program cannot be considered as a strict entity.
Background of Maternal and Child Health Programs. In the United States,
programs for the promotion of maternal and child health were originated with
the opening of the first milk station in 1893 in New York City. The original
purpose of this and other stations that subsequently were established there and
elsewhere was to combat the tremendous threat of summer diarrhea in the in-
fants and babies of the underprivileged by means of providing them with safe
milk during the summer heat. In fact, the nature of this beginning had much
to do with the ultimate development of municipal and state regulation of milk
supplies. Observance of the benefits which resulted from this meager start led
to the establishment of numerous infant welfare societies designed to bring
medical and nursing knowledge and care to those in need. In 1908 the New
York City Association for Improving the Condition of the Poor, in conjunction
with the New York Outdoor Clinic, began to provide prenatal care for expectant
mothers in the lower income groups. Simultaneously a Bureau of Child Hygiene
was established in the New York City Health Department. These two moves
were subsequently duplicated by many other communities throughout the nation.
In 1912, the Federal Children’s Bureau was established under circumstances
discussed briefly in Chapter 13. Another development of significance was the
formation at about that same time of the American Association for the Study
and Prevention of Infant Mortality. This was comprised of pediatricians, infant
welfare nurses who in a sense were the precursors of the present-day public health
nurses, social workers, public health officials, and other interested persons, all
of whom provided leadership in the rapidly expanding movement to protect
the lives and health of mothers and children. This organization was the beginning
of what in 1923 became the American Child Health Association which provided
most effective leadership until the time of its disbandment in 1935. The growing
and widespread interest in the problem commanded national attention that
resulted first in the passage of the Sheppard-Towner Act, which functioned from
1922 to 1929, and later in the inclusion of broad national consideration of
maternal and child health problems in the Social Security Act which was ap-
proved in August, 1935. The functioning of these national acts, which provided
leadership and funds, has had a marked and lasting effect upon the development
of maternal and child health programs in state health departments and, through
them, in local areas throughout the nation. Of more recent occurrence and in-
472 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

terest has been the Emergency Maternity and Infant Care Program for the wives
and infants of servicemen which was administered during the war years by
the Children’s Bureau. These various national programs, by virtue of the neces-
sity for establishing basic standards for personnel and facilities in all areas
benefiting from the subsidies, have had perhaps a greater effect upon the quantity
and quality of the care rendered expectant mothers and infants than any other
[actors.

Statement of the Problem. Despite the significant advances in maternal and
child health in the past few decades, there still exists much room for improvement.

Maternal Mortality. Despite the reductions which have been observed in
the maternal and infant mortality rates, a problem of the first magnitude still
exists in this field. This becomes evident when even the currently decreasing
rates are compared with those of many economically less favored nations and
when the rates are broken down geographically, economically, and by age, race,
and other factors. During 1955, while the number of all maternal deaths per
10,000 live births was 4.7, and the rate for white women was 3.3, the risk for
women ol other races was 13.0. Similarly, the rate of decrease during the previous
twenty years was significantly greater for white women than for women of other
races (‘Table 31).

Table 31. Decrease in Maternal Mortality, United States, 1930-1955

 

 

Year Total | White | Other
1930 67.3 00.9 117.4
1955 4.7 3.3 13.0
Per cent of decrease 93.0 94.1 88.9

 

These differences in the rates by race of mother are reflected partially in
the variations observable among the states. Generally speaking, a line drawn
along the 387th degree latitude, cutting across the northern boundaries of North
Carolina, Tennessee, Arkansas, Oklahoma, New Mexico and Arizona, divides the
nation into a southern area with a high maternal mortality and a northern area
of low to average rates. In 1955, rates ranged form below 2.5 in Vermont, Mon-
tana and Oregon to more than 10.0 in South Carolina, Georgia, Alabama and
Mississippi. There is no reason to believe, however, that real racial or geographic
differences actually exist. Analyses of economic status, standard of living, and
extensiveness and utilization of medical, nursing, and hospital facilities bring
out striking parallels with the distribution of maternal mortality rates. In 1943,
a year for which much detailed data is readily available, in all of the southern
tier of states referred to, fewer than 60 per cent of births take place in a hospital,
the figure in the case of Mississippi being as low as 26.6 per cent. Similarly, in
each of these states, many women were delivered by persons other than trained
physicians, the extremes being Mississippi again with 42.8 per cent and South
Carolina with 36.3 per cent. When this is correlated with race, it is found that
MATERNAL AND CHILD HEALTH ACTIVITIES 473

 

in every instance the majority of the nonhospital and nonmedically attended
deliveries in these states were of women of the Negro race. The over-all figures
for the nation in 1943 were 97.8 per cent of white women delivered by physicians,
77.2 per cent of them in hospitals, and 55.9 per cent of Negro women delivered
by physicians, only 31.5 per cent of them in hospitals. In Mississippi, over 80 per
cent of Negro women in labor had no medical attendance at all.

There is spectacular variation in the incidence of maternal deaths among
the several age groups. When the rates are plotted by age, a U-shaped curve
is obtained, with the greatest risks at the extremes of the fertile period and a
low point during the third decade of life. Thus, in 1955, the curve of maternal
deaths per 10,000 live births began at 3.3 for females below the age of 20 years,
declined to 2.5 for those between 20 and 24 years, then gradually increasing to
a high of 62.6 in women 45 years or older. The high rate in the very young
probably may be attributed to physical immaturity, small pelves, and possibly
a number of induced abortions. The high rates at the other end of the age scale
undoubtedly result from complicating diseases and the effects of multiparity.
The percentage of improvement that has been observed in these rates during
recent years is of interest and significance. A curve of percentage change by
age group between 1935 and 1955 is the inverse of the curve of maternal mortality.
During these two decades there was a decrease of about 90 per cent in all of
the young adult age groups in contrast with decreases of 66 per cent in women
over 45 years and only about 40 per cent in young girls between 10 and 14
years of age.

With respect to time, most maternal deaths occur during or shortly after
childbirth. In 1943, for example, when the total maternal death rate was 24.5
per 10,000 live births, this could be broken down to 15.9 during or after child-
birth, 3.5 before delivery, 4.0 during or after abortion, and 1.1 during or after
ectopic pregnancy. The greatest recent gain has been made against the risk of
death before delivery, where, during the ten years prior to 1943, a decrease of
13 per cent was observed. The risks associated with ectopic pregnancy and abor-
tion were lowered by 8 and 9 per cent respectively. The darker side of the
picture is the fact that a reduction of only 2 per cent was achieved in the deaths
occurring during or after childbirth, where the majority of deaths occurred. The
reasons for this become more apparent when the causes of maternal deaths are con-
sidered. In 1943, about 90 per cent were attributable to three categories of cause:
infections, which accounted for 36 per cent of the deaths; toxemias, 27 per cent;
and hemorrhage, trauma, and shock, 28 per cent. During the ten years, 1933 to
1943, while the proportionate relationship of these causes did not change signifi-
cantly, marked improvement to the extent of about 60 per cent decrease was
achieved with each. By 1955 only 11 per cent of maternal deaths were due to
infection and only 20 per cent to hemorrhage, trauma and shock. Toxemias,
however, remained relatively as important as before. The decline in deaths from
infection is undoubtedly associated with the recent advances made in chemo-
therapy, particularly in the development of antibiotics, the increased use of
blood transfusions, the trend away from operative interference, and improved
hospital standards. More frequent and better prenatal care with particular em-
474 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

phasis on diet, and again the avoidance of operative delivery, have undoubtedly
played important roles in the reduction of the death rate from toxemias of
pregnancy. Deaths from hemmorhage, trauma, and shock have decreased as a
result of improved obstetrical management, fewer operative deliveries, and the
more common use of transfusions of blood, blood plasma, and related products.

Infant Mortality. As would be logically anticipated, the factors involved in
the problem of infant mortality, and the improvements that have been made,
closely parallel the situation described above for the mothers of the infants.

While there is just cause [or pride in the reduction that has been effected
in the infant mortality rate, much remains to be accomplished. The nation still
suffers a loss of about 100,000 infants each year. In 1955 this resulted in an in-
fant mortality rate of 26.4 per 1,000 live births. The situation has been depicted
most vividly by comparison with war losses. “From Pearl Harbor to V-J Day
281,000 Americans were killed in action. During the same period 430,000 babies
died in the United States before they were a year old—3 babies dead for every
2 soldiers.1

Although the infant mortality rate has been steadily decreasing, here also
internal disparities are to be noted. In 1955, for example, while the death rate for
white infants was 23.6, for other races, it reached 42.8 per 1,000 live births.
The rate of recent decline, however has been about the same, slightly above or
below 60 per cent for all races between 1930 and 1955. The geographic variation
in infant mortality is approximately the counterpart of that observed with ma-
ternal deaths. Except for a few sparsely settled states for which the birth and
infant mortality rates are of questionable statistical significance, the southern
tier of economically ill-favored states again poses the greatest problem. In 1955,
infant mortality ranged from 20 in Utah and Idaho, and 22 in Connecticut and
Massachusetts, to 37 in Mississippi and 43 in New Mexico. Again, as in the case
of adult women, there is no evidence that the nonwhite infant is intrinsically
less viable than infants born to white mothers. The same factors of lower
standard of living and unavailability of professional services and hospital facilities
play a predominant role. A curve depicting infant deaths or death rates by
age in days, weeks, or months is characteristically a survivorship type of curve
asymptotic to both axes. It begins extremely high for the first few minutes, hours,
and days of life, decreasing sharply by the end of the first week. In 1955, for
example, two thirds of infant deaths occurred during the first month of life
and about one third during the first day. Of predominant and increasing con-
cern is the problem of the premature infant.

In an evaluation of the problem, in order to formulate a sound program
for control, a knowledge of the causes of infant deaths is necessarily ol great
importance. About 60 per cent of them are due to prenatal and natal causes
of which prematurity is by far the most important, causing 11.8 deaths per 1,000
live births in contrast with rates of 4.9 for congenital malformations and 3.7
for birth injuries. Deaths [rom this cause were reduced about 21 per cent
between 1933 and 1943, particularly as a result of improved facilities and per-
sonnel for the prompt and adequate care of the premature infant. The second
most important cause of infant death is the influenza and pneumonia complex.
MATERNAL AND CHILD HEALTH ACTIVITIES 475
The importance of this has ben markedly reduced in recent years as the result
of the use ol antibiotic drugs. About hall as important at the present time is
the once devastating group of gastrointestinal diseases, predominantly dysentery,
diarrhea, and enteritis. The incidence ol infant deaths [rom these causes has
undergone considerable reduction as a result of sanitary measures, improved
nursery techniques, and chemotherapy. Of still less importance are other com-
municable diseases, one of which, however, merits particular mention. This is
whooping cough, a disease which all too often is considered inconsequential.
In reality it is a truly important cause of death as well as of disability in infants
under the age of 1 year. Its incidence has been lowered somewhat by means of
active immunization, but this valuable protective measure is resorted to far
too infrequently, and often too late to be ol real value.

The Preschool Child. There are in the United States approximately 15
million children between the ages of 1 and 5 years, the period which is customarily
spoken of as the preschool age. When a child passes his first birthday, he enters
a period of life which is most favorable from the standpoint of the risks of
mortality. At the present time, the risk of death between the first and the fifth
birthday is only about 1.1 per 1,000 preschool children. This was by no means
always the case. At the beginning of the century, the death rate of this age group
was about 20 per 1,000. It is in this period of life that some of the greatest
triumphs of preventive medicine and public health have been accomplished.
The decreases noted may be credited chiefly to the successful treatment and,
what is of greater importance, to the prevention, of the so-called acute communi-
cable diseases of childhood. This is brought out forcefully by a comparison of the
leading causes of death in this age group for 1900 as against 1949 (Table 32).
In the earlier year, 1900, the preschool death rate from influenza and pneumonia
was about 387 per 100,000 as compared with a rate of about 15 in 1955. At
the beginning of the century, diarrhea, enteritis, and dysentery were important
causes of death accounting for a combined death rate of about 330 per 100,000
compared with about 3 preschool deaths per 100,000 population in 1955. The

Table 32. Leading Causes of Death for Children 1 to 4 Years of Age,
United States Death Registration Area, 1900 and 1955
(Rates per 100,000 Population)

 

 

1900 1955
Influenza and pneumonia 386.6 Accidents ‘ 32.6
Diarrhea and enteritis 303.0 Influenza and pneumonia 14.9
Diphtheria 271.0 Congenital malformations 12.1
Tuberculosis (all forms) 101.8 Malignant neoplasms 11.1
Measles 87.6 Meningitis (except tubercular) 4.8
Accidents (nonmotor vehicle) 75.3 Gastritis, enteritis 44
Scarlet fever 64.1 Other infectious and parasitic diseases 4.3
Whooping cough 60.0 Cardiovascular and renal diseases 3.1
Dysentery 29.4 Bronchitis 2.3
Nephritis 19.5 Tuberculosis 1.7

 
476 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

decreases in deaths from diphtheria, measles, scarlet fever, and whooping cough
have been equally dramatic. While deaths from motor vehicle accidents in this
age group have necessarily gone up since 1900, it is interesting that accidents
from other causes have decreased very significantly. In fact, the 1900 rate was
more than twice the current rate.

Of greater significance than the forces of mortality in the preschool ages
is the fact that while deaths are infrequent here, the age period is one of high
morbidity. Thus, the National Health Survey indicated an annual [requency
rate in eighty-three cities of disabling illnesses for children between the first and
fifth birthdays of 251 per 1,000. Fortunately, as indicated in Table 33, not only
is the recovery rate for preschool children high but the duration of their illnesses
is brief.

Table 33. Frequency Rate of Disabling Illness in a 12-Month Period, by
Age, in 83 Cities, 1935-1936*

 

 

 

 

Disabling Illnesses Days of Disability Days of Disability

Age in Years Per 1,000 Persons Per Person Per Illness
All ages 170 10.4 57
Under 15 225 6.4 26
Under 1 120 3.6 27

1-4 251 6.9 24

5-9 305 8.2 24
10-14 153 4.9 29
15-19 107 4.7 40
20-24 148 6.4 42
25-34 151 7.3 46
35-44 136 9.3 63
45-64 155 15.2 89
65 and over 273 34.8 123

 

 

 

 

*From Holland, Dorothy F.: The Disabling Discases of Childhood, Pub. Health Rep. 55:156,
Jan. 26, 1940

The preschool years represent a period of marked nutritional and emo-
tional change for the child, as well as one of increased effective contacts for
the acquirement of communicable diseases and involvement in accidents. From
the point of view of the public health approach, therefore, this stage of life
is now one in which attention must be given, not so much to the prevention
of death, as to the prevention of physical and mental illnesses and trauma which
may handicap the future of the lives of those concerned. Since the individual
in this age span is undergoing very rapid growth and development, what may
often appear at the moment to be inconsequential influences ol a nutritional,
emotional, dental, or physical nature may have an ultimate cumulative effect
far out of proportion to their initial appearance. The need, therefore, is for
programs designed to minimize the daily impact of influences of this nature,
MATERNAL AND CHILD HEALTH ACTIVITIES 477

 

programs for nutritional improvement, accident prevention, continuous health
and dental supervision, including, for example, the recently developed techniques
for the prevention of dental caries in the preschool child by the topical appli-
cation of sodium fluoride. Mental illness is perhaps the greatest cause of dis-
ability in the adult population at the present time. It is in the preschool period
of life where the seeds of much of this are sown. There is [further indicated,
therefore, a great need for the application of the principles of sound mental
health and for the more widespread establishment and use of mental health and
child guidance services.

The School Child. Following the preschool period, the child enters a still
larger world involving more extensive contacts, a wider geographic range, an
increasing number ol personal and social conflicts, and many and varied learning
experiences. There are at the present time about 30 million children in the age
group between 5 and 15 years of age. The situation with regard to mortality
and morbidity among school children is similar to that of preschool children.
Again the death rates are low, having dropped [rom about 4 per 1,000 in 1900
to less than 1 per 1,000 at the present time. Again the drop is largely attributable
to success in the prevention and treatment of the acute communicable diseases
of childhood. (Table 34.) In addition, the lowering of the threat of tuber-
culosis is noteworthy. At the beginning of the century, over 36 school children
per 100,000 died each year from this single cause. At the present time, it is
relatively inconsequential as a cause of death in this age period. Of further
interest is the reduction in the number of school age deaths from diseases of
the heart to approximately one fifth of what they were in 1900.

Table 34. Leading Causes of Death for Children 5 to 14 Years of Age,
United States Death Registration Area, 1900 and 1955
(Rates per 100,000 Population)

 

 

 

 

1900 1955
Diphtheria 69.7 Accidents 20.0
Accidents, nonmotor vehicle 38.3 Malignant neoplasms 7.0
Pneumonia and influenza 38.2 Congenital malformations 2.7
Tuberculosis 36.2 Influenza and penumonia 2.5
Diseases of the heart 23.3 Rheumatic fever 1.0

 

As in the case of the preschool child, school children represent a group in
society which, while subject to low death rates, experiences at the same time a
high incidence of illness (see Table 33). As a result, here again mortality data
provide at best a very faulty measure of health problems and progress. Thus,
while the death rate in this age group from rheumatic fever was only 1.0 per
100,000, in 1955, it is estimated that almost 1 per cent of the school population
suffered from this disease, the crippling and life-shortening effects of which are
delayed until later in life. Similarly, despite the great reduction in the tuberculosis
death rate in this age period, it is undoubtedly here that a significant amount of
infection with the tubercle bacillus takes place. Throughout this period of life
478 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

the stresses ol rapid growth remain cvident and are emphasized both from a
physical and mental standpoint by the sexual maturation of the individual in
the later school years.

Two circumstances are of considerable importance to the community health
program as far as the older school child is concerned. The first is that throughout
this period the individual is preparing himself for living by learning. In addition
to this is the often overlooked [act that the older school child of today is the
parent and citizen-voter of tomorrow. Both of these factors have a direct bearing
upon the support and success of the public health program in any community.
In other words, this receptive impressionable period should be the most fruitful
for the dissemination of health knowledge and for the establishment of under-
standing and support of community health measures.

The Approach to the Problem. Since so many [actors can affect the well-
being of mothers and children, programs related to them must be multifaceted.

General. In order to meet adequately the many problems presented in the
field of maternal, infant, and child health, it is necessary for the official health
agency of a community to carry out a well-conceived and interrelated series of
activities, each of which looks forward to the subsequent periods of life. The
objectives of all phases of the program should be both service and education.
It must be realized, of course, that the health department alone cannot begin
to render all of the service and education required. In fact, no other part of the
health department program requires the cooperation of so many people and
agencies in the community. In the final analyses, except in extremely poor areas,
most of the direct medical and dental service to mothers, infants, and children
will be rendered by private physicians and dentists. Similarly, the health de-
partment can probably never substitute for the health teaching of children in
the home and in the classroom under the guidance of intelligent parents and
professionally trained teachers. No other phase of the public health program
requires so many cooperative contacts with nonofficial nursing agencies and
with the many social agencies which are found in the average community. Within
the health department itself, the cooperation of all of the staff is necessary for
success in this field. Everyone in the organization, including the vital statistics
and engineering staffs as well as the nurses, contributes to the protection and
improvement of the health and welfare of these population groups.

Beyond this, the active cooperation and assistance of many lay persons
and groups in the community must be obtained. Few aspects ol the public health
program excite the active interest of the public as much as does the maternal
and child health program. In addition to using lay advice and support by means
of advisory committees, maternal health councils, or similar techniques, many
health departments have found it possible to improve and expand their service
programs considerably by using volunteer workers both in clinics and in the field.

One further general consideration deals with the necessity for conducting
continuous research and surveys in order to keep the program in tune or in
balance with the maternal and child health problem. This involves attacks
from a number of angles. In areas with good reporting, morbidity and mortality
data provide the most obvious source of guidance. In the United States a surpris-
MATERNAL AND CHILD HEALTH ACTIVITIES 479

ing amount of data is available through the publications of the Bureau of the
Census and the National Office of Vital Statistics as well as through analyses
conducted by the states and communities themselves. Daily? has pointed out
that, generally speaking, the statistical needs for maternal and child health pro-
grams can be divided into two categories: vital statistical data usually available
in any state, and supplemental statistical information which is usually necessary
for the proper interpretation of the vital statistics. He lists the following vital
statistics relating to maternity and infancy which are usually available for any
state, county or large city and which are a part of the basic information in
planning any health service for mothers and infants:

I. Live births and stillbirths (number and rate)
(a) Urban, rural
(b) Resident and nonresident
(c) In hospitals, in homes
(d) Attended by physician, not attended by physician
(e) Legitimate or illegitmate
(fy Race
2. Maternal deaths (number and rate)
(a) Urban, rural
(b) Resident and nonresident
(c) In hospitals, in homes
(d) Attended by physician, not attended by physician
(e) Causes
3. Neonatal deaths (infant deaths under 1 month of age) number and rate
(a) Urban, rural
(b) Resident and nonresident
(¢) In hospitals, in homes
(d) Attended by physician, not attended by physician
(e) Race
(f) Causes of death
(g) Age at time of death

This must be supplemented by information relating to available medical
and hospital facilities, the economic distribution of the population, the occupa-
tions of women in the childbearing ages, literacy, and many other socioeconomic
factors. In addition, data must be sought with regard to the quality of care
rendered and the complications of pregnancy and infancy that occur in the area
under consideration. This will require the periodic or continuous analysis of
hospital and medical records, an activity which is best performed for the health
department by a committee of the medical and hospital groups in the community.

The Maternal Health Program. The natal process naturally divides itself
into several rather definite phases, each of which presents certain problems and
needs.

Preconceptional Aspects. Contrary to the expectations of many, an adequate
maternal health program should have its beginning long before the child is
conceived and even before the expectant mother reaches physiological maturity
and marriage. The preconceptional aspects of the program involve a trifold ap-
proach of education, medical service, and eugenics. Much education having a
480 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

direct and significant influence upon future parenthood may be accomplished
with the high school and even grade school girl and boy. Scientifically correct
and socially acceptable facts may be presented to school children relating to many
phases of social hygiene, including the anatomy and physiology of reproduction,
the dangers of veneral diseases and abortion, the importance of medical super-
vision during pregnancy and infancy and the responsibilities of parenthood. The
staffs of health departments should cooperate actively with school and other
groups engaged in such educational programs.

The health department is the chief agency for the promotion, implementa-
tion, and enforcement of legislation dealing with premarital and prenatal ex-
amination requirements of which serologic tests for syphilis and x-rays of the
chest should be only a part.

The eugenic approach to maternity hygiene may be manifest by any one
or a combination of three activities. The first of these is education, the basic
principles of eugenics being an important and necessary part of any teaching
program of sex education, social hygiene, or preparation for parenthood. Second,
the health departments of a few communities and states, where it has been
socially acceptable, have sponsored programs, usually in cooperation with the
Planned Parenthood League, which provide contraceptive information and ma-
terial and operate clinics for the remedying ofl sterility. Such programs are
implemented in a number of ways: as a supplementary service in maternal health
clinics, through specifically established planned parenthood clinics, through the
activities of the public health nurse in the home, or by means of referral to private
physicians. A third manner in which the health department may be concerned
with eugenics is where, as in a number of communities and states, commissions
exist to pass upon the desirability of sterilization of certain defective individuals.
In a number of such instances, the health officer is made a member of the
commission.

Antepartum Period. The antepartum period of pregnancy is most important.
The objective is to get expectant mothers under early and continuous super-
vision of a qualified medical advisor. This objective should be supplemented
by related activities including antepartum public health nursing service and
instruction in the home; the provision of auxiliary facilities such as consultants,
laboratory service and nutritional aid; and an organized approach to special
problems such as illegitimate pregnancy, abortion, care for women engaged in
industry during pregnancy, and such technical problems as the management of Rh
incompatibility. A subject which is receiving increasing attention is the avoidance
of German measles during the first trimester of pregnancy because of the relation-
ship between this disease and congenital malformations.

In order that as many expectant mothers as possible receive prenatal medical
and nursing supervision, it is necessary to set up some [orm of administrative
procedure whereby to locate them as early in their pregnancies as possible.
The need for and manner of doing this varies from one community to another,
depending upon many social factors. The health department has at its disposal
a number of sources of information. Knowledge ol pregnancies may come to
the health department staff through their personal observations during their
MATERNAL AND CHILD HEALTH ACTIVITIES 481

 

daily rounds, by statements or suggestions from neighbors ol expectant mothers,
and from previous patients. Some health departments have found it worth while
to maintain continuous contact with business establishments which sell layettes
and other baby equipment. A highly desirable goal is for the private physicians
practicing in the area to notify the health department of each new obstetrical
case. Part of the problem is already solved in that the patient is already under
medical supervision. However, even here the health department may render
service through public health nursing supervision and education wherever the
medical attendant wishes and follow up of women who miss appointments.

Antenatal medical supervision may be rendered in one of three ways: by
general practitioners, by obstetricians, or in prenatal clinics operated by the
health department or other agencies. Considering the country as a whole, the
first of these provides the larger part of the care, and the last the least. Great
social and geographic variations exist. The majority of obstetrical specialists
practice in the large cities. Prenatal clinics are found serving primarily the lower
economic groups in large urban centers, and certain rural areas particularly in
the southern states. Most of the prenatal medical care rendered in rural areas
is provided by general practitioners of medicine. It should be remembered, how-
ever, as previously pointed out, that while most white women have some medical
supervision during their pregnancies, about one half of negro expectant mothers
receive none.

Intrapartum Period. While the actual delivery of a pregnant woman would
appear to be a matter of joint interest for the woman and her accoucheur, there
are many places where the health department may enter into the intrapartum
period. It has been pointed out in Chapter 8 that many health departments,
primarily on the state level, have legal responsibility for the licensure, inspec-
tion, and regulation of maternity hospitals and nurseries. In many places,
public health agencies maintain active programs for the purpose of assuring
hospitalization of selected obstetrical cases and emergencies. Most states and
cities where the problem exists have the legal responsibility for the regulation
and control of midwives. Ordinarily, this is accomplished by licensure, super-
vision, the provision of some training, and examination. The ultimate goal in
most instances, however, is the eventual elimination ofl this type of obstetrical
service in favor of medical supervision. A few health departments which serve
areas with significant numbers of home confinements conduct programs designed
for the improvement of this type ofl service. Some of the activities in this regard
are the provision of sterilized obstetrical packs and layettes, the preparation
of the expectant mother for delivery in her home, and the provision of obstetrical
nursing asistance to the general practitioners who officiate at the deliveries. The
purpose of the latter activity is trifold: service to the patient and the physician,
education of the patient, and, in some instances, education of the physician.

Throughout the entire maternal health program and particularly in its
intrapartum phase, the intention of the public health agency must obviously
be to support, assist, and promote the use of private physicians, and not in any
way to supplant them. Additional ways in which assistance is rendered is by
provision of materials for ophthalmia prophylaxis, umbilical packages, birth
482 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

registration materials, and in some instances the loan of equipment for blood
typing, transfusion, and other emergencies. Many health departments have
been active in the development of standards for obstetrical consultation and in
some instances in the provision, through direct employment or by subsidization,
of the consultants themselves. A procedure of far-reaching consequence, which
has been promoted by many health departments in conjunction with their re-
lated medical societies, is the formal review of all maternal deaths by a maternal
and child health committee of the medical society. In many such instances,
the physician who attended the deceased mother must appear before the com-
mittee, outline his management of the case and attempt to explain the reasons
for its unfavorable outcome. This represents in effect a review ol the attendant’s
work by a jury of his peers, and where forthrightly carried out it has undoubtedly
promopted more careful supervision and obstetrical management of women in
labor.

Postpartum Period. As in the case of the antepartum program, the first
essential in the postpartum program is case finding. The location of women
who have recently delivered is accomplished with relative ease. Where an efficient
birth registration program is in effect, birth records provide a fruitful source
of data. In addition to this is the arrangement achieved in some localities
whereby hospitals routinely and promptly notify the health department of all
deliveries which have occurred within their confines. In many instances the
health department is notified when the patient is about to return home. Early
notification is most desirable since it enables the public health nursing staff to
make primary contact while the patient is still in the hospital in order to facilitate
her hospital discharge and re-entrance into the home, and to prepare her home
to receive her. Unfortunately a great many postpartum public health nursing
visits are first made after the mother and her new infant have been home for
some weeks. By then, much of the potential value is lost. It is when the woman
first returns to the confusing cares of her home, with the added burden of a new
infant, that she really needs and appreciates help. The value of meeting the
mother and infant practically at the doorstep has been demonstrated by a number
of health agencies, and the secret of its accomplishment is one of. interagency
cooperation and administrative timing. The problem of contacting women and
infants after delivery has been greatly complicated during recent years by the
current frequency of change of address and by the fact that many women come
into cities for hospital delivery as a convenience but return to small commu-
nities or rural areas after discharge from the hospital. These factors have also
caused much difficulty in the handling of premature and ill infants, especially
those who are illegitimate.

The health department's postpartum program has two purposes: to pro-
vide whatever public health nursing service and education to the mother
is indicated in each case, and to accomplish a smooth and automatic carryover
to the infant health program. The nurse often finds it possible to instruct the
mother in proper infant care and formula preparation. She should make certain
that the birth of the infant has been registered and that the mother and infant
are both under medical supervision. She should maintain a watchful eye for
MATERNAL AND CHILD HEALTH ACTIVITIES 483

 

the development of postpartum complications in the mother and of illness in
the infant. Referrals should be made to appropriate agencies wherever medical,
economic, or social problems are found to exist. Finally, the groundwork should
be laid for the pediatric supervision of the infant, including all indicated pro-
tective treatments from either private physicians or health and well-baby con-
ferences and clinics.

The Infant and Preschool Program. With regard to the neonatal program,
early case finding is again a prerequisite and may be accomplished by means
of the routine check of birth certificates, notification from the accoucheur, the
hospital, or the family itself, and from the records of prenatal clinic attendance.
Neonatal cases should be classified into priority groups, with premature in-
fants at the top of the list, followed by those known to have been born with
physical defects, and those who have become ill or injured during or following
birth. Many health departments maintain a number of portable warm beds
which may be loaned to parents of premature babies and have worked out ar-
rangements, sometimes with other agencies such as fire or police departments,
for resuscitation services and for emergency transfer to hospitals. At least one
large city has designed and provided electrically heated beds for prematures that
may be fitted into taxicabs for the emergency handling of the premature infant.

For the usual infant and preschool child, the health department's aim is
one of supervision and education. As much as possible this is effected through
reliance upon the many persons and agencies which exist as resources in the
community. The most obvious and important of these is again the private
practitioner of medicine, and particularly the general practitioner. This is em-
phasized by some of the findings of the American Academy of Pediatrics’ Com-
mittee for the Study of Child Health Services. About three fourths of all well-child
care is rendered by general practitioners, as compared with about one fifth by
pediatricians and about 5 per cent by others. This is despite the fact that general
practitioners give less attention to health supervision. “Presumably their time is
in greater demand for the care of the sick. Of the general practitioner’s visits
to children (29 per cent of his total practice), less than one in three visits were
for health supervision. Thus while the pediatrician saw an average of nine
children a day for health supervision, the general practitioner averaged 1.8.
Nevertheless it is the general practitioners who gave most of the health super-
vision for the nation’s children, for they outnumbered the pediatricians about
twenty to one.”* Only about 1.5 per cent of the total medical services to chil-
dren is rendered in community health clinics. In view of these proportions, it
is all the more important for the health department to solicit the active and
interested cooperation of the local medical society. One of the most effective
steps in this regard is the promotion of and active participation in a medical
society committee on maternal and child health by the health officer.

Within the health department, the larger proportion of the visits and
services of the public health nursing staff should be devoted to the infant and
 *Child Health Service and Pediatric Education, Committee for the Study of Child Health

Services, The American Academy of Pediatrics, New York, 1949, The Commonwealth Fund,
p- 52.
484 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

preschool program. The services are essentially educational in nature, the teach-
ing being done wherever possible by demonstration. One of the primary objectives
of the public health nurse in her visit to the home of an infant or preschool
child is to assure continuous well-baby medical supervision, preferably by the
family physician or pediatrician, and, failing that, in a well-baby conference
conducted by the health department. Public health nursing visits on behalf of
infants and preschool children should be made according to a set schedule,
which should be elastic enough, however, to allow for additional visits for special
cases and emergencies. Generally speaking, at least two visits should be made
during the first month of the infant’s life. The first visit, as stated before, should
be made within the first forty-eight hours following return to the home from
the hospital, or within the first twenty-four hours following delivery in the home.
A third visit should be made as the child approaches six months of age, followed
by another between the ninth and twelfth month. One of the primary purposes
of the six-month and nine-month visits is the promotion of the protective treat-
ment of the baby against whooping cough, smallpox, diphtheria, tetanus, and
poliomyelitis. Chapter 14, which deals with vital statistics, includes a description
of the manner in which this part of the program may be integrated with some
other activities of the health department in order to achieve the desired ultimate
result of a high level of community protection.

Despite the emphasis of the foregoing upon the well child, the infant and
preschool program of the health department must take special cognizance of
the sick and handicapped child population, seeking them out and referring
them to the proper community or state facilities and agencies. It should be
pointed out that in one half of the states, the crippled children services are
within the jurisdiction of the state health department. In the remaining states
these services are usually found in departments of welfare, although in six in-
stances there are separate crippled children’s commissions, in four states the
program is conducted by the department of education, in two states by a branch
of the state university, and in one state by a board of control.

Other activities which are gradually receiving increasing attention in infant
and preschool health programs include the promotion of dental hygiene, nutri-
tion, and mental hygiene.

The School Health Program. Between the fifth or sixth year and early adult-
hood, children spend a large part of approximately one half of the days of the
year in a school environment. During this important formative period the es-
sential influences for physical and mental health and for education are shared
by the home and the school. If the schools are to meet their responsibilities, it is
necessary to formulate and to put into effect sound policies and programs for
health protection and promotion during the hours of school experience.

The school is of particular importance for a number of reasons. In addition
to its potential importance with regard to health instruction and the develop-
ment of desirable habits, it represents a gathering place for a population group
which is particularly prone and susceptible to many acute communicable diseases.
Because of these various types of influences, a school health program must be
devised to include four primary considerations: the supervision of the school
MATERNAL AND CHILD HEALTH ACTIVITIES 485

 

environment, health protection and promotion, health instruction, and the hand-
ling of special problems.

The School Environment. In connection with schools, the word environment
should be interpreted in its broadest sense. It should take cognizance not only
of the immediate school premises but also of its surroundings, not only of its
sanitation but also of its location and salety. In other words, it should include
consideration of every potential physical, mental, and moral hazard with which
the child may come in contact in connection with his school experience. As
stated by the National Committee on School Health Policies,* “The authority
which requires pupils to attend school implies the responsibility to provide an
environment as evocative as possible of growth, learning and health.”

A discussion of the details of each of the many factors involved in the school
environment is considered beyond the province of this book. Attention should
be called, however, to the general factors which call for supervision by public
health and other authorities. Of primary importance is the location of the school.
It should be chosen with a view to accessibility, salubrity, and adequacy. Proper
choice of location will preclude the development of many sanitary problems.
Attention should be given to drainage, shade and sunlight, freedom from in-
dustrial wastes, excessive noise and excessive traffic. Provision should be made
for adequate recreational space and for the possibility of future expansion. While
the actual choice of location will not be a responsibility of the public health de-
partment, it should, however, offer its consultative services to whatever agencies
are involved.

The health department should have some authority in the matter of con-
struction and maintenance of the school. Conformance with accepted sanitary
and safety standards should be assured by frequent inspection by representatives
of the public health agency and by consultation with the school authorities.
Consideration must be given to ventilation, lighting, heating, and acoustics; to
adequacy and location of stairways and exits; to construction materials and
methods from the viewpoints of sanitation and safety; and to the adequacy and
design of toilet and handwashing facilities. Because of the numbers and character-
istics of those involved, the water supplies and sewage disposal facilities serving
schools are considered of a public nature. Even if they are part of larger munici-
pal systems, facilities of this type merit particular scrutiny and supervision. In
rural and developing suburban areas, the provision and maintenance of satis-
factory water and sewage disposal facilities is particularly troublesome and re-
quires especially persistent supervision by the health department.

Many schools, even in rural areas, provide lunchrooms and cafeterias which
often have rather extensive facilities for the preparation and serving of foods.
Such facilities should be under the constant surveillance of the sanitation staff
ol the health department in order to prevent their becoming a threat rather
than a benefit to the school children.

Schools which contain gymnasiums, play areas, and swimming pools place
an added supervisory responsibility upon the health department. Standards of
construction and maintenance should be established by the health agency and
enforced in cooperation with the school authorities. This becomes particularly
486 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
important in view of the laudable trend toward making such facilities available
to the entire community rather than to restrict their use to school children
during school hours. Related to these facilities and to the school as a whole
should be adequately equipped and adequately staffed health service rooms
for the rendering of first aid. This will be mentioned further in relation to
health protection and promotion.

The most ideally located and constructed school can rapidly deteriorate
and become a sanitary menace unless provision is made for its proper main-
tenance. As inferred above, many aspects of the physical school plant must be
subject to frequent inspection. In addition, the health department staff, as a
matter of policy, should annually conduct a complete and detailed survey of
the sanitary conditions and facilities of each school, public or private, within
its jurisdiction. Often this is best done during the summer months when some
of the other community problems slacken and during which time whatever
repairs as may be indicated may be made before the reopening of the schools
in the fall. Written reports with recommendations for improvements should be
submitted to the school principal and the superintendent of schools. Short-
comings should be discussed with them and all assistance possible given for the
remedying of whatever defects are found. Subsequently, follow-up inspections
should be made to assure the correction of any undesirable conditions.

Health Protection and Promotion. Present-day thinking indicates a social
responsibility to prepare school children physically as well as intellectually for
adulthood. For many this means graduating them in better physical condition
than when they entered school. In order to accomplish this purpose it is necessary
to establish base lines by means of physical examination. At one time it was
the custom to attempt to examine every school child every year. Eventually
this was realized to be inefficient and pointless. This procedure had two un-
desirable features. So many children had to be examined each year that they
usually received what amounted to a cursory scanning rather than ever getting
a truly complete physical examination. Furthermore, so much attention was
given to getting the children examined that it either became an end in itself
or else no time was left for the follow-up necessary to secure the correction of
defects.

Accordingly, a more reasonable approach has been developed and followed
by more progressive communities whereby children are examined only three
or four times during their entire school experience; for example, at entrance
to grade school, the fourth year, junior high school, and senior high school.
These, however, must be carefully conducted and complete examinations, re-
gardless of the circumstances under which they are performed. By reducing the
total amount of time spent on examinations, more funds and personnel time
and energy are left available for securing the correction of defects.

The arrangements whereby school children are examined varies. In some
communities salaried school physicians do the work, whereas in others private
physicians are employed on an hourly or daily basis. There may still occasionally
be seen in large schools the grossly unsatisfactory system whereby one physician
MATERNAL AND CHILD HEALTH ACTIVITIES 487

examines all throats, another all ears, another all chests, and so on without con-
sideration of the total child.

A few large communities have followed the interesting policy of restricting
the school medical work, particularly in relation to periodic examinations, to
the younger and newer men just entering practice in the community. This is
based upon the philosophy that everyone concerned benefits. The school and
health departments get the examinations accomplished, the new physicians not
yet completely established benefit from the part-time salaries, the experience
and the family contacts, the children are given more thorough examinations
because the new physicians have relatively more time, and the older busy practi-
tioners are spared the necessity of using up their time in routine examination
in which they often are not too interested. Finally, a learning situation is pro-
vided in which the younger physicians experience a satisfactory and helpful
relationship with the health department which should bear sound fruits in terms
of future professional relations.

The most desirable and in the long run probably the most efficient system
is one in which the health department and the schools educate and prompt
parents to take their school children to their family physician for their periodic
physical examinations and other protective and promotive services as well as
for their illnesses. Furthermore, when the school child becomes accustomed to
going to his own physician for such services, the likelihood of his continuing
to consult his private physician following his school years is considerably greater
than if he had come to expect such services from a full-time school physician.
The high degree of success which a program of this type may attain is exemplified
in Detroit where at the present time about 70 per cent of new entrants to school
are examined by their own physicians.” The number of children so examined
in that city rose from about 2,500 in 1934 to 26,000 in 1940 and to over 40,000
in 1948.6

An important administrative technique which is of value in conjunction
with the periodic physical examinations is the screening of pupils by their class-
room teachers. The health department may cooperate by providing inservice
training for teachers in order to acquaint them with the signs and symptoms of
illnesses, particularly the communicable diseases. Without attempting to make
diagnosticians out of them, the teachers are encouraged to survey their pupils
briefly each morning, referring any pupils with suspicious indications to the
medical personnel available to the school. Tests have demonstrated the practically
equal ability of teachers with physicians to pick out sick or ailing children
without reference to the exact cause.

The discovery of physical and mental defects or illnesses in school chil-
dren in itself is of relatively little value. In fact, whatever value it has is contingent
upon what is done with the information obtained. This means a successful
follow-up program from the school and health department to the home, to the
private physician or dentist, or to the social agency, whichever is needed for
correction of the condition.

Another phase of the school health protection and promotion program
deals with the control of communicable diseases. Of primary importance is the
488 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
degree to which the parents of the community bring their children to school
already protected against acute communicable diseases such as diphtheria, small-
pox, whooping cough, and poliomyelitis. Whether to attempt to secure these
protections by mandate or by education is discussed in Chapter 8. Suffice to say
at this point that a high degree of community and school protection may be
obtained by educational methods and that it is foolish for a health department
to make lasting enemies for its general program by stubbornly and needlessly
insisting, on the basis of law or regulation, on the immunization of every last
cnild. Too often, health officers have been so concerned with the achievement
of high paper scores and ratings that they have overlooked much harm of a
public relations nature that has been done in the process.

The screening of pupils by teachers has been discussed in relation to the
periodic physical examination. When conducted routinely each morning, this
becomes of some added value in the school’s communicable disease control
program. Children with suspicious signs and symptoms should be excluded from
class and referred to the school medical service or to their private physician.
It is desirable that there exist a policy of prompt notification of the health de-
partment. Similarly a release should be obtained from the health department
or private physician before the child is readmitted to his classroom.

A question which inevitably arises in every community is whether or not
schools should be in session during epidemic periods of communicable disease.
In general the public tends to want the schools closed. However, when this
is done, greater and more intimate contact between children usually follows
since they tend to play in their neighborhoods and circulate among crowds rather
than remain at home. Therefore, in communities with well-organized and efficient
public health and school health services, epidemics can best be controlled if
the schools remain open and engage the children in controlled activities under
intelligent and watchful surveillance.

In discussing the subject, the National Committee on School Health Policies
suggested that the decision regarding the closing of schools when epidemics occur
or threaten may be decided locally by answering the following two questions:
(I) Are nurses and medical staffs so adequate and the teaching staff so alert that
the inspection, observation, and supervision of students will keep sick students
out of school? (2) If schools are closed, will students be kept at home and away
from other students, so that the closing ol schools will not increase opportunities
for contact with possible sources ol infection?

As a general policy, when the first question can be answered affirmatively,
or when the second question is answered negatively, schools should be kept open
in the face of an epidemic. This is most often the case in large public schools
and in thickly settled communities. Schools should be closed when the first
question is answered negatively or the second question affirmatively. In smaller
communities with scattered homes, where chances for personal contact are limited,
this is frequently the situation. In rural communities where pupils are trans-
ported in buses and close contact is unavoidable, it also may be advisable at
times to close the schools.
MATERNAL AND CHILD HEALTH ACTIVITIES 489

 

Health Instruction. Schools are primarily places where children go to learn
for living. Most people consider health important for successful living. It
logically follows, therefore, that school children should have presented to them
in an understandable and interesting manner a considerable amount of informa-
tion dealing with the present and future health of themselves and their com-
munity. Customarily, “health teaching” is a requisite in most school curriculums.
However, in a great many instances the job is poorly done. Too often “health
classes” turn out to be physical training periods. With equal frequency the
material is presented by unqualified and sometimes disinterested persons. On
about the same level are the situations where didactically unsuited members
of the health department staff or private physicians are asked to give “health
talks” to the students. All of these are but poor substitutes for what is really
needed.

Teaching is a profession in itself. Everyone is not fitted by temperament
and training to teach. Certain skills, aptitudes, and training are necessary to
accomplish a satisfactory result. Therefore, inasmuch as possible, the teaching
ol health as well as of arithmetic and geography should be left to the trained
classroom teacher who is already well acquainted with the pupils. The health
department can be of greatest assistance to her by ollering advice, consultative
service, inservice training and teaching materials, and by aiding her in planning
her health teaching program. This can best be done by a health educator or
health counselor who may meet with the teachers collectively and individually
to discuss their problems. Ever-enlarging sources ol visual aids are becoming
available, and the health department, as one of its justifiable activities, should
make them accessible to the schools of the community.

Wherever possible, health teaching should be related to other subjects or
school activities. Courses in civics, geography, and many other subjects offer
opportunities for the incidental injection of health information. If a school
lunch program is in operation, a great deal ol education in food sanitation and
nutrition may be associated with it if properly operated. Many local health
departments and school authorities have developed programs of field trips and
special health study projects designed to demonstrate to school children com-
munity activities which have an influence upon the health and well-being of
themselves and their families. When properly planned and carried out, these
study programs can have a considerable educational impact. A few health depart-
ments have progressed further to the point of allowing high school students to
take turns working at simple jobs in the health department offices or even clinics
as volunteers or at a nominal temporary salary. This is a doubly worth-while
venture by virtue of its educational effect and because it is also a form of vo-
cational guidance. To be of value, however, a judicious choice of jobs and con-
stant supervision are necessary. Since, if properly planned and conducted, it
represents a learning process under supervision, the granting of academic credit
for the time spent is considered justified.

Special Problems. Of particular concern to the school health program are
measures designed to meet the special needs of certain handicapped children.
In every community there exist children whose needs for educational services
490 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

must be met in conjunction with special care necessitated by physical or mental
handicaps. Many localities follow a policy of complete segregation of these
children, if not in special institutions, at least in separate classes for the blind,
hard of hearing, crippled, pretubercular, or for those with cardiac ailments and
epileptic tendencies. While such classes undoubtedly make possible much spe-
cialized care, they have the undesirable result of making the handicapped child
feel still more apart and different from other children. For this to come about
is not conducive to good mental hygiene and development or to complete re-
habilitation. The conclusion that is shared by many is that the best policy is
to allow the handicapped to intermingle with other children in the same general
classrooms, and to provide special classes or rest periods if needed for them, de-
pending upon their handicap. It is felt that this policy has a beneficial effect
both upon the handicapped and their more fortunate classmates and results in
all children considering each other as at least basically the same.

Programs of this nature may be criticized as being impractical, time consum-
ing, and expensive. In many instances specially trained teachers are indicated. In
terms of the most desirable end result, such programs must be considered worth
while. In any case, time and money must be spent for the education and care
of handicapped children and some specialized personnel will have to be em-
ployed. By careful curriculum and administrative planning and by using the
specialized personnel partly as consultants and inservice trainers for the general
teaching staff, possibly more can be accomplished than by any other approach
to the problem.

Responsibility for the School Health Program. An old problem in public
health administration, but one which has been satisfactorily solved in many
progressive communities, is concerned with which agency in the community
should be responsible for the school health program. Children are an import-
ant part of the total community. They can affect the health of the community,
and the community in turn can affect them. It would appear obvious that to
attempt to operate the school health program apart from the general community
health program is inefficient, costly, and administratively unsound. One public
health authority has stated very frankly that the only excuse for departments of
education administering the public health, medical, and nursing services for
children of school age is that in the past many health departments have done
the work poorly.” Added to this is the factor of the establishment of school
systems in many localities much earlier than the development of public health
agencies and programs. In the absence of the latter it was natural and com-
mendable for departments of education to attempt to provide for the health
problems of the school child. However, the widespread development of sound
community health programs tends to negate these excuses.

The Committee for the Study of Child Health Services of the American
Academy of Pediatrics found that at the present time school medical services
are rendered 45 per cent by official education agencies, 41 per cent by official
health agencies, 11 per cent by education and health agencies jointly, and 3 per
cent by other agencies. The pattern is by no means uniform. There was found
to be a much greater tendency for education authorities to provide the service
MATERNAL AND CHILD HEALTH ACTIVITIES 491

in metropolitan areas and for health agencies to be responsible in isolated
counties.!

The advantages of operating the school health program as part of the
community health program are many. Many more facilities, people, and sources
of information are thereby readily available. Activities are more logical and fall
more readily into their relative positions in the total picture of health. As
just one example, consider the problem of securing the correction of physical
defects. This is accomplished most effectively by qualified, generalized public
health nurses, who, rather than limiting their interests and activities narrowly
to the school situation, secure the correction of defects in school children as
part of their general, family, and community public health nursing program.
Such an approach cannot help but broaden the understanding and increase the
capability and efficiency of the nurse, and what is said for her holds true for
the other participants in the school health program. If adequate control and
supervision of the school environment is outside the field of training of the
medical, physical training, or janitorial staffs of the schools, the well-organized
local health departments will have available the services and knowledge of a
qualified engineer and sanitarian to perform this important function. The
efficient health department will have up-to-the-minute reports of illness in the
community and can often prevent the infected child from reaching school in
the first place. Furthermore, since the community health program operates the
year around, there is obviated the problem of lack of professional functions and
activities during the summer months.

On the other hand, there are certain activities that may rightfully be con-
sidered within the jurisdiction of the schools. The most important of these is
the actual teaching of health, to which reference has already been made. This
is best accomplished by the professionally trained classroom teacher who should
feel free to call upon the official and nonofficial health agencies for assistance
in planning and presentation. Many of the larger schools and departments of
education employ a health coordinator to expedite these interagency relations
and generally to plan and integrate the health instruction program. Beyond
this, all schools should have some system for providing first aid or emergency
medical care or consultation. Many larger school systems employ full-time school
physicians for this purpose, while many others rely upon one or a number of
practicing physicians who agree to be on call as a public service or a nominal
fee. Even where the official health agency has general responsibility for the
school health program, the employment of a school nurse by a large school or
by a department of education is not unusual. In such instances her function,
although subject to variation, usually includes responsibility for the first-aid
or health room, the care of minor injuries, the referral to private physicians
or school physicians, and consultant services to the teachers, the principal or
superintendent, and the public health agency.

School Health Councils. In dealing with most health problems of school
children, no single person or agency can bring about complete solution. Fortun-
ately, interest in the health and well-being of school children is widespread. The
primary responsibility, of course, rests with parents. In addition to them, society
492 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

as a whole, and particularly private physicians, dentists, nurses, official and non-
official health, social, and welfare agencies, and professional societies all have
a rightful concern and responsibility. Here, therefore, intelligent and cooper-
ative planning and teamwork is what spells success. Only thus can balanced and
effective programs of school health education, protection, and promotion be de-
veloped. School health policies must be formulated, therefore, in a manner which
makes the maximum use of the resources of the community. This is best accom-
plished by means of school health councils. Every school and school system should
have a health council or committee with representation from all groups con-
cerned with school health. At the top level in the community, where general
cooperative community relationships and policies are best developed, member-
ship should include such persons as the superintendent of schools, the local
health officer, the president of the Parent-Teacher Association, a representative
of the medical and dental societies, and whatever others may appear to be in
key positions. The relationship of the central school health council to each of
the individual school health councils or committees is best determined by ex-
perience in each community. In general, it has been recommended that the
central council guide and give leadership but leave each individual school health
council with considerable authority.*

The health council or committee of each school need not follow any par-
ticular pattern. In a one-room rural school it might consist only of the teacher,
an interested parent, and a public health nurse. In larger schools the numbers of
those who may play an active role are many and varied and dependent upon local
circumstances. The essentials are that they be representative of all in the com-
munity who are concerned and may be helpful, and that they provide a simple,
democratic, and orderly means of determining and implementing wise school
health policies.

REFERENCES

1. Child Health Services and Pediatric Education, Committee for the Study of Child Health
Services, The American Academy of Pediatrics, New York, 1949, The Commonwealth
Fund.

Holland, Dorothy F.: The Disabling Diseases of Childhood, Pub. Health Rep. 55:156,
Jan. 26, 1940.

3. Daily, Edwin F.: Some Statistical Needs for Proper Administration of Maternal and Child
Health Programs, Am. J. Pub. Health 30:766, July 1940.

Suggested School Health Policies, ed. 2, New York, 1947, Health Education Council.

Annual Report, 1957, Detroit Department of Health.

Douglas, B. H.: The Private Physician and Preventive Medicine, J.A.M.A. 139:987, April 9,
1949.

7. Smillie, W. G.: Public Health Administration in the United States, ed. 3, New York, 1947,

The Macmillian Co.

No

& ov
chapter 2 1

Public health nutrition

 

 

Food and the Health of Nations. In a dissertation written in 1851 on the
subject of “Food and the Development of Man,” Otto Ule stated:

Of all the influences which determine the life of the individual, and on which his
weal and woe depend, undoubtedly the nature of his food is one of the weightiest.
Every one has for himself experienced how not only the strength of his muscles,
but also the course of his thought and his whole mental tone, is affected by the nature
of his food. And shall not hold good for nations which holds good for individuals?
Shall the sum of mankind be less affected in their physical and mental development
by the food they take, than the individuals of whom that sum is made up? This seems
to be the decision of history . . . . If nations are to flourish, they, no less than
individuals, need wholesome, strong food. The only questions is, How are we to de-
termine what food is strong and wholesome?*

His summary of the answer to the question was:

Here we have an important rule for determining a wholesome diet. The foods
we use must contain the indispensable elements of nutrition in due proportion; our
food must be mixed, varied, and alternating. And what is here said with regard to
individuals, holds good also for nations. The foodstuffs of an energetic population
are up to the standard only when they are multifariously blended, and when there
is a due proportion of substances belonging to the three groups mentioned above.t
Now, this relation between the nutrition and the physical and the mental develop-
ment of people must be apparent in the history of their civilization. Where the food
is insufficient, fluctuating between want and excess, uniform and undiversified, the
capacity of the people for work must be inferior; their bodily strength and their mental
culture must be of a low grade.*

The importance of nutrition on a national scale was probably fully realized
for the first time in this country as a result of the White House Conference on
Child Health called in 1930 by President Hoover. Although not at first antici-
pated, nutrition loomed as a factor of predominant concern, not only because

*Ule, O.: Food and the Development of Man. (Translated from the German by J. Fitzgerald,
from Die Nature, 1851.) Popular Science Monthly 5:591, 1874.

The three groups the author mentioned are: bloodformers or albuminates; heat-producers
or respiratory foods rich in carbon; and the nutritive salts.

493
494 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

of its specific importance but especially because of its relationship to so many
other circumstances related to the well-being of children. Shortly following
this the League of Nations began what was called a world food movement in an
attempt to remedy the dire nutritional difficulties of so much of the world
population, resulting from the economic depression. It emphasized the importance
of adequate diets to health and suggested that agriculture by supplying the
necessary foods to the world could overcome the depression not only for itself
but for the many industries related to it. Under the League's auspices many
studies of the relation of nutrition to the health ol various groups were carried
out. Two specific results were the formulation of the first table of optimum
dietary standards and the organization of national nutrition committees in
about twenty countries. Boudreau? states that, “It was the belief of many
that had this movement been started early enough the train of events leading to
the Second World War might have been halted . . . .” Few things cause dis-
content as much as hunger, especially in the midst of plenty.

Most of the fruits of war are bitter. Let us consider some of its better
fruits. Much has been heard during recent years of the use of food as a weapon.
The idea is not new. Captains of war recognized early the relationship between
food and conquest. All would-be conquerors from Caesar to Napoleon and
Hitler had as one of their fundamental military precepts that an army travels
on its stomach and saw to it that their soldiers received the best food available.
The use of siege as a means of subjugation is so old as to be obscure in its origin.
The cutting off of the supply of food was, of course, its chief purpose. The
technique is continued in modern times in the form of embargoes, blockades,
and mine fields. Once conquest was effected, the importance of food did not
diminish; if anything, it increased. The Roman soldier has been described as
entering conquered lands carrying sacks of flour on the point of his lance. To
keep the conquered peoples contented, their Roman rulers gave them “bread
and circuses.” In this connection it is interesting to note the position of bakers
in the Roman state. During the Roman Empire bakers were considered as
persons important to the welfare of the nation and were made civil servants,
licensed and paid by a department of food supply. It might be asked why a
state such as Rome, which was anything but socialistic, followed such a nutri-
tional policy. Undoubtedly it was because in the period of the Roman Imperium
bread had become a political factor of enormous importance. A sufficient supply
of bread meant social peace; lack of it implied hunger and bloody revolution.

The Second World War saw food used as a weapon as usual but this time
as a defensive weapon as well as for offense. The story of the stupendous efforts
of the Allied Nations to produce not only more food than ever, but also food
of a better quality in the face of many difficulties, is too well known to justify
retelling. Not so well realized, however, is the effect of this effort on the general
health and well-being of the countries involved. Taken as a whole it is en-
tirely justifiable to state that not only did the millions of young men and women
who were in uniform get better meals than they otherwise would have obtained,
but also the civilians benefited enormously from an educational standpoint
PUBLIC HEALTH NUTRITION 495

 

and from the substitution of nutritionally more desirable foods for those which
were scarce and less beneficial. The effects of this are sure to be far-reaching
and, it is hoped, long-lasting 3:

Dr. Frank G. Boudreau, Executive Director of the Milbank Memorial Fund
and his co-chairman on the Food and Nutrition Board of the National Research
Council, Dr. Russell M. Wilder, have given some indications of these effects:

It is perhaps too early to appraise the contribution of workers in nutrition to the
winning of this war, but some credit undoutedly is due them for the fact that the
country has come out of the war with unusually good health reports. Infant mortality
has continued its decline despite the war, and in contrast to the usual experience in war.
Deaths from tuberculosis have not increased as they always did before in war; indeed a
new all-time low record has been obtained. The figures for maternal mortality are better
than they were before the war, and the same is true for virtually all death rates which
reflect in any way the influence of diet on the public health. We might be less assured
of the contribution of nutrition to these better records were it not that in Great Britain
the fall in these rates has been even more pronounced, and over there all environmental
factors except nutrition were worsened by the war.*

The situation in Great Britain was summarized by Dr. H. E. Magee,’ Con-
sultant in Nutrition to the British Ministry of Health, in a paper published in
the British Medical Journal in March, 1946:

The war-time food policy was the first large-scale application of the science of nutri-

tion to the population of the United Kingdom . . .. A diet more than ever before in con-
formity with physiological requirements became available to everyone, irrespective of
income.

The other environmental factors which might influence the public health had, on
the whole, deteriorated under the stress of war. The public health far from deteriorat-
ing, was maintained and even in many respects improved. The rates of infantile, neo-
natal mortality, and the still-birth rate reached the lowest levels ever. The incidence
of anemia declined, the growth-rate and the condition of the teeth of school children
were improved, and the general state of nutrition of the population as a whole was up to
or above prewar standards. We are therefore entitled to conclude that the new knowledge
of nutrition can be applied to communities with the expectation that concrete benefit to
their state of well-being will result.t

This was supported by Sir William Jameson,” Chief Medical Officer to the
Ministry of Health of England and Wales, who said: “This can’t be just an acci-
dent. All that’s been done to safeguard mothers and children must have had some
effect—such things as the national milk scheme, vitamin supplements for mothers
and children, the great extension of schemes for school meals and milk in schools.
There are doubtless other factors—full employment and higher purchasing power
in many families, especially in the old depressed areas; as well as the careful
planning from a nutritional point of view of the restricted amount of food avail-

*Boudreau, F. G., and Wilder, R. M.: The Food and Nutrition Board of the National
Research Council: A Review of Its Accomplishments and a Forecast of Its Future, Federation
Proc. 5:267, June 1946.

Magee, H. E.: Application of Nutrition to Public Health, Some Lessons From the War,
Brit. M. J. 1:475, March 1946.
496 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

able for the nation.”* His conclusion was that “Nutrition is the very essence and
basis of national health.”
A measure of the importance of food to people other than its value in times
of strife is the proportion of the productive resources of that people that is de-
voted to providing it. The figure is always considerable, varying from about 37
per cent of the total productive resources of the United States to about 90 per cent
in China. It depends on many factors such as wealth, social constitution, the
nature of the soil, the national economy, industrialization, scientific development
and transportation. Of great importance are habits, customs, and education.
With the great advances in the science of nutrition it may seem a strange
paradox that so much malnutrition still exists, but it must be realized that there is
always a great lag between research and interpretation to the masses. In the field
of nutrition there is not only a lag in interpretation but also in human resistance.
Food has been said to represent the crossroads of emotion, religion, tradition and
habit—and food habits usually are changed very slowly. In addition to ignorance,
prejudice, and poverty, however, agricultural practices and economic policies also
play their part in the total picture of malnutrition. World leaders are beginning
to realize that people are rationed by economic status and agricultural practices
as well as by an understanding of their needs. Food intakes often reflect external
circumstances rather than the fundamental needs and some of these external cir-
cumstances are man-made and can be man-controlled.
There are good indications that the unfortunate delay in attempting to con-
trol some of these man-made external circumstances following World War I
will not be repeated. At the United Nations Conference on Food and Agriculture,
held in Hot Springs, Virginia, May 18 to June 3, 1943, forty-four nations agreed
to work together to secure a lasting peace through freedom from want. In the
records of this conference® the bearing of nutrition on human health was well
stated in four short sentences:
1. The kind of diet which man requires for health has been established.
Investigations in many parts of the world have shown that the diets consumed by the
greater part of mankind are nutritionally unsatisfactory.

3. Diets which do not conform with the principles of satisfactory nutrition lead to im-
paired physical development, ill health and untimely death.

4. Through diet a new level of health can be attained, enabling mankind to develop
inherited capacities to the fullest extent.t

In planning the United Nations Organization one of the carliest considera-
tions was the establishment of the Food and Agriculture Organization as one of
the specialized active agencies of the United Nations. The meeting of the Prepara-
tory Commission held in Washington from October 28, 1946 to January 24, 1947
was attended by representatives of seventeen nations: Australia, Belgium, Brazil,
Canada, China, Cuba, Czechoslovakia, Denmark, Egypt, France, India, Nether-
lands, Philippine Republic, Poland, United Kingdom and the United States of
America, with Siam as a member in discussions concerning rice. Rusisa and Argen-

*Jameson, W.: The Place of Nutrition in a Public Health Program, Am. J. Pub. Health
37:1371, Nov. 1947.

fConsumption Levels and Requirements, United Nations Conference on Food and Agri-
culture, Final Act and Section Report, Appendix 1, Report of Section 1.
PUBLIC HEALTH NUTRITION 497

tina were invited to send representatives; the latter sent observers. Other inter-
national organizations represented included the International Bank for Recon-
struction and Development, the International Labor Office, the International
Monetary Fund, the United Nations Economic and Social Council, and the World
Health Organization.

The Food and Agriculture Organization recognized the following challenges:

I. How to expand the total food production of the world.

2. How to increase buying power so people who are now poor and underfed
can buy the additional foods they need to maintain health.

3. How to improve distribution between nations, so farm prices will be
stable, and so starvation and surpluses will not exist side by side.

The organization feels that responsibility rests with national governments
and that the functions of the international organizations might consist of research,
supplying information and consultation, encouraging cooperation, and assistance
in making farming more efficient with the result that many farm workers in the
less-developed nations might transfer to small industries. It also hopes to play a
part in the stabilization of agricultural prices as a step toward reaching a balance
between production and consumption. A conference such as this would not have
been held even twenty-five years ago because it has been only within recent years
that the realization of the relation of nutrition to the health, peace, and happi-
ness of the world has been recognized. Seventy-one member governments are
now members of the Food and Agriculture Organization and representatives of
these government meet annually to review the world situation in food and agri-
culture, forestry and fishery, to discuss common problems and to agree on common
action. Representatives of eighteen governments comprise a smaller council and
act between the annual sessions on the decisions made by the Conference.

What of the future of these international efforts? The possibilities were
well expressed by Sir John Boyd Orr? while he was Director-General of the FAO:

I feel confident that both the highly industralized countries and the under-developed
countries will realize that cooperation in making this new machinery work is in their own
interests . . . and that they will cooperate wholeheartedly . . . . In that case, we can
look ahead to a happier future in which there will be food for the people, prosperity for
agriculture, and an expansion of world trade, all of which are absolutely essential for a
permanent peace. *

Recent Trends in the United States. To list the factors which decide the
nature of the diet of an individual or of a community or nation would seem to be
a formidable enterprise. They may however be placed within a relatively few
categories. Adapting from Margaret Mead,'° they might be said to depend on
six types of influences: (1) physiologic needs, (2) social organization, (8) ad-
vances in food technology, (4) economic resources and cost, (5) attributes of
food, and (6) psychological attitudes.

Physiological needs are affected by at least two types of desires; the wish to
avoid the discomfort of hunger and the desire for health and vigor. For most

*Orr, J. B.: Nutrition and Human Welfare. Nutrition Abstracts and Reviews 11:3, Julv
1941.
498 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

people, the former is probably the factor of predominant concern. The extent to
which the feeling of hunger is produced varies to a considerable degree with the
energy expenditure, which is influenced by hundreds of such diverse factors as
the extent of industrial and agricultural mechanization, indoor and outdoor tem-
peratures, recreation, and methods of earning a living.

Recent changes in our social organization have had far-reaching effects on
our national food habits. It is conceivable that the process of “Americanization”
involving the intermarriage of many nationalities results in considerable inter-
change of dietary customs, ideas and habits. Increased travel enables individuals
to experience many new types of foods and cooking. Of course, the one social
change which has had the most far-reaching effect has been the shift of our civil-
ization from rural, agrarian way of life to an industrialized, urban existence. This
has resulted in a considerable shift away not only from the production of food at
home but also from eating at home with the development of school lunches,
the workingman’s lunch box, restaurants, cafes, drug store lunch counters, and
drive-ins. Eating at home often tends to promote an habitual and limited choice
of food whereas eating in groups outside causes a trend toward greater variety,
interest, and choice. However, it must be remembered that steam tables often
provide food of impaired vitamin content.

Many of the food problems caused by our urbanization have eventually been
met to an amazing degree by developments in the field of food technology
which have played a dominant role in recent changes in our food habits. Rolling
daily on our railroads are thousands ofl refrigerator cars, possibly one of our
civilization’s most significant inventions. More recently, the building of good
highways has made possible the use of fleets of food trucks and milk tank cars.
Canning, dehydration, and quick freezing have produced great changes in our
dietary lives. Now, only the smallest communities lack frozen food lockers and
supermarkets. These and many other developments have made commonplace
types of foods which only a short time ago were seasonable, rare, expensive, or
exotic. Today's citizen of Middletown may have milk from Illinois, cereal from
the Dakotas, oranges from Florida, avocados from California, pineapples from
Hawaii, celery from Michigan, eggs from New Jersey.

Of course the mere desire for food and its availability do not necessarily
ensure procurement. After all, food is a commodity and can be had only for a
price. It is logical therefore that those economically handicapped simply cannot
afford any but the simplest and cheapest food habits. Furthermore, they cannot
afford the auxiliary factors influencing dietary development such as education,
travel, and the like. As a result, large numbers of our low-income population
suffer from marginal or frank deficiency diseases, often in the face ol food surplus.
For the rural family in these circumstances much good has been done by the
Agricultural Extension Services in promoting vegetable gardens in addition to
cash crops, home canning and other methods of food preservation, the construc-
tion of food cellars, and instruction in soil care and crop planning.

For urban populations with low incomes the problem has been more difficult.
The school lunch program presented in its inception an attempt to supplement
the diets of children of this group of the population but spread to become a
PUBLIC HEALTH NUTRITION 499

 

 

means of providing a noon lunch for all children who could not conveniently go
home. During the depression of the early 30s the Federal government set up the
Federal Surplus Relief Corporation, later reorganized as the Federal Surplus Com-
modities Corporation which working with other agencies provided food for school
lunches and other programs. In 1939, an unprecedented program was started by
the Department of Agriculture for supplying low-income families and those on
relief with foods at public expense. One of the interesting points on this program
was that the foods, which consisted of surpluses, were distributed not by a govern-
ment agency but by grocers. Known as the Food-Stamp Plan, a form of scrip was
printed and distributed to low-income and relief families who could use it at
markets of their choice, and, within certain limits, for the foods of their choice.
The grocer could subsequently turn his accumulated stamps in to the Federal
agency for reimbursement. The Federal Surplus Commodities Corporation actu-
ally served as a food-purchasing agent, bidding for surplus foods and then ar-
ranging for distribution and packaging. Throughout, however, supplies flowed
through the regular channels of trade. The plan as a whole was quite successful
in that it satisfied private enterprise and at the same time allowed the recipient
of the food to enjoy more nearly the status of the independent purchaser. The
magnitude of the program is evident from the total sum of 235 million dollars
made available by Congress for the removal of agricultural surpluses in 1940 and
1941. Considerable conscious and subconscious nutritional and dietary education
resulted from the plan, and it had a definite and considerable effect on the eating
habits of a large fraction of the nation’s population.

With regard to the physical attributes of foods and psychological attitudes
toward them, it is obvious that different foods have different characteristics
which may tend to make them pleasant or unpleasant, desirable or undesirable,
practical or impractical to the individual. Among these are flavor, odor, texture,
color, form, temperature, nutritive value, cleanliness, and durability. It would be
a rare person indeed who could honestly deny having some food habits based
on such factors. This, of course, is closely interrelated to the question of psycho-
logical attitudes toward food. Some foods are shunned for fear that they might be
fattening, poor mixers, or what not. Some foods are identified with low social or
economic status (example: corned beel and cabbage) others, with affluence (ex-
ample: lobster). Certain foods are symbols of hospitality, for example, wines, and
in some circles, ice cream. Of common knowledge is the relationship between
certain foods and religion. It is not without significance that every known religion
has rules relating to some foods.

Because of some and in spite of other factors influencing dietary habits and
customs, some rather remarkable changes have taken place in the types and
amounts of foods consumed by the American public during the past quarter of
a century and particularly during the war years.!! The most outstanding changes
have been steady increases in the consumption of dairy products, citrus fruits and
juices, and leafy, green and yellow vegetables. Steady downward trends occurred
in the consumption of potatoes, grain products, and some fruits.

Such changes in food consumption have naturally had an effect on the in-
take of the various specific nutrients. Surprisingly enough, the number of calories
500 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

has remained more or less constant, except for a short drop during and after
World War I and during 1935, a year of both economic depression and drought.
While the use of potatoes and cereals has declined, the increase in fats, oils, and
sugar has made up the otherwise lost calories. Per capita intake of protein de-
creased steadily from 1909 to 1933. It increased sharply in 1934 because the
drought in that year necessitated slaughtering of many animals for lack of pasture
and feed. As a result the amount of protein available in 1935 was the lowest for
the entire period 1909 to 1945. Since then the figure has increased until now it is
equal to the 1909 figure. The recent increase, however, is due in part to increased
consumption of milk and eggs as well as the return to normal of the use of meat,
poultry, and fish.

The greatly increased use of dairy products has resulted in marked increases
in calcium and riboflavin. The bread and flour enrichment program also con-
tributed to the riboflavin increase as it did to the increase in thiamine, niacin,
and iron. The latter decreased with the decrease in consumption of meats and
grain products. Some return was occurring however with recent increases in meat
consumption when the enrichment program went into effect causing an increase
of 15 per cent. With the greatly increased use of lealy, green, and yellow veg-
etables, a marked increase in the amount of vitamin A available has taken place.
A similar change in the amount of ascorbic acid has resulted from the increased
consumption of tomatoes and citrus fruits.

Taken as a whole, while the situation preceding the Second World War
tended to be somewhat unfavorable, the changes in the food habits of the Amer-
ican public in the more recent past seem definitely encouraging with significant in-
creases in most of the essential nutrients, coupled with a continuing avoidance
of “excess baggage,” partly based on increased appreciation of the relationship
between obesity and cardiac ailments.

Relation of Nutrition to Selected Health Problems. In perhaps no phase of
the public health program is nutrition more important than in the maternal and
infant health activities. Although the relationship of the nutrition of the ex-
pectant mother to the nutrition and health of her fetus seems self-evident, it is
only recently that sound, scientific prool has been forthcoming. Prominent among
the workers whose studies have stimulated great interest in this field are Ebbs,
Tisdall, and Scott’? at the University of Toronto; Burke, Stuart, and their co-
workers!® at Harvard; and Warkany'* at the University of Cincinnati. Studies
have now been reported from many countries and from many laboratories within
this country, the results of which all point in one direction. Mothers who are well
nourished protect their health and the health of their babies; mothers who are not
well nourished jeopardize their own physical well-being and give birth to infants
not adequately equipped to withstand the trauma ol extra-uterine life. In addi-
tion, a greater proportion of the miscarriages and stillbirths have been reported
in the poorly nourished mothers. Reports further indicate that while both the
fetus and the mother may be affected by the mother’s poor nutritional status, the
fetus tends to suffer the most. It is also recognized that only to a limited extent is
the fetus a parasite and that extent is limited apparently by the mother’s nutri-
tional state. If the findings reported in several studies applied to all women in
PUBLIC HEALTH NUTRITION 501

this country, as they well may, better nutrition of all pregnant American women
would result in over one million American babies each year starting their lives
at a higher level of health.

Many questions remain to be answered. For example, does inadequate
nutrition on the part of the mother play a role in the development of con-
genital anomalies? Can a woman poorly nourished all of her life compensate
for long-term poor nutrition by consuming adequate food during the period
of pregnancy? What are the added risks for the woman who, at conception, is
malnourished? In spite of the fact that research groups have not yet been able
to unravel all of the confusion out of this important aspect of preventive medi-
cine, we have adequate knowledge of the relation of nutrition to the health
of both the mother and the baby to use all resources at hand to encourage the
best state of nutrition possible in all pregnant women. Furthermore, we realize
that good nutrition throughout the entire life span is essential if optimal nutri-
tion is desired in the offspring. Nutritional status, good or bad, cannot be turned
on and off like a faucet. Adequate nutrition during pregnancy requires adequate
nutrition before pregnancy, during lactation, and on throughout life.

How then should the pregnant woman’s diet be managed? The circumstances
of the problem place the responsibility squarely in the hands of the practicing
physician to whom she goes for care. Her diet should be neither ignored nor
considered merely in terms of a table of standards. Each woman is an individual
and should be treated as such and the physician is neglecting a duty to his
patient if he fails to study her dietary problems as carefully as he checks her
blood pressure. Public health nurses and nutritionists can assist the physician
by further interpreting the nutritional needs of pregnancy and lactation to
women individually or in mothers’ classes.!

Once the woman has delivered herself of her child, it has certain nutritional
requirements and dietary problems peculiar to its early age. Many factors are
involved including its lack of teeth, limited digestive powers, enormous needs
for growth, and its need to acquire a taste for foods of a variety of flavors and
textures. The mother also has nutritional needs peculiar to her own recovery
from the physiologic strain of pregnancy and to the production of adequate
breast milk for the feeding of her infant. The advantages of breast feeding are
many and will not be recounted here, except to make passing reference to
one which is related to mental health. Suffice it to say that food habits, good
or bad, are established very early and the security, comfort, and ideal food that
breast feeding affords start the infant out with mealtime being a psychologically
as well as physiologically satisfying experience.

The school health program is perhaps the activity to which nutrition is
next most closely allied. Its relationship here is threefold: (1) the assurance
of a satisfactory midday meal while the child is away from home, (2) the im-
parting of sound nutritional information, and (8) growing out of the proper
integration of the first two, the development of desirable nutritional habits.

Major obstacles to the inclusion of more nutrition education in school
curriculums would appear to be the lack of understanding of educational con.
cepts on the part of the nutrition specialists and the lack of workable information
502 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

about nutrition on the part of the teachers. In the past, teachers’ colleges have
not provided their students with an adequate background in health, and nutri-
tion has been particularly neglected. Consequently, graduate inservice nutrition
education is now being given in many states. The training is offered by one
or several agencies or institutions employing personnel who are experienced in
both the field of education and the field of nutrition. Among the groups assisting
with such training programs are county, city, and state health departments;
colleges and universities, particularly those engaged in training home economics
teachers; the American Red Cross and government agencies such as the Agri-
cultural Extension Service.

Graded programs in nutrition are now receiving increased attention and
both commercial and academic groups as well as the official and nonofficial
agencies are making available helpful guides planned on graded levels. The
use of tools appropriate to the age and interest of all grade levels is an absolute
necessity in this as in all health fields. In the primary grades, the emphasis is
best placed on food, i.e., how it grows, how it tastes, etc. In the upper elementary
grades, simplified technical information is developed, such as the need of partic-
ular foods for growth. In the high schools, the scientific approach will hold the
student’s interest provided that his earlier nutrition education has given him
the information necessary for this more mature approach.

Nutrition education which can accompany a well-managed school lunch
program holds great potentialities, but these potentialities are far from realiza-
tion in many school “feeding” programs. Schools that feed but do not teach
are falling short of one of the aims of providing a lunch at school. Through
the school lunch children have an opportunity to become acquainted with
foods not familiar to them and simultaneously to learn good patterns of eating
by practicing them throughout their school years at the noon meal, at least.
The school lunch program should be a part of the broad health program for all
children in a school.

The passage in June 1946 of the National School Lunch Act has provided
a more permanent basis to Federal aid for school lunches. There has been steady
progress in the School Lunch Program with the number of children served in-
creasing at the rate of about 10 per cent per year. Thus participation has in-
creased from about 6 million children in 1947 to 9,400,000 in 1952.16 During the
school year 1953-1954, a total of over 10 million children in 56,000 schools bene-
fited. Most of the food used in the program is purchased locally. Of particular
significance is the fact that while Federal contributions in cash and commodities
have remained constant, support from state and local governmental sources and
from parents’ payments has almost doubled since 1947.

Related to the foregoing is a special program to increase milk consumption
by children in high school grades and under, which was in effect for the 1954-
1955 and 1955-1956 school years. This school milk program was authorized by
the Agricultural Act of 1954. Section 204 (b) of that Act provides that, “Be-
ginning September 1, 1954 and ending June 30, 1956, not to exceed $50,000,000
annually of funds of the Commodity Credit Corporation shall be used to in-
crease consumption of fluid milk by children in non-profit schools of high school
PUBLIC HEALTH NUTRITION 503
grade and under.” The funds made available for this program will be used
to make payments to schools in connection with the cost of additional milk
served to children.

Although the school lunch program is generally considered to be a joint
affair between Federal, state, and local authorities, it is of greatest importance
that the principal, teachers, parents, and school lunch managers be interested
in and understand the program. On a Federal level, information regarding the
establishment and management of the program and the use of “surplus” foods
is available through the United States Department of Agriculture. On a state
level, inquiry can be made through the state health department and through
the state department of education. On a local level, health departments and
school authorities can obtain all necessary information for the technical infor-
mation necessary to the establishment and management of a school lunch pro-
gram. However, the technique of serving food is not enough; the art of in-
corporating nutrition education into the entire curriculum so that the feeding
experience is really a laboratory demonstration is essential if the aim of develop-
ing good food habits in children not only for the school year but for life is to be
reached. Todhunter'™ has aptly described some goals which must be attained
if the school lunch is to contribute to the nutritional well-being of the child.

(a) Educators and school administrators must understand the importance of nutrition
for school children and recognize the value of the school lunch in nutrition
education.

(b) The school lunch must be a part of the total school program. Teachers need to
have training which will provide sufficient background in nutrition to be able
to give children adequate guidance in food selection and the development of de-
sirable food habits.

(c) The school lunch program must be managed by trained lunch managers, assisted
by employees who have been given adequate training for their specific jobs.

(d) The school lunch must be eaten by “trained” children—that is, children who are
learning about foods in relation to nutrition and health and who recognize the
school lunchroom as a laboratory for educational experiences.

(e) The school lunch program must run on a non-profit basis, financed in the same
way that other school services are financed. The sale of nonessential foods and
beverages at lunch times or at any other period of the school day should not be
permitted.

(fy) There must be further research and study of the nutritional needs of children,
of ways of developing new food habits, and of how to teach nutrition to boys
and girls so that they will put into practice what they are taught.

(g) Nutritionists, dietitians, public health workers, and health educators must be alert
to the significance of the school lunch as a contribution to the nutritional well-
being of the child and must direct their efforts to the fulfillment of such a program
as has been described. *

Nutrition education can and should be a part of the total school curriculum.
History, for example, cannot be adequately taught without some emphasis of
the part that food, or the lack of it, has played in the major developments
and tragedies of the world. Many factors such as religion, emotions, agricultural

*Todhunter, E. N.: Child Feeding Problems and the School Lunch Program, J. Am. Dietet.
A. 24:422, May 1948.
 

practice, and income must all be considered in the study of racial and individual
food habits. Food habits are slowly developed. Once formed they are even more
slowly changed. Nutrition education and the true appreciation of the part that
food plays in the attainment of total health is slowly acquired. Consequently,
nutrition education and application cannot be limited to one class, one semester,
or one year at one ol the age levels il its true value is to be translated into
healthier, happier children and adults.

One of the greatest concerns with regard to an aging and an aged popu-
lation is nutrition. In many respects the former group is ol more importance
than the latter because there are many more people growing old than there
are those already infirm by virtue of age. Far more can be accomplished for
those who are aging than for those already advanced in years. Furthermore,
the circumstances of middle life determine in large part whether the subse-
quent advanced years will be healthy or infirm. If life is worth prolonging, it
is worth nurturing in a healthy condition rather than in a state ol chronic
illness and dependency. Man’s most productive years should be during the
fourth to the sixth decades, yet it is here that incapacitating chronic illness
strikes so often. Arteriosclerosis, hypertension, arthritis, diabetes mellitus, de-
generative conditions of the kidneys and liver, cancer, and various other dis-
orders increasingly are becoming dominant challenges to the public health
and medical professions. These are all conditions of as yet somewhat uncertain
etiology. However, it is known that the way ofl lie has much to do with the
development of all of them and considerable research indicates a [requent direct
or indirect relationship with nutrition.

Certain facts about the older population should be borne in mind. In gen-
eral, they tend toward a more sedentary type of existence involving less physical
activity. A larger percentage of their time is spent indoors where the temperature
is warm. The period of tissue and organ development is largely past and certain
changes in food habits have been enforced by virtue of impaired dental func-
tion, elimination difficulties, and various physiologic changes. One of the most
common results is the acquisition of excess weight. One thing that is certain
is the effect of overweight and obesity on life expectancy. From middle age
onward there is almost a direct line relationship—the age specific death rates
are increased roughly 10 per cent for each ten pounds of excess weight. Thus
an excess of twenty-five pounds will lessen life expectancy by 25 per cent. The
exact reasons for this are not entirely clear because the premature deaths are
not all just due to cardiac failure from carrying an overload. For example, the
incidence of diabetes mellitus is two and one-half times as great, and cardiovas-
cular-renal disease one and one-half times as great in the obese as in those of
average age.!819 Sebrell?® has pointed out:

.. . As we pass through the middle years, the percentage of body fat usually rises,
though the overall weight may remain the same. Thus, among groups of standard weight,

fat may comprise only 10 per cent of the body weight in younger men, as compared

with 21 per cent in older ones. The prevalence of obesity increases to about age 40 for

men and 50 for women, and declines after age 60. This decline is due not only to loss of

fat, but also to the loss of fat people.
The fact that obesity is correlated with aging and chronic disease does not in itself
PUBLIC HEALTH NUTRITION 505

 

imply a causal relation. Unknown etiological factors may be common to these conditions.
In various studies, however, caloric restriction has prevented cancer in mice, prolonged
greatly the life of rats, and reduced the signs of diabetes in humans. Moreover, striking
decreases in the incidence and severity of diabetes and hypertension accompanied under-
nutrition and loss of weight in certain European countries during both World Wars. *

In the final analysis, all obesity results from overeating in relation to one’s
physiologic and environmental needs. The second of these factors has tended
to be overlooked, indicating the importance of obtaining assistance from workers
in several other fields in the development and conduct of obesity control pro-
grams. Sometimes, for example, excessive eating is an expression of disturbed
emotional balance, as Waife?! puts it, a substitute for some lack in the pattern
of living, as the vicarious satisfaction for emotional starvation. The possible
psychological roots of excessive eating are many. “Paucity of companionship,
love, and affection, dearth of opportunities for expression of personality, meager
sources of pleasure, and sensuous gratification are some of the factors. Fear of
economic insecurity, frustration from undesired social position, shame for in-
adequate capabilities, and shyness are often compensated by overeating.” The
discovery and solution of these causative problems may be more successful if
the services of psychiatrists, psychologists, and social anthropologists are incor-
porated in certain phases of the public health nutritional activities.

In contrast with obesity in the middle and advanced years is the problem
of underweight and excessive leanness due to caloric restriction. The reasons
for this may be impaired dental function, allergic difficulties, disinterest in eat-
ing because of living alone or, as in many instances of overeating, for emotional
reasons such as anorexia nervosa. When this occurs there is not only lessened
resistance to tuberculosis and to various acute infections but there may also
result serious disability from ocular, vasomotor, endocrine, and skeletal changes.
In addition, there is the risk of mild to full-blown avitaminoses, particularly
pellagra, beriberi and scurvy. These in turn may aggravate further the underly-
ing causes by bringing about additional oral or psychic conditions.??

Although all concerned agree that much is still to be learned about the
relationships between nutrition, chronic diseases, and the aging process, there is
ample justification, if not urgency, for public health agencies to use in their
planning and to disseminate among the public the very considerable knowl-
edge which is available and also to stimulate motivational research. In addition
there is a need, as Keys? suggests, to protect the public [rom nutritional nostrums:
“Part of the problem of providing nutritional help for older persons consists
in countering the claims of the food faddists, the purveyors of special nostrums
offered for nutritional purposes, and the writers who find a ready sale for
books and articles promising miracles from peculiar diets. The older person
who observes deteriorative changes in himself is especially vulnerable; the greater
the loss of the sense ol well-being, the stronger is the urge to believe any promise

ra

of help.”

*Sebrell, W. H.: Potentialities in Chronic Disease, Pub. Health Rep. 68:737, Aug. 1953.
Keys, Ancel: Nutrition for the Later Years of Life, Pub. Health Rep. 67:484, May 1952.
506 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

In the field of oral hygiene and public health dentistry, good nutrition
practices play a primary role. Conversely, there is much that the dental worker
can do to promote healthier food habits.2* It begins with the diet of the ex-
pectant mother and continues with the nature of the feedings and the subsequent
more substantial diet of the infant. Also, the relationship between dietary in-
adequacies and the development of pathologic conditions of the gingivae may
be mentioned. As Massler?> emphasizes, “The physical character of the food is
not a nutritional factor but it is an important dietary consideration. The natural
cleansing action of the food is an important adjunct to good oral hygiene. The
detergent action of the food must supplement the toothbrush in preventing the
accumulation of food debris, with subsequent caries and local gingivitis. Since
relatively few individuals use the toothbrush correctly or effectively, the physi-
cal character of the food is an important consideration in planning a well-
balanced diet.” *

A further consideration of considerable consequence is the effect which a
diet high in carbohydrates, especially free sugars, has on the growth of lactobacilli
in dental plaques with resulting carious breakdown of the enamel and other
tooth substance.2¢ Certainly here is a fruitful area in the realm of public health
nutrition for the partial solution of a difficult problem of extensive magnitude.

The Place of Nutrition in the Public Health Program. Nutrition should
be considered an important activity of a health department because good nutri-
tion is a prerequisite of good health and because good health is necessary for
the full realization of useful, enjoyable lives. When we speak of good health
and nutrition, we should not mean just adequate health and nutrition, but
rather those qualities plus a reserve. That is, health and nutrition might be
thought of in three gradations: negative, borderline (or just adequate), and
positive. It is for the latter that we must strive.

From what point of view should a department of public health be con-
cerned with problems of nutrition? It should not be in terms of dispensing foods
or nutritive concentrates to the undernourished and needy because that con-
stitutes a part of public welfare. Nor should it be in terms of studying and
examining individuals as such and rendering therapeutic assistance because
that represents part of the private practice of medicine. Rather, ideally as with
all other problems, the health departments approach to nutrition should be
all-embracing, viewing the people as a whole and not as individuals. This ap-
plies to both investigative and remedial activities.

Because of shortages of funds and especially because ol insufficient numbers
ol adequately trained personnel, relatively few local health departments, except
those in large urban centers, have special or distinct programs of public health
nutrition. Many other reasons exist to indicate the desirability of operating the
public health nutrition programs on the state level. Many states have state
nutrition committees which may serve as nuclei around which to build the
program. Some of the most intimately related agencies such as the Agricultural
Extension Programs are organized on the state level. Many, if not most of the

*Massler, M.: Nutrition and the Oral Tissues, Am. J. Pub. Health 35:926, Sept. 1945.
problems involved, are state-wide rather than county-wide. Finally, as will be
seen, the type of program visualized would involve local contacts by the accepted
local public health personnel rather than by the nutrition staff whose function
would be most efficient and fruitful in an advisory and consultative capacity.
Because of this, it would appear most practical to limit attention essentially
to programs carried out on the state level, which after all exist in large part
to assist and support the efforts of local health personnel.

The first states to employ nutritionists were Massachusetts and New York
in 1917, and they have maintained continuous service ever since. At first their
activities were merely those of specialized educators working essentially with
the schools. Gradually they expanded their interests to include work with tuber-
culosis clinics, community education, and staff education. Largely as a result of
Federal funds made available under the Maternity and Infancy Act (Sheppard-
Towner Act), Illinois, Michigan, Mississippi, and Connecticut began nutrition
services. Because of the source of Federal funds, the Children’s Bureau, these
activities were all placed in the respective state divisions of maternal and child
hygiene. In 1929 the law was repealed and because of the economic depression,
only Connecticut, along with Massachusetts and New York, continued the activi-
ties. In 1935, the passage of the Social Security Act enabled the Children’s
Bureau, and through it, the states, to pick up where they left off. Soon afterward,
the war, with its attendant food shortages and rationing plus the disturbing
results of draft examinations, made the public and health officials more nutrition-
conscious than ever before in history. As a result, by 1948, fifty out of fifty-three
state and territorial official health agencies were budgeting funds for the em-
ployment of one hundred seventy nutritionists. At first, most of the nutrition
services were financed by outside funds. Thus, in 1945 and 1946, 63 per cent
came from the Children’s Bureau, 9 per cent from the Public Health Service,
and only 28 per cent from the states.”” Since then, state and local health de-
partments have increasingly assumed the responsibility for these activities.

Organization and Functions of State Nutrition Program. Up to the present
there has been much difference of opinion concerning the manner in which a
nutrition program should fit into the structure of a state health department. In
some states it has been organized as a separate division or as a staff agency
directly responsible to the commissioner. In others it has been placed in divisions
ol medical services, public health nursing, and local health services. Most com-
monly it has been allocated to the bureau or division of maternal and child
health. Undoubtedly this has come about as a result of the noteworthy pioneering
of the United States Children’s Bureau, and a suggestion for a different arrange-
ment should not be construed as an attempt to detract from the credit due its
far-sighted leadership. Rather, it is felt that public health activity in the field
ol nutrition is of such importance as to justify its inclusion as a more fundamental
activity of wider scope rather than to risk the possibility of its benefits becoming
limited to one or two groups in society, in this case children and expectant
mothers.

While each state must of necessity organize its program with consideration
to its peculiar problems, facilities, and organizational history, it is believed that
508 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

the most logical place for the state nutrition program, in most instances, is in the
division of local health services. As will be seen from what follows, the out-
standing function of the state health department in nutrition, as in most
other fields, is to provide leadership, guidance, consultation, and advice to those
working on the local level where the public is ultimately found. The tested
pattern is the result of accomplishing these aims by means of channeling the
services of the state specialists through a division of local health services. This
administrative technique has proved itself to make for economy, efficiency, and
coordination from the viewpoints of both the state and local staffs.

The nutrition program should be under the direction of an individual who
is immediately responsible to the director of local health services. The ideal
qualifications of the director of nutrition should include a medical education
with special clinical experience in nutritional diseases, a basic background in
biochemistry, and training and experience in public health. The obvious diffi-
culty in obtaining such a person can be solved to some extent by careful choice
of the personnel who will carry out the detailed activities of the program under
his direction. The most important qualifications are the medical and public
health backgrounds, which will enable the director of nutrition to give the
necessary medical guidance and to integrate the program into the other activities
of the health department. The program should be so organized as to carry out
a double purpose: first, because of the everpresent need and the unusual present
demand for education and promotion in the field of nutrition, a service pro-
gram should be organized; second, since it behooves all progressive health de-
partments to assume some responsibility for evaluation and the advancement
of knowledge, especially as it relates to potential public health practice, a re-
search program is advisable.

In order to carry out any corrective and promotive program on a sound
basis, it is desirable, if possible, to determine at the outset the type and extent
of existing problems and to furnish a base line from which to appraise any
changes that might be due to subsequent activities on the one hand or economic
and biologic influences on the other. It is necessary therefore that everything
possibly related to the state of nutrition of the people in the area be carefully
considered and studied. The nutrition staff should accumulate and appraise
data about groups of individuals or regions of the state which might be of value
in the service program. This involves (1) a study of the material and economic
resources of the community or state, i.e., types and amounts of foods produced,
exported, retained, imported, (2) a study of food production potentialities, (3)
a study of food preparation customs, (4) a study of actual food consumption pat-
terns, (5) a study of the nutritional status of the population, including an ap-
praisal of the incidence, distribution, and types of deficiency diseases.

Depending on the amount of funds and personnel available, the latter
activity may vary considerably from a mere study of reports of illness and death
to the carrying out of extensive surveys on representative groups of the popula-
tion.

Within the past decade, the survey method of approach has been applied
to the field of nutrition in an attempt to evaluate existing nutritional states
PUBLIC HEALTH NUTRITION 509

 

of populations. The procedure which has been developed is a trifold approach,
using clinical examinations and histories, dietary analyses and/or food invento-
ries, and various laboratory tests which have been developed. Admittedly, all
of these procedures are subject to considerable variation and error due to the
influence of the personal factor in clinical examinations and the listing of
food intake, the difficulty of measuring food accurately, the variables intro-
duced by various types of cooking, and the fact that many of the laboratory
tests are still in the developmental stage. Nevertheless, by recognizing these
drawbacks and by reasonable applications of the results, the survey method
can be useful in indicating outstanding problems in any given area. These
procedures are admittedly too costly for many state health departments at this
time. However, in some areas they have been carried on as a cooperative enter-
prise of the health department and the departments of home economics, bio-
chemistry, and medicine of progressive universities.

It was previously stated that a health department’s service activities in nutri-
tion should not be of the nature of dispensing public welfare. If not, then what
remedial measures can be taken? They can take the form of ever-increasing
education, by showing the people what is wrong, by teaching them why it is
wrong, and finally by assisting them in their efforts to overcome the problems
themselves. To accomplish this end sometimes involves the breakdown of almost
traditionally faulty diet habits and the translation of scientific diet analysis
and planning into readily understandable and usable layman’s terms. As one
writer aptly put it, the facts of good nutrition must be made part of the local
folklore.

A change in the mores of a people, especially as related to such a self-preserv-
ing function as nourishment, is usually accomplished slowly and with consid-
erable difficulty. In the process we must deal with deeply ingrained racial,
regional, and familial customs and with prejudices, prides, jealousies, and even
superstitions and fears. To tell individuals and communities what is wrong
and what remedies are needed is not enough. The more subtle, the more fruitful,
the more enduring approach is one which maneuvers community thought into
the position of itself recognizing the needs and the remedies at hand. In essence,
we must show communities and families how they can help themselves.

How may this be done? In most communities in the United States there
already exist many agencies and individuals not only interested in but actually
already engaged in the promotion of better nutrition. State and local depart-
ments of education, welfare, and health, home demonstration agents, county
farm agents, the state agricultural extension services, the Farm Security Adminis-
tration, the Federal Departments of Agriculture and Labor, the American Red
Cross, home economics teachers, community garden, canning, and lunchroom
projects and many more are already in the front lines of activity. Working
separately, there results not only some duplication of effort, but also failure to
recognize the existence of some problems which are perhaps of too great a magni-
tude for any one agency, but not for the concerted effort of the whole group.
The development of intelligent cooperation and initiative among all these groups
through health department leadership, then, is one function of a public health
510 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

nutrition service. In other words, much of the function of the health department
is that of a coordinator and catalyst for existing community resources.

Beyond this, consultative service should be offered by well-qualified nutri-
tionists to the various persons and agencies mentioned, the end in view being
to demonstrate how nutrition education can be injected into daily routine with-
out adding appreciably to the daily burden.

These phases of the work should be under the immediate supervision of
a well-trained, experienced, and personable nutritionist with a knowledge of
the state and its governmental and voluntary agencies. Working under her direc-
tion should be a number of regional consulting nutritionists and possibly one
or more institutional nutritionists with a special background in institutional
dietetics. The state should be divided into regions roughly comparable in size,
number of counties, population, inclusion of large cities, industries, etc. It
is to be suggested that, at first, activities be restricted to counties with full-time
public health services, since their existence will facilitate public acquaintance
and acceptance of the work of the nutritionist. The length of time to be spent
in each local area, the frequency of visits, and the particular type of activity
and approach should be worked out on the basis of cumulative experience in the
locality, by the regional nutritionist herself. In some places, frequent visits of
short duration or irregular visits of several weeks’ duration may be more success-
ful than regularly scheduled routine visits of one week.

At all times the nutritionist should keep in mind the actual and potential
contributions which local home economists, teachers, home demonstration agents,
and many others can make and should plan accordingly to promote the use of
their services wherever possible. She should remember that efforts on her part
to render direct service to the public will reach only a few, and that her real
contribution is to promote the use of local talent and facilities for nutritional
betterment by timely suggestions, correlation, and cooperation.

Legislation for Enrichment of Foods. One other type of activity in the
field of nutrition that should be mentioned concerns a more centralized and
forceful kind of activity. Referred to is the possibility of a community or of
a state attacking nutritional problems at their source, that is, the place of pro-
duction or distribution of a product. Perhaps the earliest example of this sort
was concerned with the addition of iodine in the form of sodium or potassium
iodide to public water supplies, chocolate, and more practically, to table salt.

During periods of war, animal foods become scarce because animals are
expensive to feed and to produce; cereal products are consumed in greater
quantities for they are the least expensive to produce in terms of acreage, man
hours, and cost. Consequently, it was apparent to the Food and Nutrition Board
of the National Research Council during the World War II period that cereals
as a major part of the nation’s diet must offer adequate nutrients.

On January 18, 1943, a government order known as War Food Order No. 1
went into effect. This order required that all white bread be enriched to meet
the requirements of the order in thiamine, niacin, riboflavin, and iron. It re-
mained in effect until October 18, 1946. By extending the practice of enrich-
ment to low-priced bread, this program brought its benefits to low-income groups
PUBLIC HEALTH NUTRITION 511

where the need was greatest. Since the War Food Order was an emergency meas-
ure, and in peacetime inapplicable to interstate situations, an increasing num-
ber of states have passed legislation for the continuance of a policy of enrich-
ment of all white flour and bread within their borders. By now, well over half
of the states have adopted flour and bread enrichment legislation.

Because corn is a staple food in the southern states and substantially replaces
white flour products, the Food and Nutrition Board recommends the enrich-
ment ol all corn products to the level of Federal standards in areas where the
consumption of corn is substantial? In some areas of the South, the enrich-
ment of corn products has met with remarkable success. For example, during
a period of about fifteen months the Alabama Extension Service persuaded over
four hundred fifty corn mills representing about 90 per cent of the State’s milling
industry to begin voluntary enrichment of corn meal. South Carolina inaugurated
its program in 1943, and the program has been continuously successful. In
March 1949, the South Carolina legislature strengthened the program by
amending the State’s degerminated corn products enrichment law, making it
mandatory to enrich all types of corn meal and grits sold for human consump-
tion. Georgia, Mississippi, and North Carolina also have corn enrichment laws.
In some areas, the corn enrichment program has been delayed principally be-
cause of the nature of the corn milling industry; some products are degerminated
while others are not, and a large proportion of both kinds is marketed ‘through
small mills.

The repeal, by some states, of legislation which imposes class or restrictive
taxation on margarine and the enactment of laws providing for its enrichment
by the addition of 15,000 units of vitamin A per pound are further examples
of centralized approach to the problem of ensuring adequate food, especially
to low-income groups. A particularly important step forward was made on
March 16, 1950 when the United States Congress enacted Public Law 459 which
repealed the Federal tax on margarine.

REFERENCES

1. Ule, O.: Food and the Development of Man (Translated from the German by J. Fitzgerald,
from Die Nature, 1851.) Pop. Sc. Month. 5:591, 1874.

2. Boudreau, F. G.: Nutrition in War and Peace, Milbank Mem. Fund Quart. 25:232, July 1947.

3. Boudreau, F. G.: Future Implications of the Nutritive Value of the American Wartime Diet,
Am. J. Pub. Health 85:243, March 1945.

4. King, C. G., and Salthe, O.: Developments in the Science of Nutrition During World War
II, Am. J. Pub. Health 36:879, Aug. 1946.

5. Boudreau, F. G., and Wilder, R. M.: The Food and Nutrition Board of the National Re-
search Council: A Review of Its Accomplishments and a Forecast of its Future, Federa-
tion Proc. 5:267, June 1946.

6. Magee, H. E.: Application of Nutrition to Public Health, Some Lessons From the War, Brit.
M. J. 1:475, March 1946.

7. Jameson, W.: The Place of Nutrition in a Public Health Program, Am. J. Pub. Health
37:1371, Nov. 1947.

8. Consumption Levels and Requirements, United Nations Conference on Food and Agriculture,
Final Act and Section Reports, Appendix 1, Report of Section 1.

9. Orr, J. B.: Nutrition and Human Welfare, Nutrition Abstr. & Rev. 11:3, July 1941.
512

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

10.
11.

12.

18.

19.

20.
21.
22.
23.
24.

25.
26.
27.
28.

29.

Mead, M.: The Factor of Food Habits, Ann. Am. Acad. Polit. & Social Sc. 225:136, Jan. 1943.

The Problems of Changing Food Habits, Report of Committee on Food Habits, Bull. No.
108, Washington, 1943, National Research Council.

Ebbs, J., Tisdall, F., and Scott, W.: The Influence of Prenatal Diet on the Mother and
Child, J. Nutrition 22:515, Nov. 1941.

Burke, B., Beal, V., Kirkwood, S., and Stuart, H.: Nutrition Studies During Pregnancy, Am.
J. Obst. & Gynec. 46:38, July 1943.

Warkany, J.: Manifestations of Prenatal Nutritional Deficiency; In Harris, R. S., and
Thimann, K. V. (editors): Vitamins and Hormones: Advances in Research and Ap-
plications, New York, 1945, Academic Press, Inc., vol. 3.

Lowenberg, M.: Coordinating Maternity Care: The Role of Nutrition, Am. J. Pub. Health
41:13, Nov. 1951.

. The National School Lunch Program, A Progress Report, Washington, 1952, U. S. Depart-

ment of Agriculture, Production, and Marketing Administration, PA-208.

. Todhunter, E. N.: Child Feeding Problems and the School Lunch Program, J. Am. Dietet.

A. 24:422, May 1948.

Vilter, R. W., and Thompson, C.: Nutrition and the Control of Chronic Disease, Pub. Health
Rep. 66:632, May 1951.

McCay, C.: Effect of Restricted Feeding Upon Aging and Chronic Diseases in Rats and Dogs,
Am. J. Pub. Health 37:521, May 1947.

Sebrell, W. H.: Potentialities in Chronic Disease, Pub. Health Rep. 68:737, Aug. 1953.

Waife, S.: The Pathogenesis of Obesity, Am. Pract. 2:47, Sept. 1947.

Editorial: Nutrition and Vital Resistance, Am. J. Pub. Health, 37:915, July 1947.

Keys, Ancel: Nutrition for the Later Years of Life, Pub. Health Rep. 67:484, May 1952.

Davis, W.: What Can the Dental Health Worker Teach Regarding Nutrition and Diet, Am.
J. Pub. Health 31:715, July 1941.

Massler, M.: Nutrition and the Oral Tissues, Am. J. Pub. Health 35:926, Sept. 1945.

Jay, Phillip: The Role of Sugar in the Etiology of Dental Caries, J.A.D.A. 27:393, March 1940.

Report to Food and Nutrition Board, National Research Council, Nutrition Programs in
State Health Departments, Pub. Health Rep. 65:417, March 1950.

Conference on Corn Enrichment, Clemson Agricultural College, Clemson, South Carolina,
July 14-15, 1947.

Editorial: Enrichment of Corn Products, J. A.M.A. 134:877, July 1947.
chapter 2 2

Public health dentistry

 

Magnitude of the Problem. Studies of incidence and prevalence of dental
ailments carried on during the past ten to fifteen years have placed problems
of dental health conclusively in a position of major importance with regard
to the national health needs. Fortunately, that same period of time has seen
the dramatic development of the field of preventive dentistry and of public
health dentistry, something which at the beginning ol that period could not
have been forecast. As recently as 1938 two ol the major contributors! to the
progress which has since been made stated: “Inasmuch as the etiology of dental
caries is unknown, prevention of the disease causing these defects is still in
the experimental stage. It is generally acknowledged, however, that the treat-
ment of early carious lesions by the proper placement of chemically and physically
stable filling materials will largely prevent carious teeth from terminating in
tooth loss, or tooth mortality. A primary purpose of dental health programs
becomes, therefore, the promulgation of procedures whereby the early detection
and treatment of carious teeth is accomplished, and tooth mortality thereby
prevented.”* Two years later, one of them?” frankly stated that “On the basis
of the considerations here discussed, preventive dentistry represents at the
present time perhaps more an objective than an accomplished fact.” Up to
that time, the public was most certainly aware ol their teeth and the ailments
to which they were subject. One cannot escape the impression, however, that
the general attitude was one of fatalism and complacent acceptance of the fact
that teeth were a necessary evil and that one necessarily had to expect increas-
ing difficulties with them as one became older. Fortunately, however, and in
the face of obvious difficulties of prime magnitude, that situation did not con-
tinue to hold true, so that it was possible [or Dr. Knutson? to explain at the
10th Anniversary Luncheon of the Dental Health Section of the American Public
Health Association in 1953, “I look back over the past ten years and conclude
that more has been accomplished during the decade than during the previous
fifty years.”

¥Knutson, J., and Klein, H.: Tooth Mortality in Elementary School Children, Pub. Health
Rep. 53:1021, June 24, 1938.

513
514 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

Three factors in particular contributed to the tremendous change in out-
look which has come about during this recent period. Perhaps the first which
should be given recognition is the generally consistently progressive attitude
of the dental profession as a whole in the United States, as exemplified by its
many searching inquires into means of prevention of dental ailments and methods
whereby dental care of good quality could be made available to larger numbers
of the people who need them. Secondly, there was the tremendous impact which
resulted from the drafting of a fourth of our dentists and particularly the shock-
ing results of the physical examinations of inductees. One of the most startling
findings was that of the first 2 million men examined for service in the armed
[orces, more were rejected because of dental defects than [or any other physical
reason; in fact, about one out of every twelve men examined was rejected on
this basis.* The third contributing factor to the progress of recent years is to
be [ound in the brilliant researches and studies which have been made by nu-
merous investigators and particularly by a small group of dental officers of the
United States Public Health Service. These inquiries into the incidence and
prevalence, dental physiology and pathology, the relationship of various dietary
factors and particularly sugars, and the climactic studies of the relationship of
fluorides to mottled enamel and the prevention ol caries, are certain to go down
in epidemiological history as classics.”

In order to appreciate fully the magnitude of the problem which has con-
fronted the dental profession and those concerned with public health dentistry,
it is necessary to consider the incidence and prevalence, the accumulated needs
and maintenance needs for the many types of dental services, which include
diagnosis, prophylaxis, fillings, extractions, treatment of soft tissue diseases, pros-
thetics, orthodontics, and special services such as oral surgery, correction of
congenital oral deformities, and radiation therapy. Overlying all of these, of
course, is the constant need lor dental health education.

It has been found® that the maintenance needs of the white adult popu-
lation of the United States is approximately 79 million fillings per year or
slightly over one filling per person per year. For children under 18, Klein and
Palmer? report a maintenance need of about one filling per year per child, or
an annual total of approximately 33 million fillings. However, as Klein® points
out, the white adult population receives less than one third of the fillings it
needs, and the white child population receives only about 7 million of the 33
million needed or one fifth of the annual maintenance needs. There results
therefore the more serious problem of accumulated needs which is estimated?
to amount to about 244 million fillings for white children between the ages of
6 to 18 years and about 285 million fillings for the white adult population.
It may be assumed that the approximate 10 per cent nonwhite population of the
United States with its generally lower economic income has at least the dental
needs of the white population.

The study of Walls, Lewis, and Dollar® estimates the accumulated needs
for extraction to be 2.25 per person, while Klein? suggests the figure of 2.8 per
person. Maintenance extraction needs varying from .15 to 43 per person per
year have been given by different authorities for various groups studied. If
PUBLIC HEALTH DENTISTRY 515

 

Klein's figure of .328 per person per year is accepted, about 25 million extrac-
tions are needed each year by adults in the United States.

Information with regard to the diseases of the soft tissues of the mouth
is very unsatisfactory. The Walls, Lewis, and Dollar study® found that of adults
coming to dental offices for care, 1.85 per cent had Vincent's infection, and 12.6
per cent had pyorrhea. Because of [requent inexact diagnosis of these conditions
and because they may frequently recur, the information is of little value. With
regard to the need for root canal therapy, the same surveyors arrived at a figure
of 3.35 per cent of adults coming on their own initiative for dental care. Data
with regard to malocclusion and the needs for orthodontia are similarly un-
satisfactory, but the available data indicates a great need with figures up to
50 per cent of school children in need of orthodontic treatment being claimed.

On the basis of a study by Collins!® maintenance figures for prothesis have
been computed by Klein to be .144 prothesis per person per year, or approxi-
mately 11 million per year for the adults of the United States. Little is known with
regard to the needs for special dental procedures such as the repair of congenital
defects of the oral cavity, dental or oral tumors, granulomas, and other miscel-
laneous conditions requiring dental sugery. One study in Pennsylvania has shown
that one in 800 children is born with a cleft of the lips or palate necessitating
plastic and dental surgery.1t

In order to find any of the conditions mentioned in the preceding dis-
cussion, it is necessary of course that the patient be examined and a diagnosis
made. This in itself represents a considerable proportion of the total dental
load. Those participating in the Institute on Dental Health Economics, held
at the University of Michigan in 1944, recommended that “to care for the ac-
cumulated needs of children from 2 to 18 years of age, one complete diagnosis
including radiographic examination is necessary. For a maintenance program,
periodic examinations of these children is needed every four months with com-
plete diagnostic studies as they are deemed necessary by the dentist. To care
for the accumulated needs of adults each individual needs a complete diagnosis;
for maintenance one re-examination is necessary every six months with complete
diagnosis at the discretion of the dentist.”* Beyond this, the same group expressed
the opinion that a complete dental health program should include at least
one dental prophlyaxis per year per person over two years of age.

Summarizing the tremendous dental needs just of the white population
between 20 to 65 years of age in the United States, Klein® found that each
100 persons in this group whose family incomes are at least $5,000 a year (in
1943) receives each year approximately 100 fillings, 30 extractions, 10 crowns
or bridges, 2 plates, and 40 prophylaxes. Generalizing from this, he stated: “On
the other hand, each 100 persons of the general adult population, i.e., of any
income class, although they need about as much service as the well-to-do now
get, have on the average per year only about 30 fillings, 40 extractions, 3 crowns
or bridges, 2 plates and 6 prophylaxes.” He concluded, therefore, that, “the

¥Institute on Dental Health Economics, Committee Reports, School of Public Health,
University of Michigan, July 1944, p. 3.
516 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

white adult population receives then each year: less than one-third of the
fillings needed, less than one-third of the crowns and bridges, about all the
plates, about one-seventh of the prophylaxes, and more extractions than would
have been required if service had been adequate in other respects.” Meanwhile,
“the children receive only about one-fifth of the fillings they need.” At that
time, he asked, “Should we attempt to take care of the mass of dental need
in the whole population by increasing our present dental manpower five-fold?
In terms of the estimates given above, nearly 260,000 fulltime dentists would
be needed to work with the 65,000 we now have under 65 years of age if the
problem of accumulations and this year’s crop of need were to be resolved within
one year. The training of that many dentists would require several generations.
Obviously such an increase at this time is not warranted.” *

This leads to the question of the size and distribution of the personnel
available to serve the dental needs ol the nation. The 1958 American Dental
Directory listed 100,937 dentists, in the fifty states, as of mid-1957. It is estimated
that about 87,000 practice clinical dentistry, 3,000 are in teaching, research, and
administration, and 7,850 are in the dental services ol the Federal government.!?
The 1950 census count of dentists was 75,025, an increase of 6.6 per cent over the
1940 count. However, in order properly to evaluate these figures, two addi-
tional factors should be considered. Since 1940 the population of the United
States increased about one third. In addition, due to improved average economic
status and more extensive health educational activities on the part of dentists
and health agencies, a much larger proportion of the population is now asking
for care. Thus, 25 years ago about 20 to 25 per cent of the population visited a
dentist during the year, whereas at the present time about 36 per cent does so.

Unfortunately, these dentists are not distributed evenly in relation to popu-
lation and need. Low ratios of dentist to population are found particularly in
the South, in rural counties, and in low-income areas. The Bureau of Economic
Research and Statistics of the American Dental Association in 1957 listed 237
counties in the United States with no dentists. One state had almost five times
as many persons per dentist as the state which was at the other extreme.

Trained dental hygienists and dental assistants have more than proved
their worth in recent years. Studies made by Klein's brought out that many
service hours can be gained and many more patients served through the ex-
pansion ol operating equipment and the use ol dental assistants. He found
that the added availability of a dental hygienist or a dental assistant increased
the patient load capacity per dentist 33 per cent. If a second chair were added
in addition to the assistant, the patient load capacity increased 62 per cent.
More recent studies by Knutson and others have substantiated this particularly
in relation to the care of children.

An extra dividend of this study was data and experience on the effective utilization
of dental assistants. It was found that a dentist can double his out-put with the help of
one fulltime and one halftime assistant. In addition, the dentist who uses assistants effec-
tively can give better service at less cost and with less fatigue. The study showed too that

*Klein, H.: Dental Needs Versus Dental Manpower, J.A.D.A. 31:263, Feb. 1944.
PUBLIC HEALTH DENTISTRY 517

 

once the children are on a maintenance level, one dentist with the help of trained chair-
side assistants can render service to approximately 1300 children annually. *

Despite the proved value of dental hygienists and dental assistants, we are
confronted again by grossly inadequate numbers available plus very few centers
which provide for their training. The 1954 report issued by the American
Dental Association on the Status of Dental Personnel in the United States indi-
cated that there were 8,506 dental hygienists registered by twenty-nine boards of
dental examiners in 1953. States not included in this count had relatively few
dental hygienists. The report indicated that the number of schools of dental hy-
giene had increased to 31 and that the number of graduates had increased from
431 in 1949 to 727 in 1953. All states now have laws lor licensing dental hygienists.

With their value proved so conclusively, it would certainly seem reasonable
to anticipate an expansion of the field of dental hygiene. Sixteen years ago Mc-
Call'6 visualized the dentist ol the future as a highly trained expert director of a
cooperative team which would include the dental hygienist who under his guid-
ance would place amalgam and other plastic fillings for children; a dental tech-
nician who would take impressions or insert and adjust dentures; and the dental
assistant. The dentist himself would be [ree to devote himself to diagnosis, pre-
scriptions for preventive dentistry, operative periodontic and orthodontic treat-
ment, crown and bridge work, and direction of auxiliary personnel.

To complete the background picture in order to consider the present and
plan for the future, a few words should be said about cost. Despite the fact that
facilities and personnel for dental care services are grossly inadequate and in-
sufficient, the American public is spending about one eighth of its health dollar
or more than a billion dollars a year for this purpose. In addition, the Veterans
Administration is paying 40 million dollars a year more to private dentists for
veterans’ service-connected dental benefits. This is in addition to dental care
given at veterans’ hospitals and clinics which are staffed by Federally-employed
dentists. With this as a base and if nothing were possible to decrease the incidence
of dental disease, it could be estimated with reason that from 3 to 5 billion
dollars a year would be necessary to serve the dental needs of the American popu-
lation each year. One other facet ol the cost picture should be mentioned. “In-
surance statistics show,” as Aston! says, “that employees with poor mouth condi-
tions have a greater incidence of illness resulting in absence from work than those
with good mouth conditions. Current surveys corroborate this statement, reveal-
ing an average of four and one-half days per employee per year lost from work be-
cause of toothache or some dental ailment. An industrial manager should have
to consider only such figures to see that a dental care program can save the plant
money by reducing absentees.”’t

Factors Involved in Caries. Belore considering some of the remarkable de-
velopments of the past decade which have led to the possibility of practical and

¥Knutson, J.: Dental Public Health Accomplishments and Predictions, Am. J. Pub. Health
44:335, March 1954.

TAston, E. R.: Responsibility of the American Association of Industrial Dentists, Pub. Health
Rep. 67:694, July 1952.
518 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
fruitful public health dental programs, it may be of value to explore briefly some
of the many factors which have been considered to have a relationship to the de-
velopment of dental caries. Dental caries and the consequences thereof constitute
by far the major proportion of the total dental problem which confronts us.
At a workshop at the University of Michigan in 1947 a group of one hundred
fourteen scientists related to the field's defined “dental caries” as follows:
Dental caries is a disease of the calcified tissues of the teeth. It is caused by acids
resulting from the action of microorganisms on carbohydrates, is characterized by a de-

calcification of the inorganic portion, and is accompanied or followed by a disintegration
of the organic substance of the tooth. *

Innumerable factors have been related at one time or another to the develop-
ment or lack of development of dental caries. Some of those particularly con-
sidered have been pregnancy, chronic debilitating diseases such as diabetes and
tuberculosis, endocrinopathies, radiation, psychic trauma, nutritional deficiencies,
inadequate dental exercise, inadequate dental cleansing, enzymes, bacteria of
various species, and inherited or acquired immunity or susceptibility.

One of the commonest ideas is that the general state of health and nutrition
has a close relationship with the presence or absence of dental caries. It is now
known that once the teeth have erupted, their enamel is thenceforth unaffected
by increased intake of calcium, phosphorus, or any of the vitamins. Similarly, it
has been shown that except in the most extreme instances, calcium is not with-
drawn from the formed teeth. The latter disproves one of the oldest and still very
common folk ideas, of a tooth lost for every baby. As lar as can be determined,
the state of health and nutrition of a mother during pregnancy and lactation have
little or no relationship to the subsequent possible development of dental caries in
her child. As Florio! says: “Any woman should have regular dental supervision.
It is highly questionable whether there is any particular virtue in having a dental
examination and corrections made during pregnancy, unless it is simply easier to
impress the mother at such times.” He continues to say, “There are excellent
reasons for vitamin and mineral supplement [or the mother, but the soundness
of the baby’s teeth is not one of them.”

The group which participated in the Michigan Workshop,' on reviewing the
literature and their own experience, came to the conclusion that not only did
general health and nutritional status have no significant bearing on the amount
ol caries, but that there is some evidence that malnourished people tend to have
a decreased incidence of dental caries, apparently as a result of the change in
composition, quantity, viscosity, and bacterial or antibacterial nature of the saliva.

Disturbances of various endocrine glands from time to time have been
claimed to have an effect on the development of dental caries. The reasoning has
been based upon the role which some endocrine substances play in determining
the structure and configuration of the dental arch, in their effect on the composi-
tion of the saliva, and possibly in relation to the development of resistance or
susceptibility to caries. There has been no acceptable substantiation of such

*Easlick, K. A.: Dental Caries, Mechanism and Present Control Technics, St. Louis, 1948,
The C. V. Mosby Co., p. 201.
PUBLIC HEALTH DENTISTRY 519

claims, and it is generally considered that no relationship exists between endocrine
disturbances and the amount of caries. Much attention has been given to the pos-
sibility of inherited susceptibility or immunity to dental caries. Hunt and his co-
workers2? were able to breed selectively a strain of rats which were immune to
dental caries and another strain which on the same diet were highly susceptible.
Many investigators, including Klein, Jay, Bunting, and others, have reported
families which appear to experience few or no caries. Bacterial and serological
analysis in some of these instances have shown that the lactobacillus was absent
from the mouths and digestive tracts of such individuals and that the blood
aglutination titer to lactobacilli was high. Despite these various studies, the gen-
eral feeling is that inherited or acquired susceptibility or immunity to dental
caries, if a reality, plays a minor role in the total caries picture and that further
investigation is indicated. Marked racial differences, however, appear to exist.
Klein and Palmer?! found the average numbers of decayed, missing, or filled
teeth per person of both sexes at 15 years of age to be 6.6 for Hagerstown whites,
6.5 for San Francisco whites, 4.1 for Hagerstown colored, 3.1 for Indian children
ofl all tribes studied, and only 1.1 for Navajo Indian children. In other words, at
age 15 white children were found to have about 1.5 times more decayed, missing,
and filled permanent teeth than colored children, and more than twice the num-
ber shown by Indian children. With regard to the latter, however, it should be
noted that the rate for Indian children of the Northwest was higher than for the
white children studied, and that the Navajo children lived in a high fluoride
area.

Perhaps as a result ol highly successful commercial salesmanship, it is widely
accepted that various oral hygienic practices will reduce the probability of de-
velopment of dental caries. Included in this category is the use of the toothbrush,
dentifrices, miscellaneous mouthwashes, lozenges, medicated chewing gum, and
professional dental prophylaxis. The conclusion of the Michigan Conference
on Dental Caries was that while these agents and procedures are worth while
from the standpoint of general oral hygiene, cosmetic effect, and the stimulation
of healthier gingival tissues, no evidence exists to indicate that their use bears a
relationship to the suppression of caries. Of particular interest was the conclusion
that professional dental prophylaxis could not remove all bacterial plaques from
the surfaces of the teeth, especially in the pits, fissures, and contact points, and
that even where they were removed, they tended to re-form in a matter of days.
Accordingly, the Conference group stated that “there is no statistical evidence
that prophylaxis three or even more times a year will reduce the dental caries
attack rate.”18

Considerable research has been carried on in an attempt to determine a rela-
tionship between various microorganisms and the development of dental caries.
Most attention has been given to the streptococci, proteolytic bacteria, and
acidogenic bacteria. These researches, especially those relating to the lactobacilli,
have brought us much closer to the goal of understanding the mechanism of dental
caries development and of devising practical preventive measures. By now, it may
be considered to have been conclusively demonstrated that there exists a relation-
ship between the formation of dental caries and the number of lactobacilli in the
520 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

mouth. The careful studies of Jay, Bunting, and their associates in particular ap-
pear to have settled this question as well as the question of the correlative part
which is played by a high intake of carbohydrates, especially [ree sugars,2?23,24,25

Because of the long-standing unsolved nature of the problem, it would now
appear that much more is known of the nature and cause ol caries than is realized
by the public in general. Before proceeding to a consideration ol some of the other
developments of the past decade which have brought us to the point where a
practical preventive dental program is possible, it is worth summarizing, in the
words ol Easlick,*® what is now known about the etiology of dental caries:

Somewhat over-simplified perhaps, but nevertheless quite readily understandable,
the factors may be outlined which are essential for dental caries. In the first place, the
patient must be susceptible to dental caries; very few people are immune. In the second
place, the patient must have teeth and the hard tissues of his teeth must be soluble in
weak organic acids. In the third place, acidogenic (acid-forming) bacteria, certainly, and
apparently aciduric (acid-tolerating) organisms must be present and active in large num-
bers in the patient’s mouth. In the fourth place, the food, the substrate on which
aciduric bacteria live, must be made available frequently in the patient’s mouth; in
other words, the host must ingest fermentable carbohydrate and usually in the form of
sugar. In the fifth place, certain specialized “promoters” of chemical activity, the neces-
sary enzymes, must be present in the patient’s mouth or must not be inhibited when
manufactured by resident bacteria, because at least 13 chemical reactions are required to
degrade a fermentable sugar to lactic acid. Finally, in the sixth place, the organic acids,
once produced, must be protected from the neutralizing effect of the patient's saliva in
order that they may react with the mineral surface of a tooth. A tough, adherent film,
the bacterial plaque, therefore, appears essential to the caries process.

These six essential factors, (1) susceptible patient, (2) acid-soluble tooth structure,
(3) aciduric organisms, (4) carbohydrate substrate, (5) bacterial enzyme system, and (6)
bacterial plaque, deserve careful consideration. They serve as research guideposts since
interference with any of these factors, or any combination of them, presents possi-
bilities for prevention or for the reduction of the patient’s dental caries. *

Recent Developments. At the annual meeting of the American Public Health
Association in 1953, Knutson, for the purposes ol prognostication, looked back
over the events ol the preceding decade which presaged a new era in dental
health:

At the beginning of the decade we did not have a single practical method for pre-
venting dental caries on a public health basis. To be sure, we had an abundance of
evidence of high correlation between the consumption of refined sugars and the prev-
alence of dental caries. However, the practicability of a preventive program based on re-
duced sugar consumption had not been demonstrated. Our dental programs were con-
fined largely to the carly detection of new carious lesions and the prompt filling of
carious teeth.

Detailed knowledge of the characteristics of the disease suggested programs designed
to care for the dental needs of children on an incremental basis rather than those which
were attempting to deal with the consequences of postponed care. Such dental care pro-
grams would minimize needs arising from neglect and would avoid the totally un-
manageable problem posed by the accumulation of dental defects over many years. This
practical approach to the dental care problem is as sound today as it was then. However,
the need for emphasizing care rather than prevention made those early years in dental

¥Easlick, K. A.: The Caries Problem of the School Child, Am. J. Pub. Health 39:984, Aug.
1949.
PUBLIC HEALTH DENTISTRY 521

 

public health trying, indeed. Because they provided direct dental care, it was difficult to
win acceptance of those programs. Public health administrators and dentists were over-
whelmed by the size of the problem and the projected costs of a program designed to
meet it.

No wonder those of us who lived through the days of the early, limited substance
programs appreciate present caries preventive measures which can be applied so effec-
tively and economically on a public health basis. *

Strange though it may appear, one of the most important developments of
recent years was the devisement of a practical definitive means of evaluation of
dental needs and problems. In order to study the prevalence of caries in the chil-
dren of various Indian tribes, Klein and Palmer were faced with the necessity of
finding some means ol defining the over-all condition ol the teeth of an individual
and of large groups. Collins,*” in compiling data to depict the physical state of
school children in 1931 presented the condition of their teeth in terms of the
numbers per child which were carious, extracted, and filled. Several years later
Galafer®s presented similar data on dental needs and treatment, but in terms
ol the amounts in each category per 100 children specific for age groupings. Klein
and Palmer? then combined these ideas and developed the D.M.F. (decayed or
missing or filled) concept by means ol which they were able to define and statis-
tically handle the prevalence ol caries, defining prevalence rate as the number of
children per 100 children examined who have one or more teeth decayed or miss-
ing or filled. Ina footnote they explained: “The term ‘decayed or missing or filled,’
which is abbreviated throughout this report as D.M.F., means, with respect to a
child, that the mouth contains one or more actively decayed, one or more filled, or
one or more missing permanent teeth. It follows that a child having one or more
teeth affected in any or all ol these classes has a D.M.F. or carious mouth. It lol-
lows also, that a count of the number of teeth decayed, plus the number filled,
plus the number missing, gives a count ol the total number of teeth affected by
caries which in this report is synonymous with the D.M.F. count.”? Simple as this
concept may appear to us now, its development represented a fundamental neces-
sary to the advancement of the epidemiology of dental disease. Subsequently,
Klein, Palmer, and others devised variations in the method of use ol the D.M.F.
count. Thus, the per cent of people with one or more D.M.F. represents the prev-
alence ol caries experience in a group. The number of D.M.F. teeth per person
represents the caries tendency of a group of people. The number of D.M.F. tooth
surfaces per person represents the total caries tendency. The differences in the
numbers of D.M.F. teeth between one point in time and another represents the in-
cidence of caries. By means of these factors it has been possible to depict by use ol
graphs not only incidence and prevalence, but also expectancy curves.2!

By far the most dramatic and significant development in dental health during
the decade has been the discovery of the relationship of fluorides to dental caries.
Teeth blackened by minerals or, more correctly, hypoplastic teeth, which in areas

*¥Knutson, J.: Dental Public Health Accomplishments and Predictions, Am. J. Pub. Health
44:331, March 1954.

Klein, H., and Palmer, C.: Dental Caries in American Indian Children, Pub. Health Bull.
No. 239, Dec. 1937, p. 7.
522 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

ol higher fluoride concentration develop posteruptively a characteristic brown
stain, were first described more than a hall century ago by Eager,?* who studied
the condition in a localized area of Italy. Not long afterward, in 1916, Black and
McKay?! presented the first of an outstanding series of reports on what was called
“mottled enamel” in children in certain areas of Colorado. Repeated searches for
the cause of mottled enamel culminated in the report by Smith, Lantz, and
Smith32 in 1931 which definitely implicated a relatively high amount of fluorides
in the soil and water. Up to this time, and for a number of years thereafter,
mottled enamel was looked upon essentially as a pathological condition and
fluorine as its undesirable causative agent.

During the 1930's however some investigations, not only in the United States
but also in Argentina, China, Japan, and South Alrica, began to notice and ques-
tion a possible relationship between high fluorine content of soil and water and
mottled enamel on the one hand and apparent resistance to caries on the other.
Fosdick and Hansen®* in their 1936 report on dental changes in Pueblo Indian
children commented, “It is interesting to speculate on the possible relationship of
fluorides in fermentation and the reduced susceptibility of mottled enamel to
decay.” In early 1937 Arnim, Aberle, and Pitney?! reported on unusual complete
freedom from caries in 1,605 permanent incisors of 204 Indian children examined
in New Mexico and Arizona. The waters used by the tribes contained more than
1.0 part per million of fluoride. Meanwhile, Armstrong and Brekhus® reported a
fluorine content of 0.0111 per cent in the enamel of noncarious teeth of indi-
viduals from high fluoride areas compared with 0.0069 per cent in carious enamel.

In connection with their 1937 report on dental caries in American Indian
children, Klein and Palmer? raised the question ofl the possible beneficial effect
of a certain amount of fluoride in the drinking water. They noticed that children
of certain tribes in the southwestern part of the United States had much lower
caries attack rates than those living elsewhere. They noted that the section in-
volved had been found to be an endemic fluorosis area. They suggested, “This fact
may have important implications, and would seem to justily some discussion.
Fluorides are well known as enzyme inhibitors, and it may be suggested that per-
haps a measure of the responsibility for low caries attack rates in the south-
western area may be the result of the drinking of fluoride water. Such water may
provide an enzyme inhibitor which will operate to limit the chemical degrada-
tion of tooth-impacted carbohydrates to organic acids, so reducing the production
ol local acidity about the teeth, and so limiting an important vector in caries
initiation.”* There followed a large series of investigations by many scientists
who compared the fluorine content of the enamel of teeth from different areas and
of carious as against noncarious teeth, animal feeding experiments, and many
comparative community studies. All substantiated the thesis that while an exces-
sive amount of fluoride in water would produce mottled enamel, a certain
amount, as low as 1 p.p.m. of fluoride in water consumed during the period of
tooth calcification resulted in a significantly lower incidence ol dental caries.

*Klein, H., and Palmer, C.: Dental Caries in American Indian Children, Pub. Health Bull.
No. 239, Dec. 1937, p. 37.
PUBLIC HEALTH DENTISTRY 523

 

Because of the lack of knowledge at the time with regard to toxicity and costs,
the first step to be taken for the practical application of the new knowledge was
to apply fluorides directly to the teeth. This procedure was reported indepen-
dently in 1942 by Bibby3¢ and Cheyne.?7 Bibby painted the permanent teeth of
children every four months with a solution containing 1,000 p.p.m. sodium
fluoride. Cheyne used a solution hall that strength of potassium fluoride, but at
three-month intervals. Both reported a 50 per cent reduction in caries as compared
with the respective control groups. The success of these studies, which were widely
publicized, led to a one-million-dollar nationwide demonstration program spon-
sored by the Public Health Service for the purpose of bringing about widespread
knowledge and use of the technique.?8

Another event of this period to which attention should be called was the
establishment of the National Institute of Dental Research in 1948 by the Public
Health Service. The establishment of this Institute in itself may be considered
one of the outstanding developments of recent years. Not only did it represent
formal recognition by the Congress of the importance of dental health problems,
but it provided funds and facilities for research, research grants, and fellowship
programs.

Meanwhile, studies were underway which demonstrated that fluorides in the
concentrations being considered were not toxic.3%4%41 At the same time, sanitary
engineers and waterworks chemists and operators developed policies, procedures
and mechanisms for maintaining within very narrow limits the fluoride levels in
water.4243.44 With public sanction, a number of carefully controlled community
studies were initiated in which fluorides were added to the public water supplies.
The results of these studies indicated conclusively that the addition of fluorides
up to a concentration of about one part per million to the drinking water supply
results in up to two-thirds reduction in the incidence of dental caries. Even those
who at 16 years of age had received fluorides for only six and one-half years
experienced a reduction in expected caries of 18.1 per cent. 1546.47

The results were rapidly and widely accepted and communities began to put
them to practical use. Now, the procedure is endorsed by the American Dental As-
sociation, the Association ol State and Territorial Dental Health Directors, the
American Association of Public Health Dentists, the American Public Health
Association, the National Research Council, the Public Health Service, the As-
sociation of State and Territorial Health Officers, the American Medical Associa-
tion, and a majority of state health departments.®s A survey showed that as ol
September 1957 there were 1,532 communities in the United States served by 798
water systems which were fluoridating their waters, and that over 32 million
people were benefitting from the procedure.*?

One other significant development during the past fifteen years should be
mentioned. Because of the growing public and professional awareness of the im-
portance of the problems of dental health, and because of the remarkable strides
which had been taken in rapid succession and which provided a number of prac-
tical measures which could be taken for the solution of those problems, the
specialty of public health dentistry was firmly established. Early in the period a
Dental Health Section of the American Public Health Association was established
524 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES }

 

which by 1945 had defined the field of public health dentistry and had established
educational qualifications of public health dentists.” About the same time the
American Association of Public Health Dentists came into being along with a
Dental Health Section of the American Dental Association. Annual professional
and official conferences of those most directly concerned with programs of dental
health came into being with the establishment of the Conference of State Dental
Directors with the Surgeon General of the Public Health Service and the Chief
of the Children’s Bureau on the one hand, and the Council on Dental Health of
the American Dental Association on the other. The specialty was formally rec-
ognized in 1952 through the establishment of the American Board of Dental Pub-
lic Health which is sponsored jointly by the American Dental Association and the
American Public Health Association.

That public health dentists are not content to rest on the laurels of the truly
explosive progress which recently has occurred is evidenced by the modest state-
ment of one of their spokesmen. In summing it up Knutson concluded:

The nature of accomplishments during the past 10 years made this a decade of
beginning in the field of dental public health. Water fluoridation, topical fluorides, oral
cancer detection and control programs, the team approach to the diagnosis and treat-
ment of cleft lip and cleft palate cases, orthodontic care programs, utilization of chairside
assistants, the National Institute of Dental Research, approaches to the epidemiology of
dento-facial deformities and periodontal diseases, and principles of prepayment for dental
care services—all these are no better than well begun and several are in the budding
stage. ‘The objectives of all and the merits of most of them have been firmly
established . . . .*

Public Health Dental Programs. On the basis of what has gone before, it can
readily be understood that the present-day public health agencies and the rela-
tively few but well-qualified public health dentists on their staffs are in a quite
different situation than that which existed but a [ew years ago when all they
could do was to try to devise ways and means ol reducing by dental therapy the
discouraging flood of accumulating dental needs. By now a rather clear and prac-
tical approach has been unfolded with clearly defined and proved preventive
measures which if properly applied hold promise of reducing the needs for caries
correction to a point at which they may be handled reasonably adequately along
with the prosthetic, orthodontic, and dental surgical needs of the community.

Easlick®¢ has listed the contributions which modern present-day dentistry
can make to a child's health. While recognizing that most preventive and pro-
motive dental health activities must be aimed at the child population, his itemiza-
tion may be generalized and adapted to apply to the total population as follows:
Using all modern knowledge available, dentistry and society could prevent and
control most dental caries; prevent or control solt tissue inflammation and disease
of the supporting tissues ol the teeth; with specialist cooperation, correct maloc-
cluding teeth and prevent a relatively small number of the gross tooth irreg-
ularities that may interfere with mastication, with the health of the supporting
tissues, and with the emotional stability of the individual; with specialist coopera-

*Knutson, J.: Dental Public Health Accomplishments and Predictions, Am. J. Pub. Health
44:331, March 1954
i PUBLIC HEALTH DENTISTRY 525
tion, can treat the problems arising from anomalies of the oral cavity, e.g., the
cleft palate, congenitally missing teeth, supernumerary teeth, hypoplastic teeth,
and other developmental dental abnormalities; can treat and restore teeth in-
volved in accidents; can detect oral cancer in the early stages; can prevent and
eliminate oral infection which may contribute to body disease.

In reflecting upon how our existing considerable knowledge may be applied
to the successful accomplishment of these goals, the following six areas of ac-
tivity would seem to be logically indicated: (1) planning and arrangements
for evaluation, (2) prevention of dental caries, (3) remedial treatment ol caries,
(4) remedial treatment of other dental and oral defects, (5) public dental health
education, and (6) professional development.

As will be brought out subsequently, the state health departments are the
chief agencies which provide dental health services. They operate principally,
however, through local health departments which work in cooperation with
the dental profession, the schools, and other local organizations. While the state
and local health agencies and their public health dentists are often in the
position of having to spearhead community activities in this field, the establish-
ment of policies and the development of programs should always be carried
out in conjunction with members of the dental societies, and for certain com-
ponents of the program, with school health committees, departments of educa-
tion, and other key groups. The close relationship with the dental profession
and schools is particularly important, since their understanding cooperation
and support is fundamental to a successful dental program.

On the basis of experience acquired in the successful development of a
dental health program in Oak Ridge, Tennessee, Stroud and Brumback®' have
set down certain guideposts to planning which because ol their practicality and
good sense are repeated here in part:

1. The first step should be a survey of local needs in order to determine the nature and extent
of the problem.

2. A list of resources already available to aid in meeting the needs should be prepared. This
should include practicing dentists, official and nonofficial agencies, civic organizations, parent-
teacher associations, etc.

3. Resources outside the community should be called upon early in planning. The state pub-
lic health department can help in many ways. ‘The U.S. Public Health Service has many
aids available for use. (To these may be added the state dental society and the American
Dental Association.)

4. Local practicing dentists should be active members of the planning group from the start. A
committee of dentists should advise the group throughout the inauguration and operation
of the program. No action should be taken without approval of the dentists.

5. In planning, representatives of all local organizations having an interest in health should
be invited. Their advice can help to avoid many pitfalls and their active interest is essential
to a really successful program.

6. If the program operates under the auspices of a lay group as in Oak Ridge, the active ad-
ministration and supervision should be provided by the local public health department. If
funds are to be administered by the lay governing council, this council should be incor-
porated. Officers responsible for such funds should be bonded and the budget should include
an amount to pay for a periodic audit of accounts.

~I

Before a program begins operation, policies and procedures should be agreed upon. Personnel
policies should be established before employing anyone.
5206 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

8. In program planning, every opportunity for education should be considered. As many com-
munity residents as possible should be encouraged to participate in the organization and
operation. In Oak Ridge, several hundred people have taken part in the planning or opera-
tion up to the present time. They are members of various community official agencies, private
practitioners of dentistry and medicine, housewives, members of clubs and voluntary organ-
izations, scientific workers, teachers, students, businessmen, and private citizens not falling
into any of the above categories. Each has made a valuable contribution to the program and
all have learned something about dental health.*

It is advisable to include in the planning stages of a program provision
of a means of its evaluation. Since caries constitutes the bulk of the dental
problem, and since the chiel goal to be attained is the reduction in the amount
ol dental caries, the prevalence of that condition in the population to be served
should be determined. Since the D.M.F. count of adults is closely correlated
with that of children, an initial survey of a sample of the child population
alone may serve the purpose. Based on the observation that a functional relation-
ship exists between the proportion of children having at least one D.M.F. per-
manent tooth and the average number of D.M.F. permanent teeth per child,
Knutson®? has developed a simplified method which may be used to determine
the initial base line and subsequent evaluation.

Since it has been clearly shown that proper fluoridation of water supplies
will decrease dental caries prevalence up to 65 per cent, it is obvious that the
primary goal of a public health dental program should be the acceptance and de-
velopment of this procedure. In order to accomplish this, a number of steps
should be suggested. Probably the first thing which should be done is to obtain
a positive statement ol policy on fluoridation by the state dental society and
the state health agency. Following this, it will probably be advisable to promote
the establishment of a state fluoridation committee to work with the state public
health dentists and the state dental society. Such a group may be of considerable
value in providing information and data on fluoridation to the general public
and the press, to local dental societies, and to state and local nonprofessional
organizations and officials. It may also assist by drawing up a sample fluoridation
ordinance in conformance with state legislation and by collecting information
on costs.

On the local level, again the local dental society should provide the leader-
ship in organizing a local committee and should play an active role in the
planning and establishment of the local program. Franz Maier,” senior sanitary
engineer of the Division of Dental Public Health of the U. S. Public Health
Service, has warned that, “before advocating fluoridation of any particular water
supply in a state, the state dental director should be prepared to answer three
questions invariably raised: Will it do any good? Will it do any harm? How
much will it cost?” To answer these questions he added, “The director will
want to obtain from the state sanitary engineer: (1) the fluoride content of
the specific water supply, (2) estimates of the capabilities of waterworks person-
nel, (3) cost of fluoridation based on a detailed study of the water supply.”

*Adapted from Stroud, H., and Brumback, C.: A Dental Health Program for Your Com-
munity, Am. J. Pub. Health 40:1426, Nov. 1950.
PUBLIC HEALTH DENTISTRY 527

The sanitary engineering division of the state health department along with
other divisions or agencies may be called upon to assist in the determination of
the type of floride compound and the type of feeder to be used. In addition,
they may advise on the most suitable point of application of the fluoride, the
adequacy of the safety precautions for operators, and the effectiveness of con-
trols to maintain a proper fluoride concentration. With regard to cost, it may
be said generally that at the present time, the total expense amortized over
thirty years on a per capita basis will average an estimated 5 to 14 cents per
person per year.

Despite its greater cost and more difficult method of use, topical applica-
tion of fluoride to the teeth of children has a place in many if not all public
health dental programs. Sometimes shortsighted but effective opposition to
fluoridation of water may exist in a community. It must also be remembered
that effective and economical fluoridation of water necessitates concentrated
populations and it is inapplicable to very small or scattered populations. Thus,
these factors of opposition, proscrastination, and scattered populations account
for the fact previously referred to that by January 1954 only five hundred water
systems in forty-one states and the District of Columbia were fluoridating their
water. The number of persons served thereby is about 17 million only slightly
more than 10 per cent of the population of the country. Incidentally, it should
be noted that now two thirds of the population of the United States lives under
urban circumstances.

Another reason for retaining the topical-fluoride procedure is that since
water fluoridation is most effective during the years of enamel calcification, it
is advisable for those children whose teeth have already been calcified when
fluoridation is begun to have topical fluoride applications. Subsequently, as
the benefits of fluoridated water become effective, topical fluoride applications
may be discontinued gradually beginning with the younger age groups. The
extent to which the topical procedure is carried out in the offices of private
practicing dentists on the one hand, or through public facilities on the other,
will depend entirely on the local situation. Wertheimer? has described some
of the difficulties encountered by the program in Michigan, which was one of
the first to be established. Of particular interest was the partial solution of
the difficult personnel problem by means of summer employment of junior dental
students. Following proper preparation and demonstration as well as discussions
on the place of dentistry in public health, public relations, the group method
approach, and the care of equipment, the students were found to do a quite
acceptable job. It is interesting that this approach reduced the cost to $1.36
per child in contrast to $2.42 and $3.28 per child for the previous two years.
Wertheimer also points out that this approach gives the following additional
benefits to the dental students: (1) experience in group method of topical fluoride
application, (2) development of skill in handling children, (3) learning about
dental conditions of children in communities in contrast to select groups usually
seen in dental schools, (4) orientation in public health and the concept that
dental disease is a public health problem, and (5) opportunity to observe com-
munity action as an approach to the solution of problems.
528 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

It must be recognized that fluoridation of water and topical application of
fluorides do not bring about complete caries control, and do not eliminate the
need for other dental health measures. A certain amount of caries will always
develop, hence there probably always will be a need for some remedial treat-
ment of caries. For this and other reasons, an essential part of the public health
dental program should be the promotion of regular dental supervision as an
essential part of individual hygienic living. With a major proportion of caries
subject to prevention, it may be possible in the future to repair what caries
develop on an incremental basis. Even in the face of vast accumulated dental
needs, it has been found practical and fruitful in a number of places to restrict
caries corrective programs to children in a restricted age span. For example,
some programs which began by caring for children from 5 to 10 years of age
found it possible during the second year of the program to add the new crop
of b-year-old children, and in addition to continue with the 11-year-old children
who were in the original group the year before. As each year goes by, new
b-year olds were added, and all children previously cared for were continued.

To plan for the adequate provision of dental care for adults is somewhat
more costly and complex than to do so for the children of the future. For
one thing, the oral ills of adults are more varied, and often require more
meticulous and time-consuming work than those ol children. Gruebbel® has
outlined modern standards of dental care for adults to involve the prevention
and treatment of (1) diseases of the teeth, (2) periodontoclasia, (8) anomalies,
(4) cysts, (5) malignant and precancerous lesions, (6) oral manifestations ol sys-
temic disturbances, (7) traumatic injuries and the preservation or restoration of
mouth function. It is difficult to conceive of any of these being handled on other
than a strictly personalized or individualized basis. Furthermore, the constantly
increasing proportion of older people, and the increasing hazards of facial injuries
due to automobile and other accidents, mitigate against an early lessening of
the group needs for some of these services. Even with a marked decrease in the
total amount of dental caries, making available a larger proportion of dentists’
time for the care of these adult ailments, their very nature makes the cost of
remedying them a highly important factor.

One cannot avoid the expectation that the ultimate reasonable solution
of adult dental ailments will depend upon the development of practical, ac-
ceptable, and widely available prepayment dental care programs. The Ameri-
can Dental Association has carried on or sponsored numerous investigations
along this line during the past ten to filteen years and since 1942 has been sug-
gesting that dental societies experiment with various prepayment plans. The
plan drawn up by the American Dental Association®® to provide family dental
service to low-income groups involves the payment by the subscriber of one
dollar each month for himself, plus an additional one dollar monthly for his
first dependent, and fifty cents a month more for additional dependents. Thus
the total fee for a subscriber with two or more dependents amounts to $2.50
a month. Certain services, such as orthodontics and the construction of crowns,
bridges, and dentures, are not included. It should be realized further that the
suggested fees applied to the year 1944.
PUBLIC HEALTH DENTISTRY 529

Since 1945, the St. Louis Labor Health Institute has provided all types of
dental service with the exception of orthodontics to members of its supporting
union on a prepayment basis. During 1952 the plan served approximately 10,000
individuals at a cost per dental participant per year of $9.39 and a cost per
prepayment family per month of $2.35.°7 Numerous other plans have been
and are being experimented with, with varying degrees of success. Phair has
described a number of them in a worth-while analysis of the difficulties com-
monly encountered.?s

It is to be recommended that plans for a forward-looking community public
health dental program include consideration of the development of a prepay-
ment dental care plan for adults as well as children. For guidance in this, the
House of Delegates of the American Dental Association has adopted a set of
principles? which are presented here:

1. The plan should be developed, maintained, and promoted to the public with the

advice of authorized representatives of the local or state dental society.

The plan should foster and encourage the provision of a high quality of dental
treatment.

no

3. The dentist who serves the patient must have complete freedom and responsibility
in recommending treatment as his own professional judgment dictates.

4. The patient must have freedom to choose the dentist to whom he may wish to apply

for treatment. Similarily, the dentist must have the right to accept patients who apply

for treatment.

The plan should make provision for direct payment to the dentist.

6. All rules and policies that are related to the dental aspects of the plan, including
examination, diagnosis, treatment, prevention, and professional education, should be
determined by officially designated representatives of the dental profession.

7. Fees for dental services paid to dentists under the plan should be determined by
authorized representatives of the dentists who will render the dental services. In all
cases, payments should be consistent with the provision of high-grade dental service.

8. The plan should designate explicitly both the type and amount of service and the
conditions under which it will be provided so that both the patient and the dentist
will know exactly the extent of their participation in the program.

9. Sound and efficient business practices should be used in the management of the plan
in order to assure low administrative cost. *

At the present time, the part of a community dental health program which
relates to the remedial treatment of dental and other oral defects, including
orthodontics, prosthetics, and dental surgery lor congenital defects, would seem
to lie clearly in the hands of private practicing dentists, aided to whatever degree
may be possible by the services, facilities, and contributions of public clinics
for indigent or low-income groups, philanthropic agencies, and prepayment
dental care plans. The scant attention given to these conditions here is in no
way indicative of their relative importance. Indeed, as Gruebbel® visualizes,
for example, “Orthodontic services . . . may some day prove to be high on the
list of essential services. The health professions are finding increasing evidence
of the value of orthodontic care to the physical and mental well-being and social
adjustment of children and youth. It has been estimated that there are approxi-
mately 40 million children under the age of 16 years in the United States, of

* Transactions of the American Dental Association, Tr. Am. Dent. A., 1953, p. 225.
530 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

whom 7 to 8 million need major orthodontic care, and of whom less than 4
out of every 100 who need it are actually receiving treatment.” *

Underlying all of the other activities should be a carefully planned dental
health education program so varied as to reach all segments of the public, with
particular emphasis on “sensitive” groups. For many years, those who attend pre-
natal, well-baby, and other public health clinics have been exposed to dental
health educational procedures. It is puzzling however to understand why so
few hospital waiting rooms and private physicians’ offices do anything to encour-
age their clients to seek dental supervision. Considering the numbers of persons
involved and the receptive circumstances in which they find themselves, this
is suggested as a channel of public education worthy of far more intensive
exploration and use.

A very important area for dental health education is in relation to the
school health program. Those responsible for the community dental health
program should work particularly closely with the board of education, class-
room teachers, and physical education personnel, assisting them in the prepara-
tion of sound and practical information in the field, screening of classroom
teaching aids, and obtaining material for them from the various dental and
public health associations.60

On the state level, public health dentists should work closely and in a
similar manner with state departments of education, dental schools, and teachers’
colleges. Another arca worthy ol particular attention is that concerned with
the school lunch program. The public health dental personnel in collaboration
with teachers of nutrition and home economics, and with the school lunch-
room managers should attempt to bring about a change in lunch and snack
habits, particularly with regard to the intake of carbohydrates. With this in
mind, a great many school systems have discouraged the use and even availability
of candy and soft drinks in their lunchrooms and elsewhere on school premises.
While it is fully recognized that school children may obtain these products
elsewhere, it is at least a partial step in the right direction to bring about a
change in the habit pattern at mealtime.

A final and basic part of the community dental health program should
be concerned with the improvement of professional standards and practices.
This is particularly appropriate at this time, considering the many recent de-
velopments which have come about since the graduation of many of those now
practicing dentistry. Still another reason is the increasing awareness of the re-
lationship of various fields in medicine, economics, and sociology, to the modern
practice of dentistry. A number of states have found it very worth while to
sponsor postgraduate seminars on subjects related to modern dental practice.
Outstanding in this regard are the Tennessee dental seminars, which for a num-
ber of years have been bringing continued professional education to practicing
dentists in or near the locality of their practice.! This and similar types of activi-
ties go far in strengthening the local dental society, raising the standards of local

*Gruebbel, A. O.: Standards of Dental Care for the Different Age Groups, Am. J. Pub.
Health 39:981, Aug. 1949, p. 981.
PUBLIC HEALTH DENTISTRY 531

 

practice, and assuring the cooperation and active participation of the dentists
of the community. In connection with seminars and postgraduate training, it
is suggested that the subject matter not be restricted to dentistry or even public
health dentistry, but include also the occasional consideration ol mental hygiene,
economics, newer techniques for the diagnosis and treatment of cancer,* and
other similar subjects.

A previous section of this chapter dealt briefly with the need for and useful-
ness of dental hygienists and dental assistants. It was pointed out at that time
that only a minor per cent of practicing dentists are making use of this valuable
potential source of assistance. The promotion of the use of dental hygienists
and dental assistants is certainly a worth while and legitimate aspect ol the
community dental health program since its success would be a greater total
amount of dentists’ time available to the community.

An easily overlooked area of action in a program such as that under con-
sideration is related to the solution of the ever-present problem of personnel
shortages. Those responsible for the program should consider activities in the
nature of career guidance to high school and college students as an important
responsibility.

REFERENCES

I. Knutson, J., and Klein, H.: Tooth Mortality in Elementary School Children, Pub. Health
Rep. 53:1021, June 1938.

2. Klein, H., and Palmer, C.: Therapeutic Odontotomy and Preventive Dentistry, J.A.D.A.
27:1055, July 1940.

3. Knutson, J.: Dental Public Health Accomplishments and Predictions, Am. J. Pub. Health
44:331, March 1954.

4. Causes of Rejection and Incidence of Defects, Medical Statistics Bulletin, Selective Service

System 2:1, Aug. 1943.
The Epidemiology of Dental Disease, Collection of Papers of Henry Klein and others, 1937-47,
Fed. Sec. Agency, Public Health Service, 1948.

6. Walls, R. M., Lewis, S. R., and Dollar, M. L.: Study of Dental Needs of Adults in the
United States, Chicago, 1941, American Dental Association.

7. Klein, H., and Palmer, C.: Dental Problems of Elementary School Children, Milbank Mem.

Fund Quart. 16:267, 1938.

Klein, H.: Dental Needs versus Dental Manpower, JLA.D.A. 31:263, Feb. 1944.

9. Institute on Dental Health Economics, Committee Reports, School of Public Health,
University of Michigan, July 1944.

10. Collins, S. D.: Frequency of Dental Service Among 9,000 Families Based on Nationwide
Periodic Canvasses, 1928-31, Pub. Health Rep. 53:629, April 1939.

11. Grace, L.: Study on Incidence of Cleft Palate, J. Dent. Res. 22:495, Dec. 1943.

12. American Dental Directory, Chicago, 1958, American Dental Association.

13. Preliminary Report on Volume of Dental Care, Health Statistics from the U. S. National
Health Survey, Washington, March 1958, Department of Health, Education, and
Welfare.

14. Distribution of Dentists in the United States by State, Region, District and County, Bureau
of Economic Research and Statistics, American Dental Association, 1958.

15. Klein, H.: Civilian Dentistry in Wartime, J.A.D.A. 31:648, May 1944.

16. McCall, J. O.: Dental Practice and Dental Education in the Future, J.LA.D.A. 31:16, Jan. 1944.

ot

x

*See The Dentist in the National Program of Cancer Control by Deibert.*
532 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

17. Aston, E. R.: Responsibility of the American Association of Industrial Dentists, Pub. Health
Rep. 67:694, July 1952.

18. Easlick, K. A.: Dental Caries, Mechanism and Present Control Technics, St. Louis, 1948,
The C. V. Mosby Co.

19. Florio, L.: In Leavell, Hugh R., Clark, E. G., and others: Textbook of Preventive Medicine,
New York, 1953, McGraw-Hill Book Co., Inc.

20. Hunt, H. R., Hoppert, C., and Erwin, W.: Inheritance of Susceptibility to Caries in Albino
Rats, J. Dent. Res. 23:385, Oct. 1944.

21. Klein, H., and Palmer, C.: On the Epidemiology of Dental Caries, University of Pennsyl-
vania Bicentennial Conference, Philadelphia, 1941, University of Pennsylvania Press.

22. Jay, Phillip: Bacillus Acidophilus and Dental Caries, J.A.D.A. 16:230, Feb. 1929.

23. Jay, Phillip: The Problem of Dental Caries With Relation to Bacteria and Diet, J. Pediat.
8:725, 1936.

24. Bunting, R. W., and Palmerlee, F.: The Role of Bacillus Acidophilus in Dental Caries,
JADA. 12:381, April 1925.

25. Jay, Phillip: The Role of Sugar in the Etiology of Caries, J.LA.D.A. 27:393, March 1940.

26. Easlick, K. A.: The Caries Problem of the School Child, Am. J. Pub. Health 39:984, Aug.
1949.

27. Collins, Selwyn: The Health of the School Child, A Study of Sickness, Physical Defects and
Mortality, Pub. Health Bull. No. 200, Aug. 1931, Table 27.

28. Messner, C. T., Gafafer, W. M., Cady, F. C., and Dean, H. T.: Dental Survey of School
Children, Ages 6-14 years. Made in 1933-34 in 26 States, Pub. Health Bull. No. 226,
May 1936.

29. Klein, H., and Palmer, C.: Dental Caries in American Indian Children, Pub. Health Bull.
No. 239, Dec. 1937.

30. Eager, J.: Chiaie Teeth, Pub. Health Rep. 16:2576, 1901.

31. Black, G. V., and McKay, F. S.: Mottled Teeth: An Endemic Developmental Imperfection
of the Enamel of the Teeth Heretofore Unknown in the Literature of Dentistry, Dental
Cosmos 58:129, 1916.

32. Smith, M. C., Lantz, E., and Smith, H. B.: The Cause of Mottled Enamel, Science 74:244,
1931.

33. Fosdick, L., and Hansen, H.: Theoretical Considerations of Carbohydrate Degradation in
Relation to Dental Caries, J.A.D.A. 23:406, March 1936.

34. Arnim, S., Aberle, S., and Pitney, E.: A Study of Dental Changes in a Group of Pueblo
Indian Children, J.LA.D.A. 24:478, March 1937.

35. Armstrong, W., and Brekhus, P.: Chemical Constitution of Enamel and Dentin, J. Biol.
Chem. 120:677, Sept. 1937.

36. Bibby, B. G.: Preliminary Report on the Use of Sodium Fluoride Applications in Caries
Prophylaxis, J. Dent. Res. 21:314, 1942.

37. Cheyne, V. D.: Human Dental Caries and Topically Applied Fluorine: A Preliminary Report,
J.AD.A. 29: 804, 1942.

38. Knutson, J. W.: The Nationwide Topical Fluoride Demonstration Program, J.A.D.A. 39:438,
1949.

39. Cox, G. J., and Hodge, H. C.: The Toxicity of Fluorides in Relation to Their Use in Den-
istry, J.A.D.A. 40:440, April 1950.

40. Heyroth, F.: Toxicological Evidence for the Safety of the Fluoridation of Public Water
Supplies, Am. J. Pub. Health 42:1568, Dec. 1952.

41. Hagan, T. L., Pasternack, M., and Scholz, G. C.: Waterbourne Fluorides and Mortality, Pub.
Health Rep. 69:450, May 1954.

42. Tentative Standard Specifications for Sodium Fluoride, J. Am. Waterworks Association

42:899, Sept. 1950.

43. Bull, F. A., Hardgrove, T. A,, and Frisch, J. G.: Methods and Costs of Water Fluoridation,
JADA. 42:29, Jan. 1951.

44. Maier, F. J.: Engineering Problems in Water Fluoridation, Am. J. Pub. Health 42:249, March
1952.
PUBLIC HEALTH DENTISTRY 533

 

46.

47.

48.

49.

50.
51.

ot ot Ot
St A

ot
&

oo

. Arnold, F., Dean., H,, and Knutson, J.: Effect of Fluoridated Public Water Supplies on

Dental Caries Prevalence, Pub. Health Rep. 68:141, Feb. 1953.

Ast, D., and Chase, H.: The Newburgh-Kingston Caries Fluorine Study, Oral Surg. 6:114,
Jan. 1953.

Hutton, W. L., Linscott, B. W., and Williams, D. B.: The Brantford Fluorine Experiment,
Canad. J. Pub. Health 42:81, Jan. 1951.

Inter-Association Committee on Health, Statement on Fluoridation, J.A.D.A. 44:331, March
1952.

News Note: Am. J. Pub. Health 47:1283, Oct. 1957.

Educational Qualifications of Public Health Dentists, Am. J. Pub. Health 35:45, Jan. 1945.

Stroud, H., and Brumback, C.: A Dental Health Program for Your Community, Am. J. Pub.
Health 40:1426, Nov. 1950.

Knutson, J.: Simplified Appraisal of Dental Health Programs, Pub. Health Rep. 62:413,
March 1947.

Fluoridation Keynoted at Dental Conference, Pub. Health Rep. 66:1172, Sept. 1951.

. Wertheimer, F.: Michigan Summer Topical Fluoride Program, Am. J. Pub. Health 44:484,

April 1954.

Gruebbel, A. O.: Standards of Dental Care for the Different Age Groups, Am. J. Pub. Health
39:981, Aug. 1949.

Proposed Plan for Prepayment of Dental Insurance, Chicago, 1944, American Dental
Association.

McNeel, J. O.: Dental Program of the St. Louis Labor Health Institute, Am. J. Pub. Health
44:878, July 1954.

Phair, W. P.: Problems in the Development of Prepayment Dental Care Programs, Am. J.
Pub. Health, 44:872, July 1954.

. Transactions of the American Dental Association, Tr. Am. Dent. A., 1953.
. A Dental Health Program for Schools: Council on Dental Health, American Dental Society,

1954.

. Sebelius, C. L.: Training of Dentists for Dental Health Program Service, J.A.D.A. 44:38, 1952.

Deibert, A. V.: The Dentist in the National Program of Cancer Control, Am. J. Pub. Health
39:772, June 1949.
chapter 2 3

The control of communicable diseases

 

Since this book deals primarily with the administrative phases of public
health and since there are many excellent texts on the clinical aspects of the
various communicable diseases, it is the intention of this chapter merely to
present certain broad aspects of the subject, particularly those determining ad-
ministrative control measures. It is assumed that the public health student or
worker will be taking or will have taken courses in communicable diseases
and epidemiology which present the details. Accordingly, the following should
in no sense be considered a short course in itsell or a substitute for more de-
tailed study but should be regarded merely as a general introduction to certain
phases of the field.

The Biological Significance of Infection. At first glance it may seem
extraneous to devote space to a discussion of such elementary philosophic con-
siderations as the essential meaning of infection. However, all of us, even though
accustomed to living in the most advanced and cultured societies, are influenced
to a surprising degree by many elemental emotions and superstitions. In our
attempted sophistication, we strenuously strive to convince ourselves and each
other of our essentially great difference from the other things that exist upon
the earth. In so far as possible we attempt consciously or subconsciously to avoid
recognition of the fact that we share with all living things certain fundamental
needs, desires, and drives, i.e., the need for food and shelter, the desire for
personal survival, and the drive for perpetuation of our kind.

Any approach to the communicable diseases and their control should be
based upon a frank recognition and understanding of these irrefutable facts.
It must be realized that the various species of microorganisms that cause disease
in man have no innate malevolence toward him, but in their struggle for
survival and perpetuation have found in his body a convenient steppingstone
and have adapted their biology accordingly. By like token, it may be said
that man himself, probably more than any other species, has contrived in his
adaptation to take advantage of many other living creatures, extending in
kind from the myriad of microorganisms that exist in his intestinal tract and
assist him in his digestive process, to the fish, fowl, and cattle that give him
sustenance and the beasts that bear his burdens.

534
CONTROL OF COMMUNICABLE DISEASES 535

 

 

By far the most desirable situation for a microorganism is one in which it
lives in nonfatal harmony with the other creatures upon or within which it
exists. For a microorganism so to evolve that its multiplication results in the
demise of its host, represents perhaps the ultimate in biological failure. By
killing its host, it also kills itself. The anthrax bacillus, for example, depending
upon multiplication in the blood stream of its human host, completely defeats
its purpose when it kills its host and thereby traps itself within the dead body,
whence only with great difficulty it can be transmitted to others. If, for the
purpose of discussion, we were to assume the tuberculosis organism to be en-
dowed with some [orm of intelligence, it might be said that the more astute
of its kind would be content with producing only moderate degrees ol the
disease of tuberculosis. By allowing its host unsuspectingly to continue his
customary rounds, the organism assures itself not only of continued existence
but also of ample opportunity for further transfer and perpetuation. In a
biological sense, the more virulent and more toxic strains which kill, and kill
quickly, also represent impatient and overambitious biological failures.

     
  
      
 

 

 

MODE MODE OF MO DE OF
SOURCES —L ExT TRANSMISSION ENTRANCE poten TiaL HOST
HUMAN CASES GENERAL HEALTH
HUMAN CARRIERS DIRECT CONTACT NUTRITION
ANIMAL RESERVOIRS DROPLET INFECTION HEREDITY
INANIMATE RESERVOIRS Np» — A IMMUNITY
ETC
FOMITES
VECTORS
me Ne — |
CONJUNCTIVAE CONJUNCTIVAE
RESP TRACT RESP TRACT
G.I. TRACT GI. TRACT
G.U. TRACT GU TRACT
OPEN LE SIONS OPEN LESIONS
MECHANICAL MECHANICAL
(BITES ETC.) (BITES ETC)

Fig. 29. Sequence of events in transmission of diseases.

General Requisites for Microorganismal Survival. In order for a micro-
organism that has involved itsell in a biological relationship with man to survive
successfully, a certain chain of circumstances or events must be followed (Fig. 29).
As long as a parasitic microorganism is entirely confined within its definitive
host, it can in no way offer an immediate threat to other potential hosts. Many
examples of this may be cited. Except for certain stages of the disease it causes,
the spirochete of syphilis is completely contained within the body of its host,
who, although actually infected, cannot transmit the disease. Similar to this,
in the field of protozoology, is the malarial parasite which except for relatively
short intervals is nontransmissible.

The necessity for getting out of the host implies a mode of exit for the
parasite. This is not as simple as it sounds since each parasitic microorganism
has adaptively restricted itself to a few paths and often one particular path.
Thus, the parasite of malaria is restricted to egress through the skin of its host
and even then only at certain phases of its life cycle. Except for biological
accidents, the spirochete of syphilis, because of overspecialization which has re-
536 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

sulted in marked f[raility, must rely upon exit through the sexual organs of
humans which, in the process ol their use, provide the spirochete with the
maximum protection of its fraility. A great many parasitic species have so adapted
themselves that the nose and throat offer the most expeditious exit. Still others
rely essentially upon the discharges of the gastrointestinal tract. If in some
way the typhoid bacillus were suddenly to decide upon the skin or genitalia
as a means of exit, it would in all probability cease to be a threat to man. All
external parts of the human body, including, of course, the respiratory, genito-
urinary, and intestinal tracts, serve as sites of exit for one or more of the
many microorganisms that affect man. Obviously the more limited the means
of egress, the greater the opportunity for successful control, at least in a theoreti-
cal sense.

The picture becomes greatly complicated, however, by certain other biologi-
cal and cultural aspects of human existence. Thus, while for all practical pur-
poses the spirochete ofl syphilis has restricted itself to a single mode of exit,
successful control or elimination of the disease is more easily proposed than
accomplished. In theory, syphilis could be completely eradicated by prohibit-
ing all human sexual intercourse. Such a prohibition, however, even if tolerated,
would in turn eliminate man himself. This being impractical, it therefore
becomes necessary to find some other approach to the problem. Theoretically,
typhoid fever and many related diseases could be eradicated by the complete
control over the defecatory functions and habits of man. This function, how-
ever, is essential to continued human existence, and the regulation of it is no
mean task considering its involvement in various superstitions, social attitudes,
and agricultural economies. Therefore, it must be borne in mind continually,
that the theoretically ideal or obvious approach to the control of a communi-
cable disease is by no means destined to be practical or successful. The indirect
attack is often the most [ruitful. Furthermore, it can be stated with considerable
reason that the greatest handicaps to control are factors relating to man himself
rather than to the pathogen.

On gaining exit, the parasitic organism must now find some means of
transportation to the body of a new potential host. Here again, depending upon
the biological characteristics of the particular pathogenic organism, the method
of this transfer is limited to a certain one way or few ways. Some organisms,
like the syphilitic spirochete, require very direct and intimate conditions ol
transfer. Certain others, of which those causing malaria and yellow fever are
examples, must rely for transfer not only on another living thing such as a
mosquito, but even only on certain species of that insect. Many organisms,
however, have made themselves more adaptable and have allowed for rela-
tively prolonged existence outside the human host and for transfer in any
one of a number ol ways. The typhoid bacillus can be cited as an example.

Even when the proximity of a potential host is gained, successful transfer
of inflection does not necessarily follow. The pathogen must now find a biolog-
ically suitable mode of entrance. The limitations surrounding this requirement
are similar to those relating to the mode of exit. The choice, in order to be
successful, must conform with the adaptive processes through which the organisms,
both parasite and man, have gone. Generally speaking, but by no means ex-
CONTROL OF COMMUNICABLE DISEASES 537

 

clusively, the mode of entrance is the reverse of the mode of exit, e.g., the diphthe-
ria organism leaves and enters through the nasopharynx, the tuberculosis organism
through the respiratory tract, the typhoid organism through the gastrointestinal
tract, and the malarial organism through the pierced skin.

Finally, a number of factors come into play in deciding whether or not
the parasite which has gained entrance is going to be successful in remaining
and thriving. Among the most important of these may be mentioned the general
state ol health and nutrition of the host, the presence or absence of Immune
bodies, and the virulence and toxicity of the parasite. Because of the future need
of the parasite to continue still further beyond the new host, consideration
must be given to some other characteristics of the host. For example, the typhoid
organism is most successful if it achieves infection of a food handler or of some-
one who is indiscriminate in his defecatory habits. Its chances of future success
are considerably limited when it finds itself within a business or professional
person who works and lives according to a social pattern that provides obstacles
to further transfer. Gonococcal infection of the eyes of a newborn child does
not nearly parallel the degree of success from the point of view of the gonococcus
that is represented in the infection of a prostitute. In the first instance, the
organism has been sidetracked. Likewise, infection of an individual about to
move to a mosquito-free area is largely wasted effort on the part of the malarial
organism.

Each one of the steps mentioned represents a necessary link in the chain
of disease perpetuation. By like token, each represents a place where control
measures may be applied. Here, as in the well-known adage, the chain is only
as strong as its weakest link, and the successful severance of any one link will
go far, and in some instances completely, in controlling particular diseases.

This concept may be approached in still another way. In the accompanying
diagram (Fig. 30), the well person represented by [W] is the center of potential
attack by many types of organisms and in many different ways. He finds in his
environment a number of factors which threaten him: [S] clinically ill infected
humans, [C] apparently well but infected human carriers, |F| inanimate trans-
mitters of disease or fomites, [V] animate transmitters or vectors, [A] animate
nonhuman reservoirs of disease in the form of lower animals, and [I] inanimate
reservoirs of disease such as soil.

The well person may receive infection by means of many combinations of
these [actors, depending upon his biologically adapted habits and activities,
those of other humans, and those ol vectors, animal reservoirs, and the patho-
gens. In certain instances, as in the case ol the venereal diseases, direct and in-
timate contact must take place between the well and the infected human. This
is indicated diagrammatically as [S] [W]. In certain other instances the well
person may be infected across a certain distance by droplets from an infected
human in a nonintimate relationship, [S]—— [W]. Measles and smallpox
present examples of this. With some diseases, an apparently healthy human carrier
may be interposed as in the circumstance of a clinically ill diphtheria patient
passing the organism to another human who remains apparently well but who
in turn transmits the organism to another well person who then becomes clinically
ill, [S]— [C]—— [W]. The intervening factor in some diseases, such as ty-
538 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

phoid, may take the form of inanimate transmitters often referred to as fomites.
Thus, the typhoid patient or carrier may transmit the disease indirectly to a
well person by means of food, milk, or water, [S|— [F|— [W]. With
diseases such as malaria and the rickettsial diseases, the interventing factor may
take the form of a mosquito, tick, louse, or other biting insect. The pattern here
is [S]|— [V]—— [W]. Healthy individuals may sometimes be infected as a

Hemoly fre
Strep.
©
Homrolytre
Strept.

     
   

Hema lytsa (F)

lo o/

 

APosy ys dso

—

    
 

Bedding Lat

Werls Disease foul VRE ( a)

 

angle
Mammals

Fig. 30. Modes of spread of communicable disease. IW, well human; §, sick infected human;
C, well infected human (carrier); F, inanimate transmitter (fomite); V, animate transmitter
(vector); A, animate reservoir; /, inanimate reservoir.
result of intimate contact with healthy carriers, [CG] [W]. An example of this
is found in the transfer of hemolytic streptococci from the hands of an accoucheur
to the tissues of a woman in labor, thereby resulting in puerperal sepsis. Certain
pathogenic organisms may be transferred over a distance from healthy human
carriers to the well person, [C]—— [W]. Here again may be mentioned hemolytic
streptococci now causing scarlet fever in the recipient. Furthermore, many organ-
isms, of which the hemolytic streptococcus is again an example, may be trans-
CONTROL OF COMMUNICABLE DISEASES 539

 

ferred first from a carrier to an inanimate fomite such as food, thence to the
new human host according to the pattern [C]—> [F]—— [W]; if the organ-
ism is the hemolytic streptococcus, it may perhaps result in a case of septic
sore throat. On the other hand, the healthy human carrier may infect an animate
transmitter such as a cow who, developing mastitis and thereby infecting its
milk, may cause septic sore throat in a new human host, the resulting pattern
being |C]— [V]— [F]— [W].

Animate but nonhuman reservoirs of disease may threaten the well person
in a number of ways quite similar to the foregoing. Again instances are found
where intimate contact is necessary between the animate reservoir and the poten-
tial human host. Thus, the handling of the carcass of an infected rabbit may re-
sult in the transfer of tularemia to man, [A] |W]. Bites as in rabies and rat-bite
fever are further examples in this category. Some animal diseases, such as glanders
in horses, may be transmitted over a distance in a manner similar to measles
with the pattern [A]—— |W]. Other animal diseases may be passed on to
human hosts by means of inanimate intermediaries or fomites, [A]— [F|]—
[W]. Here might be mentioned the contamination by rats of bedding or food
from which the human host becomes infected with the leptospirillum causing
infectious jaundice. Some diseases which primarily affect lower animals but
with which humans may be infected may require an intermediate vector usually
in the form of a biting insect. An important example is jungle yellow fever,
transferred by mosquitoes from small jungle mammals to man. Here the pattern
is [A]— [V]—— [W]. Finally, even man’s inanimate environment may be
a source of infection, either by direct contact as in the case of tetanus acquired
[rom the soil, [I] [W], or over a distance as may possibly be the case in trans-
mission of actinomycosis, [1]— [W].

The foregoing scheme by no means presents an all-inclusive picture. Some
diseases of man, particularly those caused by protozoa, involve far more com-
plicated patterns of transmission. ‘The large tapeworm, Diphyllobothrium latum,
for example, infests man according to the following scheme:

dog water crustacea fish human
[A] [1] [A] [A] [W]

 

 

 

Of a similar magnitude is the pattern of schistosomiasis or bilharziasis:

sick human water snail water human

[S] [1] [A] [1] [W]

 

 

A still more complicated cycle is that of the live fluke:

grasses and

 

 

sheep water snail water vegetables sheep
[Al] [1] [A] [1] [¥] [Al
\ |
AN human
NU l 4

NWT
540 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

For purposes of further discussion, however, it is probably best to ignore
these more complicated protozoal infestations and to limit consideration to the
simple circumstances shown in the diagram. It is observed that the ultimate
sources of infection in the diagram occur at the periphery and that, if it is
found possible to place a block between any given peripheral source and the
central potential host, infection cannot take place. Looking at the problem
from the standpoint ol total discases, it might be said that the central potential
host would be completely saleguarded from all diseases il a cordon could be
thrown around him, at any point between him and all of the various peripheral
sources ol infection. Carelul consideration of the diagram indicates the possi-
bility of a series ol concentric cordons, the most central of which would bar
all infection, the more peripheral affecting the more complicated types of infec-
tion patterns.

Theoretically speaking, the more links there are in a chain of infection,
the more difficult it is for the organism to survive. Each link presents another
place where something may go wrong. From the point of view of humanly con-
ceived control measures, each additional link provides another point of attack
where obstacles to disease transmission may be interposed. Because of this,
syphilis, with the simple [S] [W] pattern involving only the spirochete and
man, is proportionately more difficult to control than malaria. In the latter
instance control measures may be applied singly or jointly to any of a number
ol factors: the plasmodium by treating or isolating infected persons; the adult
mosquito, their breeding places, or the mosquito larvae; or the potential hosts.

By the same token, it is equally true that the greater the number of ways
an organism may be transmitted, the greater are its chances of survival. When a
pathogenic organism is restricted completely to one particular path, as is the
malarial parasite, the problem of control, once the basic facts about the disease
are discovered, is greatly simplified. Contrast with this the hemolytic streptococcus
which, as shown on the diagram, may be transmitted by direct or indirect contact
with either a case or a carrier or through a wide variety of fomites and vectors
acting as intermediaries. An organism which could so adapt itself as to be trans-
missible by any or all of the paths indicated would present a dire threat indeed.
Probably the closest approach to this is the Bacillus pestis, which can spread
by intimate contact, by droplet infection, by innumerable fomites, and a number
ol animal vectors. It is not without significance that this particular organism
came closer to eradicating the human race than any other known factor in human
history.

In view of the foregoing, the details of the control of specific communicable
diseases must take into consideration the biological characteristics of the patho-
genic organism, of the potential host, and ol any vectors or animal reservoirs
that might be involved. In order to acquire essential knowledge concerning the
disease and in order to apply that knowledge effectively, attention must be
given both to the adaptive habits of the organisms and to the social and cultural
habits of the hosts.

General Principles of the Control of Communicable Diseases. Control meas-
ures may be aimed at any factor or at any link involved in the chain of trans-
CONTROL OF COMMUNICABLE DISEASES 541

 

mission, i.e., the organism, its present host, its vectors, its reservoirs, or the po-
tential host himself. The following is a general classification of these measures.

PREVENTION OF SPREAD.

Measures Aimed at the Organism. The ultimate point of attack is logically
the pathogenic organism itself. Since the end in view is always the destruction of
the living cause of disease, any measures that could be devised to strike directly at
it would be of great value. This approach, however, is unfortunately difficult
to find since pathogenic organisms by their very nature seldom exist in the
free state. It is interesting that some of the earliest attempts by primitive people
to combat communicable diseases were along these lines, taking the form of the
generation of noise and smoke, the latter subsequently dignified by the term
fumigation. These methods were intended originally to drive away the evil
gods of disease and were later continued against miasms. While current scientific
knowledge makes their use ridiculous, it may be pointed out that as recently
as the beginning of the twentieth century pitch barrels were burned and can-
nons fired in New Orleans as a means of combating yellow fever. Our ties with
the past are further demonstrated by the continued sale of materials for fumiga-
tion and the wearing ol asaletida bags in some parts of the country. A somewhat
direct approach to attacking the organism is found in the treatment of persons
who are infected. The community as well as the personal benefit that results
from so doing has justified, even in the minds of those with narrow horizons,
the treatment under public health auspices ol cases ol syphilis and tuberculosis.

Measures Aimed at the Sources of Infection. Sources ol infection may be
eradicated, their communicability may be reduced, or they may be rendered
noninfectious by treatment.

Eradication of sources: When the source ol infection is a known accessible
animal reservoir, its elimination provides an effective means of eradication of the
disease. Many instances of this method of attack in modern public health prac-
tice may be mentioned. Bovine tuberculosis has been practically eradicated in the
United States by the destruction of infected cattle. However, this could not be
done in a Hindu society. Psittacosis may be eradicated by the elimination of in-
fected parrots and other psittacine birds. Plague, typhus fever, Weil's disease, an-
thrax, tularemia, and a number of other diseases may be controlled by a similar
attack against their animal reservoirs. Theoretically, this approach could be ap-
plied effectively to diseases peculiar to man by the eradication of persons found to
be infected. This was done at least partially during medieval times with regard
to lepers, the deliberate neglect of whom was tantamount to elimination. A more
conscious and direct use ol this method was made occasionally in recent times
by the leaders of the Nazi regime. A more humane and scientific adaptation of
the method is seen in the surgical removal ol a chronically infected part of the
human body. Thus cholecystectomy has been used in an attempt to cure chronic
typhoid carriers, and tonsillectomies have [requently been performed on chronic
diphtheria and streptococcus carriers. Even these techniques, however, have
become less justified with the introduction of antibiotics.

Reduction of communicability of sources of infection: The eradication of
the sources of infections is really not necessary for the control of the infec-
542 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

tions they contain. When dealing with diseases in human beings the most practical
primary point of attack sometimes takes the form of reducing the communicability
ol those infected. This may be accomplished by a combination of two control
measures: (1) limitation of their movement, and (2) treatment of their infection.
Limitation of human activity for public health purposes takes the form of isola-
tion of those known to be infected and quarantine of those known or suspected
to have been exposed to the risk of infection. Customarily the free movement ol
known cases is restricted until clinical observation and/or laboratory tests indicate
the absence of infectiousness. Quarantine [or a disease usually has been extended
over a time interval equal to the usual maximum incubation period of the disease.

These techniques, although of long historical standing, have never been too
popular. First of all, it is human to resist and to circumvent restriction of personal
action. Secondly, the measures are usually economically costly both to those
restricted and to those enforcing the restriction. Beyond these objections are
some more scientific reasons for their limited value. There are many unreported,
hidden, or missed cases of most, il not all, communicable diseases. The ineffec-
tiveness of isolation and quarantine for the control of measles gives testimony
to this. Of even greater significance is the large number of apparently healthy
carriers of some diseases who effectively spread pathogenic organisms although
they themselves do not succumb to the diseases. For this reason, isolation of a
diagnosed case of poliomyelitis and its contacts is futile. Furthermore, the ma-
jority of acute communicable diseases are most infectious during their early stages
belore diagnosis is made or confirmed. Nevertheless, when rigidly applied under
certain circumstances and to certain diseases such as smallpox and bubonic
plague, isolation and quarantine may constitute effective means of control. This
is particularly true in insular health program. An interesting example of the
latter is found in the rabies control program of England.

In order to be segregated and subsequently rendered noncommunicable,
cases first must be discovered. Fundamental to this is a system for the reporting
of cases of communicable diseases both by the physicians in the area at hand
and by health authorities in other localities whence cases may immigrate. Other
sources of information about cases are hospital records, requests for biologicals,
death certificates, and burial permits. The value of a report of a case of com-
municable disease is not in the counting of a “vital fact” or merely in the control
of the case, but in the lead it gives in finding source and contacts. This implies
engaging in what some have termed “shoeleather epidemiology.” A routine
procedure must operate to determine and locate for subsequent examination
the suspects who constitute the group in which active infection of either recent
or earlier origin is most apt to exist.

Human sources of infection may also be discovered by means of various
diagnostic procedures such as tuberculin tests and chest x-rays for tuberculosis,
stool examinations for typhoid and other intestinal infections, nose and throat
cultures for diphtheria, and vaginal and urethral smears for gonorrhea. Such
tests achieve their greatest usefulness when applied il possible on a selective
basis at certain times to certain groups. Thus, tests for tuberculosis are most
productive when applied to young adults, especially those subject to undue
CONTROL OF COMMUNICABLE DISEASES 543

 

susceptibility and exposure because of economic, nutritional, housing, racial,
industrial, or other reasons. Similarly, diagnostic tests for syphilis and gonor-
rhea are of particular value when applied premaritally and prenatally, and to
certain select groups of high average incidence and risk ol infection.

Treatment of sources of infection: To find a source ol infection is in itself
of little value. Prompt treatment is indicated in order to render the source non-
infectious as well as to cure him. Thus, treatment of cases of communicable
diseases is perhaps primarily for the protection of contacts and of the com-
munity and secondarily for the benefit of the patient at hand. This has served
in the past as the justification for the establishment of publicly supported com-
municable disease treatment clinics and hospitals. In a few instances, com-
plete treatment or cure of the case is not necessary in order to eliminate the
threat to those about him. The syphilitic, for example, may be rendered non-
infectious by the prompt administration ol therapeutic agents. Similarly, many
tuberculosis patients may be made noninfectious by means of collapse or drug
therapy. It is important under such circumstances, however, that treatment
be continued to ultimate success, else the source may lapse back to a communi-
cable stage. Furthermore, the trend of modern thought has been to concern itself
not only with the control of a disease from the standpoint of spread but also
in terms of eliminating it as a cause of disability and death. In this sense public
healih is looked upon increasingly as a summation ol personal health.

Measures Aimed at Transmitters of Disease. Many communicable diseases re-
quire some kind of transmitting agent either in the form of an inanimate fomite
or of a living vector. Not infrequently the most fruitful attack is one that is
aimed at these transmitting agents. In fact, some of the most spectacular ex-
amples of successful control have depended upon this approach. Truly re-
markable results have followed programs of water purification, sanitary excreta
disposal, food and dairy sanitation, and pasteurization. Success in these instances
is greatly enhanced by the ability to apply effective control measures at central
focal points such as water treatment plants, pasteurization plants, canneries,
bakeries, and the like. It is worthy of particular mention that the healthfulness
ol our urbanized type of society and economy depends in no small measure
upon our penchant for processed foods, the sanitary quality of which is con-
trolled with relative ease.

Almost equally spectacular results are possible and in some instances have
been achieved by the control or elimination of animate vectors of disease. Here
the public health worker has the advantage of finding a chain of events with
numerous links each of which is subject to attack. For example, the control of
mosquito-borne disease may be achieved in a number of ways. The adult mosquito
may be destroyed by chemical or other means. Its breeding places may be elimi-
nated by filling or impounding, or made unsuitable by spraying with oils and
other larvacides. The mosquito’s effective biting contact may be eliminated by
the use of screens, nets, mosquito bars, and repellents. Finally, persons with
malaria may be isolated from the mosquito, and healthy potential hosts may
avoid the consequence of actual mosquito bites by routine chemoprophylaxis.
Similar measures aimed at other vectors take the form of delousing, cattle dipping,
544 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
ship fumigation, rat proofing, proper garbage disposal, and the destruction of
rats and biting (lies. Measures relating to inanimate transmitters are the cooking
of pork, the boiling of water or milk, the disinfection of typhoid stools, the
burning of tuberculous sputum, and the ultraviolet disinfection of air.

INCREASING THE RESISTANCE OF THE POTENTIAL HOST.

Maintenance of Geneval Health and Nutrition. Although each communicable
disease is attributable to the existence ol a specific infectious agent, certain fac-
tors enter into the decision of whether or not the organism can thrive and cause
disease once it gains entrance to the body of a potential host. The inverse re-
lationship between general health and nutrition, on the one hand, and suscepti-
bility to many infectious agents, on the other, is well established. Examples
ol this are to be found in connection with pneumonia, tuberculosis, some strep-
tococcic diseases, and even some intestinal infections. A rather striking example
is hookworm disease; spontaneous elimination of hookworms has been demon-
strated merely by the improvement of the diet of the host.!

Production of Passive Immunity. This is important, il available, when recent
exposure ol persons susceptible to diseases with short incubation periods is
known to have occurred. Measures of this nature are exemplified by diphtheria
and tetanus antitoxins. Still others are convalescent sera for the prevention of
scarlet fever, measles, whooping cough, chickenpox, mumps, and some other
diseases. Certain precautions must be observed in using passively immunizing
products. Applicable to all of them is the need [or prompt administration of
large enough doses. In the case ol antitoxin, particular care must be taken to
avoid serum reactions by obtaining careful therapeutic histories and, il necessary,
by testing for sensitivity to horse serum.

Production of Active Immunity. Where available and popularly accepted,
active immunization against communicable diseases offers the ideal control
measure. It is in this area that spectacular successes comparable to those effected
by sanitary engineering procedures are to be found. The widespread use of
such simple measures as smallpox vaccination and diphtheria immunization
has all but eradicated the threat ol these two diseases in the United States and
many other countries. Active immunization ol a practical nature is also available
against a number of other infectious diseases including tetanus, pertussis, poli-
omyelitis, typhoid, yellow fever, and spotted lever. Of more limited value and
applicability are active immunizing measures against scarlet fever, meningococcic
meningitis, pneumococcal pneumonia, and influenza.

Prevention of Complications. A technique closely allied to active immuniza-
tion is the deliberate exposure of susceptible persons to measles, followed in five
or six days by the administration of immune serum in an amount not sufficient
to prevent the disease completely but sufficient to modily its clinical severity.
In this way, the patient obtains a lasting immunity by undergoing a controlled,
greatly attenuated attack of the disease. For a somewhat different reason there
has been recent advocacy of the deliberate exposure of female children to rubella
or German measles. This is done in order to preclude the acquisition of the
disease during the first trimester of pregnancy when certain malformations of
the fetus may result.
CONTROL OF COMMUNICABLE DISEASES 545

 

Every communicable disease program must provide for the eventuality of
having to care for some cases which have not been prevented. Many large cities
have met this problem by the maintenance of communicable disease hospitals
wherein adequate isolation and treatment are concurrently effected. Smaller
jurisdictions usually do not find this economically feasible and must resort to
providing treatment under the necessary isolation precautions either in a small
general hospital or in the home of the patient. In view of present knowledge
there is no reason why such expediencies should not be satisfactory, provided
that knowledge is effectuated by proper medical and nursing techniques. Further-
more, it is obvious that il isolation and treatment are to be carried out in the
home much teaching and education ol the rest of the household must be carried
on by the public health nurse.

Administrative Aids in Communicable Disease Control. As with all other
activities in public health work, certain administrative or management aids are
necessary in the control of communicable diseases.

Legislation. The major portion ol public health law in the United States
is concerned with the control of communicable diseases. The most important
basis upon which rests the enactment and enforcement of this law is the police
power, which is considered in more detail in Chapter 8. For purposes of dis-
cussion here it will suffice to remind the reader of the lolly, even in a democracy,
ol allowing each individual complete freedom of action. In fact, democratic free-
dom in order truly to exist must be limited to the right to engage in any activities
except those that may be detrimental to the common wellare. An individual
infected with a disease transmissible to others must necessarily forfeit some of
his personal freedom for the common good. It is the exercise of the police power
over these restricted freedoms that endows the health officer with actually more
power than any other individual or group in society. Only the health authority
may summarily enter premises without a search warrant or deprive an individual
ol his personal freedom without a trial or even a subpoena. The necessity and
legality for such action has fortunately been well established in the courts.

In order to make possible the administrative control of communicable dis-
eases the states and the communities they contain have [ound it expeditious and
necessary to enact many types ol legislation. The ultimate responsibility for
the promulgation and enforcement ol communicable disease laws, rules, and
regulations rests with the state. In all of the states and territories, the state
health departments have this responsibility. In fifteen instances, however, power
of enforcement is either not included in the regulatory authority or is limited
to situations in which local action is inadequate. With regard to diseases of
animals transmissible to man, the responsibility is shared with the department
of agriculture in twenty-five instances and with special commissions in six in-
stances. Other components of state government that are occasionally involved
in communicable disease control include departments ol welfare, social security,
public assistance, education, and in two instances the state university. Where
responsibility is thus divided, it is done so in consideration for the particular por-
tions of the general health program for which the respective departments are
responsible. For example, in five states the department of education is responsible
546 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

for the enforcement of the compulsory smallpox vaccination law, and in several
states a department ol public welfare or a state university has responsibilities
concerning hospitalization of communicable disease patients.”

The problem of communicable disease is ever changing, due to biological
factors and to the application ol newly acquired knowledge. It is usual, therefore,
for states periodically to revise their communicable disease codes. However, a
1910 study by Mountin and Flook? showed that only thirty-seven of fifty-two
states and territories had revised their codes within the preceding five years.
Six codes were between five and ten years old, five were between ten and fifteen
years old, one was eighteen years old, and one was twenty-five years old. Two
states did not report. Examination of the regulations by these investigators and
by Emersont indicated, however, that in many instances antiquated and ineffec-
tive measures are carried over [rom one revision to another.

Emerson? in discussing this aspect ol the problem pointed out:

. .. there remain, or have been incorporated in the sanitary regulations and public
health laws of a considerable number of our states, requirements that contribute little
if at all to the control of the communicable diseases in question, because they are
based upon misinformation as to the natural history of the disease in question. Further-
more there are frequent instances of differences of health procedures within states, in
cities, and other local jurisdictions which reveal a confusion in the minds of the respec-
tive health officers which can hardly have a favorable effect upon physicians and patients
in these communities.*

He opined that only about two thirds of the states and territories have suitable
and effective communicable disease laws, rules, and regulations. In most il not
all of the remainder, “There are departures more or less marked from those
which present day knowledge ol the communicable diseases would suggest as
reasonable and sufficient.” In analyzing the undesirable features ol such legisla-
tion, Emerson pointed to six characteristics in particular:

a. Lack of notification of some discase for which modern standards of health service
appear to demand notification.

b. Placarding premises where cases of various communicable diseases are reported,
under circumstances that make observance of isolation or quarantine neither likely
nor helpful in preventing secondary or subsequent related cases in the home of
the index case or elsewhere.

c. Failure to verify the diagnosis of certain important diseases by an expert clinician,
by laboratory test or by both.

d. Requiring isolation periods for infected persons and quarantine periods for exposed
susceptibles which are significantly inconsistent with the known periods of communi-
cability and incubation of the particular discase.

e. Failing to provide for a consecutive sanitary supervision of carriers from the time
of the clinical course of the disease, or the first discovery of a carrier state, until
it can be shown that these persons are no longer spreaders of infection.

f. Use of fumigants for terminal disinfection of some of the bacterial and virus diseases. *

Reporting. The most fundamental matter requiring legislation is concerned
with the reporting to the official health agency ol all cases ol certain diseases

*Emerson, Haven: Uniformity in Control of Communicable Diseases, Am. J. Pub. Health
32:133, Feb. 1942.
CONTROL OF COMMUNICABLE DISEASES 547

 

listed in a communicable disease code. Acquisition of such information is a
necessary prerequisite to any further steps the health authorities may wish to
take in the control of those diseases. It provides the starting point for the ap-
plication of isolation and quarantine measures and for all routine epidemiological
investigations. Although states vary somewhat in the particular diseases for which
they require reports, the accompanying list (Table 35) is more or less typical.

In addition to those listed above there are a number of other diseases the
reporting of which is not infrequently required. The obligatory reporting of
these diseases (Table 36) is not ordinarily considered justified by the benefits
that may accrue from whatever steps the health authority may take in their
concern.

Many states at the present time also include certain noncommunicable di-
seases in their lists of reportable conditions. Occupational diseases constitute
the bulk of these, while some of the Southeastern states particularly include
some of the avitaminoses, especially pellagra.

On the local level it is usually required that cases, carriers, or suspects of com-
municable diseases shall be reported to the local health officer acting as the
agent of the state. In cities and counties without local health departments it
is usually required that reports be made directly to the state health department.
While “immediate” notification is ordinarily specified, in practically all cases
this is interpreted to mean within twenty-four hours following diagnosis. Al-
though in most instances it is a physician who is in the position of having to
make a report, a number of other persons are usually specified in the laws, rules,
and regulations as also having responsibility. The following are generally included
in such lists: physicians; dentists; directors of registered laboratories; veteri-
narians; parents and guardians; superintendents, principals and teachers of all
schools; nurses, whether engaged in private duty, school, public health or in-
dustrial work; pharmacists; keepers of hotels, lodging houses, cabin camps, and
trailer coach parks; superintendents of public or private hospitals, nursing homes,
clinics, dispensaries, asylums or jails; owners or managers of any dairy farm
or place where dairy products are handled or offered for sale; and licensed em-
balmers, when the death certificate certifies that the primary or contributory
cause of death was one of the reportable diseases.

Reporting is effected locally in either one or a combination of two ways.
Some jurisdictions require written reports on all reportable diseases. Many other
places, however, make the much more reasonable compromise of accepting tele-
phonic reports on all diseases and requiring written confirmation for only a
few of the more serious such as smallpox or typhoid fever. Written reports are
usually in the form of printed postal cards providing space for entry of the
patient’s name, address, age, color, sex, and disease, and the name and address
of the person reporting.

Since the collection of data on the incidence of communicable diseases is
a function of all state health departments, the regulations of every state provide
for the transmission of information from the local health authorities or, in
their absence, from physicians directly. About two thirds of the states collect
548 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 35. Diseases Usually Considered Reportable in the United States*

 

Anthrax

Brucellosis

Chancroid (soft chancre)
Cholera

fConjunctivitis, acute infectious (of the new-

born, not including trachoma)
Dengue
iDiarrhea of the newborn, epidemic
Diphtheria
Dysentery, bacillary (shigellosis)
Encephalitis, arthropod-borne
iFavus
Food infections (salmonellosis)
Food poisoning (bacterial intoxications):
a. Staphylococcus
b. Botulinus (botulism)
Glanders
Gonorrhea
fImpetigo contagiosa
Influenza
TKeratoconjunctivitis, infectious
Leprosy
Leptospirosis
Malaria
Measles (rubeola)
Meningococcus meningitis
fever), meningococcemia
Paratyphoid fever

(cerebrospinal

Pertussis (whooping cough)
Plague
Pneumococcal pneumonia
Poliomyelitis
Psittacosis
Q fever
Rabies
fRingworm of the scalp (tinea capitis)
Smallpox (variola)
Streptococcal infection—respiratory:
a. Scarlet fever
b. Streptococcal sore throat, streptococcal
nasopharyngitis, streptococcal tonsil-
litis, “septic sore throat”
Streptococcal infection other than respira-
tory:
a. Erysipelas
b. Puerperal infection (puerperal sep-
ticemia)
Syphilis
Tetanus
Trachoma
Trichinosis
Tuberculosis (pulmonary)
Tuberculosis, other than pulmonary
Typhoid fever
Typhus fever
Yellow fever

*Information taken from Control of Communicable Diseases in Man, ed. 8, New York, 1955,

American Public Health Association.

Epidemics only.

Table 36. Diseases Not Ordinarily Considered Reportable in the United States

 

Amebiasis

Ascariasis

Chickenpox

Choriomeningitis

Coccidioidomycosis  (coccidioidal granuloma,
“valley fever”)

Common cold

Filariasis (mumu)

German measles (rubella)

Granuloma inguinale

Hookworm disease (ancylostomiasis)

Lymphogranuloma venereum (inguinale) and
climatic bubo

Mononucleosis, infectious (glandular fever)

Mumps (infectious parotitis)

Pediculosis

Pemphigus neonatorum (impetigo of the
newborn)

Bacterial pneumonia other than pneumococ-
cal

Primary atypical pneumonia

Rheumatic fever (acute rheumatic fever,
acute rheumatism)

Ringworm of the body

Scabies

Schistosomiasis, bilharziasis

Vulvovaginitis in children

Yaws (frambesia)

 
CONTROL OF COMMUNICABLE DISEASES 549

 

 

reports weekly, only one third requiring daily reports. Occasionally, states have
paid fees for reports of communicable diseases. In most instances this was in
lieu of salary to part-time officials acting in the absence of a full-time health officer.

Despite the fact that failure to report a case of communicable disease usually
implies liability to prosecution, it is common knowledge that reporting is far
from complete. A health officer would be utterly lacking in wisdom if he were
to attempt to obtain reports, particularly from private physicians, only on the
strength of his legal prerogatives. A legal point and a demonstration of authority
might be gained only at the expense of having made one or several lasting
antagonists who henceforth may avoid cooperation with the general public health
program, if they do not actively oppose it.

Persistent tact, educational efforts, and good professional relationships are
the keynotes to success. Certain generalizations may be arrived at in this regard.
The more serious a disease, the more [faithfully it is apt to be reported. Thus,
physicians seldom fail to report cases of smallpox, where they might on the
other hand pay little attention to a requirement to report measles. Furthermore,
it is not surprising that many physicians are negligent in reporting diseases
about which past experience has indicated that little official action will or can
be forthcoming. It is to be recommended, therefore, that requirements for re-
porting be limited to diseases which present a real social threat and about which
some fruitful, official steps may be taken. Sometimes a public health agency
wishes information concerning minor diseases or those about which at present
it can do little. In such instances, it is advisable that the true reasons be placed
frankly before those from whom the reports are requested rather than simply
to notify them that as of a certain date a certain disease must be reported. The
one approach invites cooperation whereas the other is branded as bureaucratic.

The hesitancy of many physicians to report by name patients suffering
from certain socially stigmatized diseases such as syphilis is understandable. In
many areas a practical compromise has been reached. In the long run, of course,
public and professional education is the path to follow toward the attainment
of a more mature attitude toward these as well as other diseases. Meanwhile, it
is possible to arrange for reports by number rather than name with the provision
that infectious patients who have become negligent in their treatment be sub-
sequently reported to the health authorities by name and address in order that
field follow-up may be carried out.

Isolation and Quarantine. Until relatively recently legal authority was freely
invoked for the assurance of isolation of cases and quarantine of contacts of many
communicable diseases. In fact, as recently as the 1920's many communities still
refused to release all cases and contacts of many diseases until after prolonged
periods of surveillance. Careful studies of the question by a number of investi-
gators, particularly Charles V. Chapin? in Providence, HolstS in Norway, and
Gordon and Badger? in Detroit, have brought out the limitations of these methods
in the control of many communicable diseases. The trend in recent years has
been toward progressive shortening and individualization of the periods of re-
striction with severity of infection, complications, age, and occupation as the
550 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
guides. The decrease in the extent to which these restrictive measures are used
has resulted not only in improved public relations but also in a very considerable
financial saving both to private citizens and to publicly supported hospitals and
health departments.

Historically, isolation and quarantine have been associated with placarding.
This procedure has been passing out of the present scene to an even greater
degree than prolonged quarantine. The case against placarding was so well stated
in the seventh edition of The Control of Communicable Diseases in Man,’ a
report by the American Public Health Association, that it is included here
verbatim.

Placarding—This official procedure under local or State authority consists of posting
a warning notice upon the door or entrance to living quarters of persons isolated
because of communicable disease. The object of such placarding is primarily to keep
unauthorized persons from entering upon the premises during the period of communica-
bility of the isolated patient. Such placarding may incidentally protect the patient
against additional or secondary infection which may be carried to him by visitors. Its
use may have some educational value.

Placarding, however, does not aid significantly the efforts of a health department
to control the acute communicable diseases ordinarily spread directly from person to
person in the United States (chicken pox, mumps, pertussis, measles, diphtheria, scarlet
fever, anterior poliomyelitis, meningococcus meningitis, pneumonia, tuberculosis, gonor-
rhea, syphilis) and consequently is not recommended for these diseases.

Placarding has definite disadvantages: it is difficult to enforce, it may be a deterrent
to reporting, it is costly in transportation. The most serious objection is the loss of time
of public health nurses and other public health department employees that should be
devoted to practical instruction in the observance of isolation and concurrent disin-
fection at the bedside of patients suffering from the more serious of the communicable
diseases. *

The current policies of the health department of a large city illustrate the
trend toward more reasonable controls of communicable disease cases and con-
tacts. The requirements may be summarized as follows:

Quarantine of Contacts

Chickenpox—none

iDiphtheria—pending negative nose and throat cultures

fPoliomyelitis—none

tScarlet fever—none

Measles—none

Pertussis—nonimmune child contacts excluded from school and public gatherings for 14
days after last exposure

Smallpox—16 days from last exposure unless successfully vaccinated

Typhoid and paratyphoid fevers—mo quarantine but familial contacts should not act as
food handlers

*Control of Communicable Diseases in Man, ed. 7, New York, 1949, American Public
Health Association, p. 14.

Wage earners permitted to enter and leave premises if they have no contact with the
patient, with children, or with food for public consumption.
CONTROL OF COMMUNICABLE DISEASES 551

Isolation of Cases

Until recovery—erysipelas, influenza, leprosy, meningococ meningitis, mumps, ophthalmia

neonatorum (from other infants only), septic sore throat, typhus fever

For specific periods—

Chickenpox—until skin entirely clear

Smallpox—until skin clear of crusts

Diphtheria—until two successive negative nose and throat cultures, 24 hours apart,
otherwise 14 days

Measles—7 days from rash minimum

Pertussis—3 weeks minimum

Poliomyelitis—7 days minimum from onset

Pisittacosis—during acute clinical stage

Scarlet fever—7 days minimum in uncomplicated cases, otherwise until recovery

Typhoid and paratyphoid—until three consecutive negative stool cultures at least 24
hours apart

Excluded from school, public gatherings, or work until recovery—impetigo, epidemic kerato-

conjunctivitis, scabies, trachoma

Excluded from intimate contact—chancroid, gonorrhea, syphilis, granuloma inguinale,

lymphogranuloma venereum

Not required but desirable—common cold, amebic dysentery, bacillary dysentery, pneumococ-

cic pneumonia, primary atypical pneumonia, tuberculosis (preferably in hospital or
sanatorium)
Separation from women in early preganacy—rubella

Compulsory Immunization. An important type ol communicable disease
legislation is that dealing with immunization requirements. With the develop-
ment of such protective measures against a specific important communicable
disease, it is natural that many persons in positions of authority would attempt
to bring about the enforced acquiescence to their use by all people. Most notable
in this regard has been smallpox, a sufficiently serious disease and one against
which a spectacularly casy, sale, and powerful preventive is available. Many
countries have seen fit to require vaccination against smallpox by law. The
pattern in the United States varies. By 1915, fifteen states and territories* and
the District of Columbia had laws which require vaccination as a prerequisite
to school attendance. T'wenty-one others’ had laws or regulations which enable
local jurisdictions to enact compulsory vaccination regulations or which require
vaccination under certain conditions such as threatened epidemics, exposure
to cases, or the existence ol a case in a school or in the community. In striking
contrast to the foregoing are several states which had certain statutory pro-
hibitions concerning vaccination (Table 37).

Mountin and Flook? found that during the decade preceding their analysis,
1932 to 1941, only one state was added to the group with compulsory smallpox
vaccination laws. On the other hand, they noted considerable shifting in the
group having conditional laws or regulations, frequently toward more delega-

*Arkansas, Kentucky, Maryland, Massachusetts, New Hampshire, New Mexico, New York,
Pennsylvania, Rhode Island, South Carolina, Virginia, West Virginia, Hawaii, Puerto Rico,
and the Virgin Islands.

Alabama, Arizona, Colorado, Connecticut, Georgia, Iowa, Kansas, Louisiana, Maine, Michi-
gan, Minnesota, Mississippi, Montana, New Jersey, North Carolina, Ohio, Oregon, Tennessee,
Wisconsin, Wyoming and Alaska.

fArizona, California, Minnesota, North Dakota, South Dakota, Utah, and Washington.
552 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 37. Statutory Probihitions Relative to Vaccination*

State Action Prohibited or Made Unlawful

Arizona Subjecting minor child to compulsory vaccination without parent's or guard-
ian’s consent.

California Adoption by school or local health authorities of any rule or regulation on the
subject of vaccination.

Minnesota Rule of state board of health or of any public board or officer compelling vacci-
nation of child or excluding, except during smallpox epidemics and when
approved by local board of education, child from public schools because un-
vaccinated.

North Dakota Making any form of vaccination or inoculation a condition precedent for
admission to any public or private school or college of any person, or for exer-
cise of any right performance of any duty or enjoyment of any privilege by
any person.

South Dakota For any board, physician, or person to compel another by use of physical force,
to submit to operation of vaccination with smallpox or other virus.

Utah For any board of health, board of education, or any other public board to com-
pel by resolution, order, or proceedings of any kind the vaccination of any
person of any age; or to make vaccination a condition precedent to attendance
at any public or private school, either as pupil or teacher.

Washington Requiring children to submit to vaccination against parents’ or guardian's will.

 

*Adapted from Fowler, William: Principal Provisions of Smallpox Vaccination Laws and
Regulations in the United States, Pub. Health Rep. 56:188, Jan. 31, 1941.

tion ol responsibility to local jurisdictions. Without question, where smallpox
has been occurring to a significant extent, compulsory vaccination brings about
results as illustrated in the accompanying map (Fig. 31). It shows for the decade
1936 to 1945 the incidence of smallpox to be significantly lower in the states
with compulsory vaccination laws and higher in the few states where compulsion
is prohibited. Since that time the incidence of smallpox has undergone a marked
reduction throughout the nation. In the process, those areas which were negligent
or which were opposed to forthright action undoubtedly rode on the successes
and results of the states and areas that undertook forceful epidemiological ac-
tion. Ordinarily, of course. acceptance of a procedure based upon understanding
is the best long-term method.

Compulsory immunization laws are occasionally found in relation to several
other diseases. A few states and a number of local communities have legally re-
quired immunization against diphtheria as a condition for admission to school.
The inaptness of this is to be found in a study of the age distribution of diphtheria
cases and deaths. In the existence of laws of this nature there is a known ten-
dency on the part of parents to defer obtaining the protection until their chil-
dren are ready to enter school, overlooking the fact that the greatest threat
from the disease is during the preschool period from the first to the sixth birthday.
     

 

 

 

 

777
8.9 N.MEX. OKLA
2.7 8.7
TEXAS
2.8

~~

Fig. 31. Vaccination legislation and average annual smallpox incidence per 100,000 population, by states, 1936-1945.
White, vaccination required for school; stippled, local option in face of threat; diagonal lines, no vaccination
laws; solid, compulsory vaccination prohibited.

 

SaSVISIA FTGVIINNWWOD HO TONLNOD

£65 sasv

 
554 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Arkansas, Mississippi, and New Mexico in the past have required immuniza-
tion against typhoid fever for “family contacts and known carriers,” “all food
handlers,” and “all susceptibles.” While the development of immunity in such
persons may go far in preventing clinical typhoid fever in them, it in no way
assures their being rendered noninfectious for others. This comment in no way
is intended to belittle the administration of typhoid vaccine to contacts of cases
of the disease. The value of this procedure on an elective basis has been well
established by Ramsey,'> who showed a 75 per cent reduction in the number of
expected cases among contacts who were promptly inoculated. A few countries
have attempted to require vaccination against yellow fever in certain groups ol
their population.

Akin to the foregoing attempts to control communicable diseases in man
is the legislative requirement in some jurisdictions that all dogs be actively im-
munized against rabies. Not infrequently this calls forth even greater public
indignation and vituperation than do attempts to obtain immunization of chil-
dren against diphtheria or smallpox.

Compulsory Examination. Another area in which legislative control of com-
municable diseases has been attempted involves the compulsory examination
ol certain people under certain circumstances. At the present time, the majority
of states have laws requiring the examination of all applicants for marriage li-
censes. Unfortunately, the premartial examination too often consists merely of
the performance ol a serologic test lor syphilis, completely ignoring other path-
ologic threats that one prospective mate may bring to the other. Forty-two states
now have premarital examination laws. The majority require that both the pros-
pective bride and groom have a physical examination, including a serologic test
for syphilis, prior to issuance of a marriage license.

Proponents of such legislation find it possible to present forceful arguments
to uphold their action, and in some peculiar circumstances, as in the instances
of premarital and prenatal examinations, little cause for disagreement is pos-
sible. Using Kentucky in the 1940's as an example, when tests for syphilis were
performed only when the disease was suspected, only one case per 1,000 per-
sons was found. This is in marked contrast with eighteen cases found per 1,000
routine prenatal examinations performed, and twenty-eight cases found per 1,000
routine premarital examinations. In that same state, when Federal requirements
were in operation for the examination of military selectees, seventy cases ol
syphilis were found per 1,000 selectees routinely examined. However, as a re-
sult of the significant changes that have come about in the incidence, treatment,
and control of the veneral diseases, the legal requirement of premarital examina-
tion for these diseases is probably no longer practical. Condit and Brewer,
for example, pointed out that even by 1949-1951, the 511,160 premarital ex-
aminations in California brought to light only 1,079 cases of syphilis of which
only 162 were in the primary and secondary stages, at a cost of $2,741 per new
case found. Only 4.3 per cent of all primary and secondary cases were discovered
by this means. More recently Hedrick and Silverman! have compared the ex-
periences of the states which require premarital examinations with those that
do not. They found that during the decade 1945 to 1956 both groups enjoyed a
CONTROL OF COMMUNICABLE DISEASES 555

dramatic 97 per cent decline in infant deaths caused by syphilis and a 93 per
cent decline in primary and secondary syphilitic morbidity. The conclusion is
that compulsory laws for premarital blood tests have very little influence on
syphilitic mortality and morbidity, are very expensive to carry out, and are no
longer justified.

Based upon the same general philosophy as premarital examinations, many
states have enacted legislation requiring prenatal examinations. Again, the chief
target is syphilis. At the present time, forty-four states, and the Virgin Islands have
enacted such laws. Prenatal health examination laws are confined to blood sero-
logic tests for syphilis with the responsibility placed upon the attendant of the
pregnant woman. Exceptions to the latter are Georgia and North Carolina, where
the pregnant woman also has the responsibility to request a test. One of the obvi-
ous difficulties is the time factor. Most state laws specify a serologic test during or
within fifteen days of the first examination. This, of course, is of limited value
if the first visit is shortly before delivery. The remaining state laws tend to be
even more general.l® One state, Alabama, enacted legislation in 1943 which re-
quired that every resident obtain a serologic test for syphilis within a certain
period of time and in 1947 enacted similar legislation with regard to universal
compulsory x-ray examination of the chest.

A rather wide variety of laws and regulations exist throughout the country
relating to the compulsory examination of various types of workers and groups
in society. The most common and significant of these are persons known to have
been contacts of cases of communicable disease. It is common practice to re-
quire a medical examination as a condition for employment as a school teacher.
It is not unusual, however, to find that no further periodic examinations are
required after employment as a teacher is an accomplished fact.

Food handlers have been singled out as a key group for whom to require
pre-employment and intra-employment examinations. It is unfortunate that, more
often than not, the chief if not exclusive concern for the requirement of food
handler examination is [ound to be an interest in the search for syphilis. Ob-
viously this ignores the fact that a food handler can transmit the spirochete of
syphilis only with great difficulty while engaged in activities customarily con-
sidered to be related to food handling. To examine food handlers for signs
and symptoms of tuberculosis, the typhoid fever carrier state, and a few other
pertinent conditions may well be warranted. To single out this occupational
group with regard to the venereal diseases, however, does not appear justified.

Some states have enacted regulations which require the pre-employment
and periodic examination of workers in certain of the heavy industries, par-
ticularly those in which risk of silicosis and radium poisoning are known to exist.
A few communities have adopted the policy of routinely examining all persons
arrested for certain offenses, particularly prostitution, because those involved
are considered to constitute key epidemiological groups.

Compulsory Treatment. The police power is sometimes resorted to in re-
quiring the treatment and, if necessary, enforced hospitalization of recalcitrant
individuals infected with certain communicable diseases. Every large health de-
partment, for example, has found it necessary to resort to this undesirable pro-
550 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

cedure occasionally with regard to cases of smallpox, typhoid fever, the venereal
diseases, and even tuberculosis.'” In a sense to do so represents an admission
of failure on the part of the educational and public health agencies of the com-
munity. However, a certain few adamantly unreasonable and uncooperative
persons must always be considered to exist and if necessary must be provided
for by law.

Regulation of Vehicles of Disease Transmission. Of tremendous public health
importance are the regulations dealing with the many vehicles ol disease trans-
mission. There exists a formidable array of laws, regulations, and codes, un-
fortunately sometimes contradictory, concerned with the production, treatment
and distribution of milk, milk products, food, water, and drugs. Other factors
that might be included here deal with plumbing, sewage disposal, stream pollu-
tion, atmospheric pollution, and the care and transportation of the bodies of those
who have died from communicable diseases. No reasonable person would contest
the wisdom of providing legislative control over these factors. The outstanding
criticisms that may be raised, however, are based upon the wide variability of their
provisions and their not infrequent contradictions and anachronisms.

Some mention should be made of the wisdom of placing too much reliance
upon legislative action in the accomplishment of public health aims. It must
always be remembered that it is natural for a free people to resent laws and
restrictions and to occasionally regard them as challenges which provide an
incentive for the popular game of circumvention. It should be realized further
that the enactment of a law in no sense constitutes an accomplished end. IlI-
conceived and poorly administered laws do provide for mutually undersirable
and costly court action which all too often in infractions of the public health
law ends in dismissal for lack of evidence or the levying of a relatively small
fine. Generally speaking, publicity attending such cases is not a particularly de-
sirable type of publicity and often tends to crystallize hitherto unorganized oppo-
sition to the general public health program.

While it is always desirable to have a practical, scientifically correct, and
complete body of public health laws to fall back upon whenever necessary, it
is equally wise to avoid insofar as possible the exercise of those laws. On the
other hand, there is little sense in the enactment of laws and regulations in the
absence of intent or ability to enforce them whenever truly necessary. For the
greatest ultimate success, reliance should be placed upon intelligent coopera-
tion by the public. This means that in the final analysis an effective program of
community health education is the most [ruitful approach to communicable dis-
ease as well as to other public health problems. To tell an individual he must
not do a certain thing does nothing to make a better person or citizen of him
and merely calls forth either dumb, unthinking acquiescence or sullen resent-
ment. To educate him in an intelligent, cooperative manner, with regard to
the undesirability of following a certain line of action, offers much more chance
of success which, when it occurs, instills the idea not only in the individual but
also in those about him, and those who follow.

Material Aids in Communicable Disease Control. The provision or use of
certain material aids has become standard practice in official public health agen-
CONTROL OF COMMUNICABLE DISEASES 557

 

cies. Of primary importance among these are standardized forms furnished to
private physicians on which they may report births, deaths, cases of communica-
ble diseases, prophylactic treatments, and other significant information. The key-
note for administrative success in designing such forms is simplicity and brevity.
To require extensive written reports from busy medical practitioners, particularly
if they have to pay the postage, is to invite failure. Such reports should be looked
upon by public health agencies only as points of departure and should therefore
be restricted to a minimum of questions such as identification and location of
an individual affected, the condition with which he is affected, and possibly
a few other items of basic information depending upon the disease, service,
and other circumstances. Prestamped or the more economical prepaid reply type
ol card should be made [reely available to all practicing physicians, along with
simple instructions concerning their legal responsibilities. This is particularly
important when physicians first enter practice in the locality and whenever
responsibilities undergo a change.

A most important adjunct to the communicable disease control program
takes the form of furnishing biological and certain other diagnostic, prophylactic,
and therapeutic material and of diagnostic laboratory service to physicians upon
request and preferably free of charge. In addition to this, the laboratory serves
a fundamental function in the sanitary control of foods, milk, and many environ-
mental factors that may influence the public health. Since this phase of the
public health program is specifically considered in Chapter 15, no detailed dis-
cussion of it will be entered upon at this point.

Consultation Service. Consultation service in the diagnosis ol communicable
diseases or for questions relating to their control represent another type of ma-
terial assistance customarily offered by public health agencies. All state health
departments at the present time provide this service to local health departments,
which in turn include it as a primary part of their service to local practicing
physicians. There are two reasons for doing this: (1) the health department
is the agency responsible for the control of communicable diseases, and (2) the
health officer by virtue of his position and responsibility usually sees more cases
of communicable diseases than the average physician. Therefore, he often has
a more extensive diagnostic background in this field upon which to draw.

Graphic Aids. Within the health department a number of material aids
and techniques have been found useful for the efficient administrative control
of communicable diseases. These fall into the two categories of graphic aids
and registers. Perhaps the most common, useful graphic aid is the spot map
of cases as they occur in the area through time. Graphs showing the incidence
of disease by day, week, month, or year are also [requently found useful. With
certain diseases, particularly measles, incidence charts which include five-year
or seven-year moving medians for epidemic and nonepidemic years have been
found to be particularly useful in estimating disease expectancy (Fig. 32). Every
health jurisdiction and the statistical data relating to it should be fractionated
to some degree in order to make more evident the predominant trends and pro-
blems. For this purpose health departments have relied particularly upon census
tracts, voting areas, or sanitary districts for which basic population data may
558 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

        

 

 

 

 

 

 

 

 

 

2,000 — i.
1800  POLIOMYELITIS ~~ |
/ \
’
1,600 ; “eo -
” I ee Ne
w 1,400 = »> \ -~
w
Et , ® “
J 1,200 t= °° ° -
o J, .
« 1,000 °o / \ “1
3
3 800 I -
z
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400 -
o
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0 et faansrsg reset dt — "7 1 | 1 1 1°
WEEK —e 44 48 S21 4 8 12 6 zo 24 28 | 32 36 | 40 [aa [a8 52
Nov | DEC | JAN | FEB | MAR | APR | WAY | yung | July | AUG | SEPT | OCT | NOv | DEC |
1,000 _
900 }— DIPHTHERIA |

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

«
<
-
2
2
w
o
x
=
©
3
2
z
° ° e_~_ aos
100} . ®e,0a% ° .
I) A I l 1 1 1 1 1 | | ! 1 [ 1
\WEEK—» 44 a8 521 4 12 6 20 24 28 32 36 40 44 48 52
| wov | DEC | JAN | FEB MAR APR MAY JUNE JULY AUG SEPT ocr NOV DEC |
10,000 |- |
9.000 | SCARLET FEVER |
8,000 [~ 1
IT
$7000 Rd TT hn
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© 6,000 re \ -
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o
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WEEK —» 44 48 52 1 4 ” 16 20 24 28 32 36 40 44 148 52
wov | DEC | JAN | FEB MAR APR MAY JUNE Jury AUG SEPT ocT NOV DEC |

Fig. 32. Communicable disease charts. All reporting states, November 1947 through October
16, 1948. The upper and lower broken lines represent the highest and lowest figures recorded
for the corresponding weeks in the seven preceding years. The solid line is the median figure
for the seven preceding years. All three lines have been smoothed by a three-week moving average.
The dots represent numbers of cases reported for the weeks of 1948.

=
 

CONTROL OF COMMUNICABLE DISEASES 559

be conveniently available. A particularly interesting and useful adaptation of
this is found in the so-called epidemiological master chart, described in Chapter
14 and illustrated in Figure 28. Rich and Terry's have suggested the use of the
industrial type ol control chart for epidemiological purposes. It is only by the
use of such tools that the public health worker can maintain a continuous
and adequate grasp of the total disease situation and the factors relating thereto.

Registers. The maintenance of case registers has proved to be of incalculable
value in the operation of adequate programs for the control of many diseases.
Most commonly used in connection with tuberculosis, resisters have also been
developed by some health departments for veneral diseases, some of the more
important acute communicable diseases such as typhoid fever and diphtheria,
and occasionally for cancer. To be of value the register should readily indicate
by some combination of filing and tickler system the location of the patient,
the stage of his disease, and the date of next indicated treatment or follow-up
procedure.

Administrative Programming in Communicable Disease Control. The official
program for the control of communicable diseases should be based upon all
the known epidemiological facts and should be carefully and logically planned
and balanced rather than allowed to pursue a hit-or-miss policy. The total pro-
gram may be divided into routine control measures and those activities neces-
sitated by emergency or epidemic situations. Much of the program may be routin-
ized to a greater or lesser degree. In order to do so successfully it is necessary
for the public health agency to obtain satisfactory answers to the following
series ol questions about each disease with which it is concerned.

1. What groups of the population are most apt to have infection?

2. Which of them are in the best position to expose others?

3. Where are they most conveniently and efficiently found?

What possible groups are most apt to be exposed?

5. When, where, how and why are they subject to exposure?

6. What practical and economical control procedures and facilities are
available? }

7. What practical and economical control procedures and facilities are ac-
ceptable to, the people involved?

-

For practical purposes the factor of timing is of paramount importance.
Communicable diseases may be subdivided into those that vary in incidence by
season and those that occur constantly, or endemically, throughout the year.
Under usual circumstances, a certain relatively constant incidence of new cases
of tuberculosis and the venereal diseases may be expected. Programs aimed at
combating them must, therefore, involve a constant hammering at the factors
involved in their spread. Contrasted with these are the so-called acute communi-
cable diseases of childhood which are subject to marked seasonal and, in some
instances, annual fluctuation. A considerably simplified picture is presented in
Figure 33 indicating the general seasonal prevalence in North America for a num-
ber of these diseases. The majority may be expected to increase markedly in
numbers of cases during the spring months of the year. Whooping cough tends
560 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

to lag a month or two behind the main group, while poliomyelitis is usually
most prevalent in the fall, and diphtheria in the winter months.

While it is desirable that children receive immunizing protection against
various diseases routinely as they reach certain ages, it is obvious that any special
immunization programs that may be considered necessary should precede the
period of expected high incidence. With this in mind, it would be far more
practical and fruitful for a health department to engage in a special whooping
cough immunization program during February and March than to wait until

 

  
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pia oc. | roe A
No .* ‘. MUMPY » “a,
g A . - RAE
° A
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\ o ° CHICKEN POX x
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oo eno hee ssdpanete saan poss ET J ER I PER Fede elie coood

 

 

JULY AUG SEPT ocT NOV. DEC. JAN. FEB. MAR. APR. MAY JUNE JULY

Fig. 33. Seasonal prevalence of acute communicable respiratory diseases.

 

   

 

 

 

 

 

 

 

 

PERTUSSIS SCARLET FEVER RUBELLA |MUMPS
VEAJLES DIPHL CHICKEN POX
w
\\
Zz
Ww
J
«
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Ww
x
a
w
2
+
«
J
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0 5 10 15 20 25

YEARS OF AGE

Fig. 34. Relative prevalence by age of acute communicable respiratory diseases.

August or September when the seasonal threat of that disease has passed. A
health officer interested in the use of convalescent serum, placental extract, or
other similar materials for the prevention or alleviation of measles in his com-
munity would best have it available during the spring than in the summer or
fall when there would be little occasion for its use. The promotion of a post-
graduate institute in the management of cases of poliomyelitis would probably
be of greatest value in the late summer months rather than at any other time
of the year.
CONTROL OF COMMUNICABLE DISEASES 501

 

Control programs should be similarly keyed with regard to age since par-
ticular diseases tend to affect certain age groups more than others (Fig. 34). A
pertussis immunization program for entering school children would be of little
avail since the period of greatest risk occurs much earlier in life, during the
first two years. Emphasis, therefore, should be placed upon the immunization
against this disease during infancy. For similar reasons the diphtheria protec-
tion program should stress immunization between the ninth and fifteenth months
of life. The importance of this has long since been effectively established by
Godlrey,'” who demonstrated that immunization of as high as 65 per cent of
entering school children against diphtheria was relatively ineffective in the
community control of the disease, whereas immunization of as few as 35 per
cent of early preschool children would effectively prevent the disease from ever
reaching epidemic proportions.

ETC.

 

©- original case

®- susceptibles who become cases

Fig. 35. Geometrically progressive transfer of infection in absence of immunization.

In this connection, it is of interest to point out the statistical explanation
for the lack of necessity, from a community standpoint, of protecting every mem-
ber of the community or even every susceptible member of the community.
For the purpose of explanation, it might be assumed that a given individual
has an average effective rate of contact of two during a period while he is in-
fectious. That is, the average infectious person, while he is still able to circulate,
may have contacts, of an intimate enough nature to fulfill the biological con-
ditions necessary for the transmission of his infection, with two susceptible per-
sons. In a totally unprotected community, therefore, the original case would
give rise to two new cases who in turn would produce a total of four, each of
whom would infect two others to produce a total of eight. The picture, there-
fore, is that of geometric progression: 1-2-4-8-16-32-64-128-ctc. (Fig. 35). If, on
the other hand, only one half of the susceptibles in the community are protected
against the particular disease, the average rate of effective contact of cases with
susceptibles is reduced to 50 per cent. Each case, therefore, according to the
502 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

laws of probability, will now give rise to only one new case and everything but
the main trunk of the tree of infection has been pruned. The picture of trans-
mission now becomes 1-1-1-1-1 (Fig. 36). While by chance an occasional case
may give rise to two or more new cases, the chances are equally great that at
some point the existing case will have effective contact with no susceptibles and
the chain of infection may die out completely.

ETC.

 

—_
= original case ==

® = susceptibles who become cases
S = susceptibles who are not exposed toa cdse and do not become infec ted
I = immunes who carrot become cases

Fig. 36. Linear transfer of infection with 50 per cent immunization.

The modern approach to tuberculosis provides an excellent illustration of
administrative programming in the routine control and eradication of a com-
municable disease. Not many years have passed since Frost20 stated the epi-
demiological prognosis for this disease.

We need not assume that tuberculosis is permanently and ineradicably engrafted
upon our civilization. On the contrary, the evidence indicates that in this country
the balance is already against the survival of the tubercle bacillus; and we may reason-
ably expect that the disease will eventually be eradicated. It is necessary only that the
rate of transmission be held permanently below the level at which a given number of
infection spreading cases succeed in establishing an equivalent number to carry on
the succession. If, in successive periods of time, the number of infections hosts is con-
tinuously reduced, the end result of this diminishing ratio, if continued long enough,
must be extermination of the tubercle bacillus. *

Already there are many signs ol impatience. A realization has come about
that, although the biological tide has turned in our favor, it is needlessly ex-
pensive and wasteful to be satisfied with the present rate of decline in the tuber-
culosis case and death rates. It has been estimated?! that an expenditure of about
330 million dollars a year for ten years would reduce the tuberculosis death
rate within that time to about one-fourth its present level, which otherwise
will take about twenty-five years. The economic saving effected by spending
that amount would be about 660 million dollars per year—a 200 per cent return.

*Frost, W. H.: How Much Control of Tuberculosis? Am. J. Pub. Health 27:759, Aug. 1937.
CONTROL OF COMMUNICABLE DISEASES j0J

 

The question of how to accomplish the reduction most effectively and efhi-
ciently arises. Early case finding is obviously the key. By finding those who are
already infected as early as possible, not only is it less expensive to restore them
to health but the length of time during which they may infect others is signi-
ficantly shortened. With the development of new and relatively inexpensive
diagnostic tools exemplified by the photofluorograph, which can be used to ex-
amine the chests of as many as 1,000 persons a day, the examination of mass
groups of people has become a practical technique.

Tuberculosis is known to be a socially selective disease. The health depart-
ment, therefore, must first familiarize itself with the extent and location of
tuberculosis in its community. This involves a careful and [ractionated analysis
of all statistical and other sources of information, e.g., reports of cases, deaths,
hospital admissions, and the like. To know that a community's tuberculosis
death rate is 35 per 100,000 is not sufficient. It must give careful consideration
to the size and location of population groups in which the disease is apt to exist
to an undue degree because ol genetic, biologic, economic, or occupational in-
fluences. These are the groups among whom mass case-inding techniques should
be particularly stressed. List of the more important are: (1) persons with sus-
picious pulmonary symptoms, (2) contacts to known cases ol tuberculosis, (3)
members of certain racial and nationality groups (e.g., Negroes, Amerindians,
Scottish, Irish, Polish), (4) workers exposed to silica dust, (5) general clinic and
hospital patients, (6) adolescents and young adults, (7) pregnant women, (8)
attendants of tuberculous patients.

Several other groups should receive special attention by virtue of their oc-
cupational opportunity to infect others. Outstanding among these are school-
teachers and food handlers.

Many of the groups mentioned are most conveniently and effectively reached
for diagnostic purposes through certain channels. Thus it is more efficient and
fruitful to arrange for the mass examination ofl industrial workers at their place
of work, schoolteachers and adolescents at their schools, and pregnant women
and clinic and hospital patients at the time of their admission to service. Suspected
cases and contacts of known cases require routine persistent field contacts by
the public health nurse.

While it is true that each of the communicable diseases is a biological entity,
certain similarities among them make it practical to group them into several
categories for administrative and control purposes. Since control measures depend
essentially upon modes of spread, that factor is also the primary one upon
which such categorization depends. Thus, while strictly speaking hookworm infes-
tation is not a gastrointestinal disease, the nature of the factors involved in its
transmission justifies including it for administrative control purposes in that
group of diseases.

The point of practical significance, of course, is that by grouping diseases
in this manner, many control measures may be considered specific for a group
rather than for a single disease. This is illustrated by Tables 38 and 39, which
summarize in a deliberately general manner the essential epidemiological factors
relating to the acute respiratory diseases and the gastrointestinal diseases. Similar
Table 38. Summary of Gastrointestinal Diseases

 

 

 

 

 

 

 

 

 

 

 

Typhoid | Dysentery, Dysentery,
Disease Fever Paratyphoid Bacillary Amebic Cholera Brucellosis Hookworm
|
Cause Eberthella Salmonella (several | Shigella (several Endamoeba Vibrio Brucella (several Necator
typhi species) species) histolytica comma species) americanus
Incubation Period 3-38 days, 3-15 days, 2-7 days 2 days to several 1-5 days 6-30 days None in true
usually 7-14 | usually 4-10 months usually sense
days days 3-4 weeks
Prevalence World-wide, warm seasons esp.; Tropics and subtropics esp. warm India, Mediterranean, | Limited to warm,
males and young adults esp. season; all ages and sexes China U. 8., Canada, | moist sandy soil;
Scandinavia; children, esp.
warm season white
Period of Communica- |
bility | Prodromes, illness, and convalescence until stools negative 20-300 days While infested

 

 

 

 

 

 

 

Source Feces and urine of cases and carriers Exception: Brucellosis; milk, tissues, blood, and discharges of infected cows, swine, goats
Spread Infected water, food, fomites, flies, Exception: Brucellosis; milk and contact with tissues and discharges
direct contact Hookworm; contaminated soil. Neither man to man
Susceptibility General susceptibility, decreasing with age Exception: Brucellosis; most persons have some natural immunity
| Passive None
Immunity
Active | One attack gives long-lasting immunity in typhoid. Relative immunity in paratyphoid and bacillary dysentery. Short immunity with vaccines in typhoid

 

and paratyphoid (about 2 years) and cholera (about 1 year)

 

Control Measures

 

1. Early diagnosis and reporting of cases and carriers

Laboratory tests

2. Isolation in all but hookworm, am. dysentery,

and brucellosis

3. Disinfection—concurrent—terminal in all but

hookworm and brucellosis

Quarantine—cholera only (5 days)

. Immunization (q.v.)
Source finding—cases and carriers, important in all 12.

Water sanitation
Excreta sanitation
Food sanitation

10. Milk sanitation
11. Shellfish sanitation

Prevention of fly breeding

13. Carrier control
14. Education

General, cases, carriers

 

 

r9§

S3LVLIS A3LINN FHL NI S3ILIAILDVY HLIVIH OIT18Nd 40 NY3L1lvd
Table 39. Summary of Acute Respiratory Diseases

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

| | |
Disease | Diphtheria Scarlet Fever | Whooping Cough Measles Smallpox Chickenpox Mumps Meningitis Poliomyelitis
| |
Cause Corynebacte- | Hemolytic Hemophilus Filtrable Filtrable Filtrable Filtrable Neisseria Filtrable
rium diph- streptococci pertussis virus virus | virus virus intracellu- virus
theriae laris
Incubation Period (Days) | 2-7 | 2-7 7-16 | 8-12 8-16 14-21 14-21 2-10 7-14
Period of Communica- Variable, Variable, Catarrhal Catarrhal Catarrhal Catarrhal Unknown, From onset Unknown, as-
bility usually under | usually 3 stage stage (4 stage (2-4 stage (0-2 assumed until 2 sumed incuba-
2 weeks, weeks from (7-14 days) days) and days) to days) and while weeks after tion period and
seldom onset until no | and 3 weeks 5 days of disappear- during glands recovery first week of
over 4 discharges of whoop rash ance of 6-10 days enlarged disease
lesions of lesions |
— | |
Prevalence World-wide but especially temp. zone—winter and spring except WC (spring), polio (late summer) and diph. (fall and winter). Affects children most
Incidence usually less and older age group affected more in rural than urban
Source Discharges from nose and throat of cases—Oce. other lesions in Diph. SF, and SP. Carriers in Diph., SF, meningitis, and poliomyelitis
Spread 1° cases, II° fomites. Occ. milk in Diph. and SF (explosive epidemics). Carriers in Diph., SF, meningitis and poliomyelitis
Susceptibility Everyone after 6 mos. of age not having active or acquired immunity. Exceptions: SF varies geographically. SP and WC susceptible from birth. Some
immunity probably acquired without disease by age and contact in all but SP and measles
Passive Convalescent serum and gamma globulin give some protection for several weeks in all but smallpox. Whole adult blood in whooping cough, measles,
mumps. Placental extract in measles. Antitoxin in diphtheria.
Immunity
Active An attack gives long-lasting immunity. Artificial immunity long lasting in smallpox and diphtheria, much shorter in scarlet fever, whooping cough,
and poliomyelitis.

 

 

Control Measures

3. Disinfection

Terminal

 

Concurrent

1. Early diagnosis and reporting (laboratory in
Diph., WC. Mening., Polio)
2. Isolation: Diph., SF, WC, SP
Of little value in the rest

4
5.
6

. Quarantine like isolation

. Source finding—D and SF (cases,

7. Pasteurization of milk, especially
in diphtheria and whooping cough

8. Prevention of overcrowding, espe-
cially in meningitis

9. Education

Immunization, q.v.

carriers, milk); SP (cases). Of little
value in the rest

 

 

s3asSvISIA IT1GVIINNAWIWOD JO TTOH.LNOD

598
560 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

groupings may be made for the insect-borne diseases, the chronic respiratory
diseases, and the genitoinfectious or venercal diseases. This concept is reflected
organizationally in the frequent establishment, particularly in the health de-
partments of states and large cities, of separate divisions or bureaus for venereal
disease control, tuberculosis control, and occasionally in the past for certain
ol the gastrointestinal and insect-borne diseases. Present trends, however, are
toward consolidation of all of these into one major administrative division of
communicable disease control or epidemiology, with bureaus for various sub-
categories, depending upon the relative magnitudes ol problems. This trend is
further manifest by the increasing number of organizations with a division of
medical services, a bureau of which relates to disease control which may in
turn be further subdivided. An example of this is illustrated by the organizational
plan of the California Department of Public Health (Fig. 37).

STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

[ ——————{ GOVERNOR | — ]
STATE BOARD i. DIRECTOR MEDICAL HEALTH
OF PUBLIC HEALTH OF CALFION.

 

 

      
 

 

 

 

    
  
 

 

 

 

  
   
    
     

  
 

 

 

 

ALIFORNIA DISASTER
(0 MEMBERS ) Cee oe PUBLIC HEALTH ce OFFICE

| E— TT LT 1
DIVISION DIVISION OF DIVISION OF DIVISION DIVISION DIVISION OF DIVISION OF

OF LOCAL HEALTH PREVENTIVE OF OF ALCOHOLIC ENVIRONMENTAL

ADMINISTRATION SERVICE MEDICAL SERVICES DENTAL HEALTH LABORATORIES REHABILITATION SANITATION

suneau or | sumeay or suneau or Air AnD arony woners oF
susiess | commomcance wareann, ano | | warm am SaviTATION

 

 

 

suncau or
SANITARY
ENGINEERING

 

VIRAL AND

MERETTSIAL
suRCAY OF Bureau oF £000 AND DAG

PERSONNEL + m= oisEAsEs
MAONIC DISEASES TuBERcuLOSIS LABORATORY

AND TRAINING cHRonic pisease vpemcun LABORATORY

wt aucties
BUREAU OF suREau OF MEDICAL SOCIAL BUREAU OF
RECORDS CRIPPLED CHILDREN seavices im PDO ren VECTOR CONTROL
AND STATISTICS seavices LABORATORY

suREau oF MENTAL HEALTH
HOSPITALS seavices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUTRITION
senvices

 

 

NOVEMBER 1938
1018 1198 14 A ero

 

Fig. 37. Organizational plan of the California Department of Public Health.

In addition to the more prosaic activities of the routine program of com-
municable disease control, public health organizations must be ever alert to
the potentiality ol circumstances that may be considered of an emergency or
epidemic nature. The health department should be so organized that “without
slipping a gear” it can marshal its resources and those of related agencies.

Much has been said and written in an attempt to define the word epidemic
in terms of the number of cases involved. At the present time this would seem
to be similar to arguing over the number of angels on the head of a pin. From
CONTROL OF COMMUNICABLE DISEASES 567

the practical standpoint, what we are here concerned with are any communicable
disease situations that call for unusual or strenuous epidemiological measures.
The staff of a modern health department becomes as concerned over a report
ol a single case of smallpox as it does upon being laced with an outbreak of
typhoid fever or dysentery involving a score of persons. Both situations are
unusual, present a serious threat to the community, and call for immediate action.
Accordingly, a strong case could be made for avoiding the use of the word “epi-
demic” and substituting the term *

On being confronted with evidence that appears to indicate a possible
emergency, the public health officer or epidemiologist must take a series of logical
steps. Most obvious, although sometimes overlooked, he must first ascertain
the true existence of an emergency. This involves careful consultation with those
making the reports, followed by confirmatory diagnosis in which the health officer
or epidemiologist himself takes an active part. Diseases are poorly diagnosed or
understood from behind a health department desk. The determination of the
etiological nature of the disease is of obviously fundamental importance. The
investigator will be guided in the subsequent steps he will take by the biological
characteristics of the clinical entity involved. Diagnostic assurance makes it
possible to avoid some missteps and wasted effort and to decide what laboratory
or other aids will be of assistance.

On determining the nature of the condition under investigation, the next
step is to establish the fact ol undue prevalence and incidence. The garden
must be weeded and like planted with like. False diagnoses due to either hysteria
or faulty clinical judgment must be eliminated. By like token, missed cases
must be found and added insofar as possible. These may be attributable again
to faculty diagnosis or to unrecognized or undiagnosed cases. Occasionally cases
are missed, not because of lack of diagnosis but because they are deliberately
hidden for misguided personal, social, or economic reasons. More than one resort
area, lor example, has attempted to quash knowledge of the presence ol dis-
ease. The occurrence of typhoid fever in several places in the past has been ig-
nored because of false pride in some new sanitary construction. These pos-
sibilities for missed cases, therefore, make it necessary for the investigator to
decide whether there is undue prevalence of recent origin or whether cases have
been occurring for a considerable period of time and are just now being recog-
nized. It is a common experience, [or example, for the first one or two definitely
diagnosed cases of poliomyelitis in a community to make the public and the
private physicians particularly alert to the possibility of that disease in former
as well as new patients.

Once the disease is diagnosed and a distinct departure from normal pre-
valence decided upon, the next step in many situations is to contact all persons
involved, the public in general, and practicing physicians in particular, in order
to apprise them of the situation in a nonemotional manner and to solicit their
assistance in whatever matters they may find possible. This may take the form
ol public education through all channels to boil water or to avoid crowds, or ol
professional education in special diagnostic methods and techniques or in
reporting.

communicable disease emergency.”
568 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Known cases should now be oriented in relation to certain pertinent factors
including time, place, events, groups of the population affected, sex, race, age,
and occupation. Each of the cases, or at least a representative sample of them,
depending upon the disease and the size of the outbreak, should be visited and
a standardized epidemiological case card filled out. This has a twofold purpose,
i.e, to find the source, and to find contacts who may become cases in the future
or in whom the development of the disease may be prevented. Out of a careful an-
alysis of the contents of the epidemiological case cards, it is hoped that some com-
mon denominator may be discovered—a particular milk supply, social event, form
of personal behavior, or the like. If such a factor can be brought to light, it
can then be made the subject of intense laboratory or other study in order to
confirm the suspicion of its causal nature, and appropriate steps can be taken
to prevent a recurrence of the emergency.

As will be readily opined by any who have been so engaged, the foregoing
paragraphs read much too easily. The investigation of a communicable disease
emergency is no mean task. It involves intelligence, intuition, patience, and
persistence. It is seldom a venture one can undertake alone. Reliable medical
cooperation, laboratory assistance, and many other things are necessary for its
successful completion. When truly complete, however, an epidemiological in-
vestigation is a work of art.

REFERENCES

I. Cort, W. W,, and Otto G. F.: Immunity to Hookworm Disease, Rev. Gastroenterol. 7:2,
Jan.-Feb. 1940.
2. Christensen, A. W., Flook, Evelyn, and Druzina, G. B.: Distribution of Health Services in
the Structure of State Government, Washington, 1953, Public Health Service Publ.
No. 184, Part 3.
3. Mountin, J. W., and Flook, Evelyn: Distribution of Health Services in the Structure of
State Government, Communicable Disease Control by State Agencies, Pub. Health
Rep. 56:14, Nov. 1941.
4. Emerson, Haven: State Procedures for Communicable Disease Control, Am. J. Pub. Health
29:701, July 1939.
Emerson, Haven: Uniformity in Control of Communicable Diseases, Am. J. Pub. Health
32:133, Feb. 1942.
6. Control of Communicable Diseases in Man, ed. 8, New York, 1955, American Public Health
Association.
7. Chapin, Charles V.: Papers of Charles V. Chapin, M.D., New York, 1934, The Common-
wealth Fund.

ot

8. Holst, Peter M.: Concerning Isolation in Contagious Disease, Tidsskr. f. d. norske Laegefor.
Nov. 9, 1933.

9. Gordon, J. E,, and Badger, G. F.: The Isolation Time of Scarlet Fever, Am. J. Pub. Health
24:438, May 1934.

10. Control of Communicable Diseases in Man, ed. 7, New York, 1949, American Public Health
Association.

11. Fowler, William: Principal Provisions of Smallpox Vaccination Laws and Regulations in
the United States, Pub. Health Rep. 56:188, Jan. 1941.

12. Ramsey, G. H.: Typhoid Fever Among Houschold Contacts With Special Reference to
Vaccination, Am. J. Hyg. 21:665, May 1935.

13. Shafer, J. K.: Premarital Health Examination Legislation, Pub. Health Rep. 69:487, May 1954.
CONTROL OF COMMUNICABLE DISEASES 569

 

18.

19.

20.
21.

. Condit, P. K,, and Brewer, A. F.: Premarital Examination Laws—Are They Worth While,

Am. J. Pub. Health 43:880, July 1952.

Hedrich, A. W., and Silverman, C.: Should the Premarital Blood Test Be Compulsory,
Am. J. Pub. Health 48:125, Feb. 1958.

Halse, IL. M., and Liberti, D. V.: Prenatal Health Examination Legislation, Pub. Health
Rep. 69:105, Feb. 1954.

Kupka, E., and King, M.: Enforced Legal Isolation of Tuberculosis Patients, Pub. Health
Rep. 69:351, April 1954.

Rich, W. H., and Terry, M. C.: The Industrial Control Chart Applied to the Study of
Epidemics, Pub. Health Rep. 61:1501, Oct. 1946.

Godfrey, E. S.: A Study in the Epidemiology of Diphtheria in Relation to the Active
Immunization of Certain Age Groups, Am. J. Pub. Health 22:237, Feb. 1932.

Frost, W. H.: How Much Control of Tuberculosis?, Am. J. Pub. Health 27:759, Aug. 1937.

Shepard, W. P.: Some Unmet Needs in Tuberculosis Control—A Challenge for the Future,
Am. J. Pub. Health 38:1370, Oct. 1948.
chapter 24

Addictive diseases

 

Introduction. In addition to the more evident communicable, organic, and
psychic disorders to which man is subject, and which in many instances he may
share with other creatures, there exists another group of conditions which are
peculiarly his own. These are conditions that involve the unreasoned compulsive
consumption of certain chemical substances, some natural and some man-made,
to his ultimate physical, psychic, and social detriment. It is interesting that
all of these substances have numerous beneficial uses and effects when used
properly and judiciously and actually affect adversely only a small proportion
ol those who may be exposed to their use. Most prominent among these agents
is alcohol, a substance of ancient development and widespread consumption.
Next in prominence and historic discovery are the narcotizing alkaloids. More
recently have been added certain substances which have been developed synthetic-
ally by man, usually for therapeutic purposes, such as the barbiturates and re-
lated drugs, amphetamine, and to some extent certain of the so-called tran-
quilizers, euphoriants, and ataraxics.!

Alcohol and narcotics have played a fascinating role in the history of man-
kind. The production of alcoholic beverages appears to have been one of man’s
earliest discoveries. The use ofl alkaloid-bearing plants probably came not too
long afterward. Because of the physiologic effects they produced, they soon
became important adjuncts to social intercourse, religion, and politics and have
played an important part in the literature of all cultures. Through the ages
there has been much speculation, especially about certain of the psychic effects
of their use. They seemed to release [rom the tangible body and allow to wander
freely the usually pent-in spirit, and sometimes seemed to bring about the ap-
parent phenomenon of second sight. Such mystical results coupled with the
unusual appearance and behavior of the physical body inevitably lead to great
wonder and awe, especially on the part of primitive peoples. From the start,
therefore, although these substances appeared to be similar to other materials
ingested as food and drink, they were nevertheless considered different and
special. Indeed, in many instances, they were treated as sacred, to be prepared
only by certain persons and to be used only at certain times such as at festivities,
religious events, or in instances ol individual or group catastrophy.

570
ADDICTIVE DISEASES 571

 

 

Undoubtedly early in their use it was recognized that among those who
used them were some who developed an uncontrollable necessity for continued
use regardless of the consequences. Thus the drunkard is mentioned in the Old
Testament and hashish was used in India and the Middle East to develop and
control groups of assassins. Through time, society typically frowned upon these
undesirable results of the use of these substances but was at a loss to understand
them. Usually they were attributed to innate depravity, some hereditary weak-
ness, or the loss of the soul. Such attitudes have continued down to the present
time. It is only quite recently that more enlightened attitudes, based upon clearer
understanding of the working of the mind and its relationship to the body
on the one hand and to the pressures of society on the other, have been taken
toward the unfortunate victims of these addictions.

Alcoholism.* Alcohol is used in many different situations, i.e., in religious
ceremonies, as a food, as a relaxant, as a customary base for many social affairs;
by many different kinds of people, i.e., men and women, young and old, well-
adjusted and emotionally disturbed; with many different results, i.e., an im-
proved appetite, a warm glow of well-being and conviviality, a blackout, or
personality deterioration. More often than not, its use and its effects are re-
garded in terms of a gradient with all persons being distributed along a scale
of consumption with a concurrent scale of response. Thus, the less the intake
the less the response. The more the intake the greater the response, its con-
sequences, and the probability of becoming an alcoholic. Unfortunately, the
situation is not as simple as this. There are some individuals who may actually
consume, even on a relatively consistent basis, a considerable amount ol alcohol
yet never become alcoholics. Conversely there are those whose intake may be
significantly less or occasional, yet they may be obvious problem drinkers. The
reason for drinking and for continuing to drink has much to do with the making
of an alcoholic. Similarly, the attitude toward other aspects of life and the
world has much to do with deciding whether or not a person is an alcoholic.
Still another deciding factor is the relative ease or difficulty of reduction or
elimination of the consumption of alcohol.

Definition. The foregoing discussion points up the factors which make
alcoholism difficult to define. Nevertheless, the more the problem is studied,
the more apparent it becomes that certain types of persons, especially under
certain circumstances do tend to become alcoholics, whereas others do not. The
alcoholic has been defined by some as an individual under emotional pressure
who drinks to get away from the way he feels but eventually is drinking be-
cause of his drinking. This is a practical definition in that it stresses the initial
psychosocial trigger followed by the eventual psychophysiological entanglement.

From an epidemiological viewpoint, alcoholism may be defined as an ac-
quired chronic progressive disease of adult life involving the compulsive intake
of excessive amounts of alcohol and leading in its more advanced stages to
certain psychological, social, and physical deteriorating sequellae. It affects

*For an extensive and up-to-date review of the problem see the Annals of the American
Academy of Political and Social Science, vol. 315, Jan. 1958. The entire issue is devoted to
the topic “Alcoholism in the United States.”
572 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

predominantly males to the ratio of about 6 to 1, adults between 85 and 55
years of age in the most productive period of life to an extent of 85 per cent
of cases, is particularly common in certain occupations such as those involving
nonroutine, pressure, decision-making, and transiency, is significantly greater
in urban areas, and is more frequently found in certain nationalities especially
Scandinavian, Nordic, Celtic, and Polish in contrast to its infrequency among
Italians, Greeks, and Jews.

Extent of Problem. The determination of the true magnitude of the pro-
blem is also difficult because so many cases never come to definitive social or
medical attention and because of the number of individuals at any time who
are on the borderline between problem drinking and chronic alcoholism. The
Yale Committee on the Study of Alcoholism? on the basis of surveys has estimated
that there are about 70 million drinkers of alcoholic beverages in the United States.
Of these, only an estimated 414 million are considered to be problem drinkers,
one million of them chronic alcoholics. This is a prevalence, however, of 2.4 per
cent of the total population or almost 7 per cent of those who drink. Further-
more, since six out of seven of them are adult males, this means an estimated
prevalence of problem drinking in the male population 20 years and over of
about 7.5 per cent! To complicate the picture further, it has been found that
this is not a disease primarily of the ignorant or of unskilled labor. To the
contrary, about 80 per cent are regularly employed up to the point of dis-
ability and three quarters of them belong to the executive class in large and
small businesses, professional men, salesmen, and skilled laborers.* The im-
plications of this with regard to social, economic, and professional productivity
and morale are obvious. The reality of the problem becomes evident from a
number of industrial surveys, notably that of the Western Electric Corporation,®
which have indicated that the average company can expect about 3 per cent
of all its employees to be alcoholics in need of special attention. Little wonder
that alcoholism is now included among the seven catagories of disease which
cause outstanding numbers of deaths and disabilities and which represent major
unsolved public health problems. The others are cardiovascular disease, mental
illness, crippling and handicapping conditions, cancer, dental disease, and di-
abetes. It should be noted incidentally, that all of these, including alcoholism,
are conditions about which something is known and about which something
can be done?

Cost of Alcoholism. In view of the foregoing, it is obvious that the cost
of alcoholism to society must be very considerable. Many different factors con-
tribute to the cost which is estimated to total about 114 billion dollars per year in
the United States alone. Absenteeism, high spoilage rates, decreased productivity
while on the job due to lowered ability and apparently to avoidance of work
situations involving hazard or which are apt to indicate the worker’s condition,
personnel turnover, and lowered morale of the alcoholic and those working
with him account for some of these costs. Added to them is the expense to society
of many [facilities for grappling with various aspects of the problem, e.g., police,
courts, jails, religious organizations, hospitals and medical care, various social
and charitable agencies, departments of welfare, domestic relations organiza-
ADDICTIVE DISEASES 573

 

tions, visiting nurse agencies, and industrial personnel guidance offices. Less
tangible is the ultimate cost of the frequently disasterous effects on other mem-
bers of the family and circle of friends, e.g., on children at school, and on other
adults at work in the home or at the alcoholic’s place of employment. Still
another social loss due to alcoholism is the amount ol crime and prostitution
which is related to it as either or both cause and effect. The amount is indeter-
minate but on the basis of obversations by many would appear to be significant.

The relationship of accidents to alcoholism is interesting. Surveys carried
out by the Yale University School of Alcohol Studies in 1943 indicated that
the estimated 1,370,000 alcoholics employed in industry accounted for 1,500
fatal accidents at work and 2,850 fatal accidents at home, in public places, and
in traffic or a total ol 4,350 fatalities.” Dr. E. M. Jellinek, the director of the
school at that time, pointed out that this was a fatal accident rate of 321 per
100,000 men or more than twice that of nonalcoholic workers in the same oc-
cupations. Trice,® however, has warned against the common misinterpretation
of this data as representing that alcoholics have twice as many work accidents
than do others. In fact, he points to studies of his own which indicate surprisingly
that as far as work-related accidents are concerned the reverse is true. On the
basis of answers given by the subjects, he hypothesized that the alcoholic while
actually on the job tends to be overcautious, concentrates more upon what he
is doing in a deliberate attempt to avoid accidents, is subject to fewer of other
types of distractions, develops a well-planned work routine, is sometimes “cov-
ered-up” by his fellow workers, and il actually in an alcoholic or “hangover”
state tends to be absent rather than to risk discovery or a work accident. The
only work relationships in which Trice found alcoholics to indulge their addic-
tion and to have work-related accidents were (1) as participants in fellow-worker
drinking groups after working hours, and (2) on jobs that require geographical
mobility, hence separation from protecting or inhibiting influences coupled with
greater accessibility to alcohol.

Alcohol-related accidents away from work present a different picture from
what happens in the nonmobile work situation. This is best illustrated by the
relationship between automobile accidents and alcohol consumption which has
been the subject of many studies. Thus, in a review of some such studies it was
found that as little as 0.03 per cent of alcohol in the blood reduced driving
skill” and that the probability of accidents increased consistently with an in-
crease of alcohol in the blood. The risk at 0.10 per cent blood alcohol has been
found to be twice that at 0.05 per cent, while an increase of the blood level
to 0.15 per cent multiplied the risk tenfold.’ With this in mind, the percentage
of automotive accidents fatalities with significant blood alcohol levels is illumina-
ting. For instance, in Nassau County, New York a series of two hundred sixty-
nine autopsies of driver fatalities showed 52 per cent with blood alcohol levels
over 0.10 per cent. Similar recent studies in Philadelphia have shown that
about 50 per cent of automobile-related fatalities involved significant blood
alcohol levels in either or both drivers and pedestrians, if the latter were involved.

It is somewhat more difficult to relate alcohol with home accident fatalities.
However, recalling Jellinek’s findings that the total fatal accident rate in alcoholic
574 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

workers was twice that of nondrinkers coupled with Trice’s findings that this
was not due to on-the-job accidents, and recognizing further that in the United
States home accidents are about twice as [requent as work accidents and at least
four times as frequent as vehicular accidents,'t it would seem reasonably certain
that a close relationship exists between drinking and the probability of home
accidents. To paraphrase the slogan “If you drink, don’t drive,” one might
say “If you drink, don’t climb a ladder.”

Effects of Alcohol. The Alcoholism Subcommittee of The Expert Committee
on Mental Health of the World Health Organization has concluded that while
alcohol must be regarded as a drug, it can be classified neither as an addiction-
producing drug nor as a habit-forming drug, but that it must be placed in a
category of its own, intermediate between these two groups.!? On ingestion,
alcohol is rapidly absorbed directly from the stomach and upper intestines into
the blood stream. It is detectable in the blood within five minutes of ingestion
and by this medium is distributed throughout the body. The average adult
body can oxidize about 10 ml. of alcohol per hour releasing energy and carbon
dioxide and water. Any that is not oxidized is excreted in the urine and through
the lungs. Thus, ingestion of excessive amounts gives rise to a build-up in the
blood stream and in the tissues, awaiting either oxidation or excretion. Blood
concentrations of 0.2 per cent usually result in mild to moderate intoxication,
whereas more than 0.3 per cent causes marked effects. Blood concentrations be-
tween 0.5 and 0.8 per cent result in death. Repeated and extensive use of
alcohol tends to result in increased tolerance.

Alcohol affects all parts of the body, especially the central nervous tissue.
Contrary to common belief, it acts not as a stimulant but as a depressant. In
so doing it inhibits the controls of behavior in the cerebral cortex. The pulse
increases and vasodilation occurs, especially in the skin, and results in decreased
body temperature due to heat loss. Because ol this, again contrary to common
thought, the use of alcohol to warm the body is not physiologically sound. Vision
and sense ol balance are impaired relatively early. In more advanced states of
intoxication the centers in the brain which regulate breathing, cardiac function,
and body heat are depressed. As with so many things, the moderate consumption
of alcohol actually appears to have little or no effect on longevity. There is good
evidence, however, that heavy drinking does shorten life in various ways.

Much of the ill effect of excessive consumption of alcohol is due to mal-
nutrition. The alcoholic typically eats inadequately because of the dulling of
the appetite, general disinterest in food, and because calories for energy are
obtained from alcohol. Since the latter are so readily available, what food is
eaten often is stored unused in the body. Hence, many alcoholics, especially in
the earlier stages may become overweight. Most important among the nutritional
deficiencies which occur are those involving vitamin B complex. This may result
in polyneuritis, so-called “beer heart” with cardiac weakening and enlargement
with attending edema, pellagra, and the typical skin and ocular manifestations
of riboflavin deficiency. Fatty degeneration of the liver may result probably
from a combination of vitamin B deficiency and direct toxic effects of alcohol
upon the liver cells. Because of lowered mineral intake, anemia is frequent.
ADDICTIVE DISEASES 575

 

Among the more dramatic effects are those relating to the psyche such as de-
lerium tremens, Korsakoft’s psychosis, and personality changes due to alcoholic
degeneration of cortical tissue. In connection with the latter, the advanced
alcoholic tends to become socially unstable, careless about his appearance or
actions, suspicious, irritable, belligerant and quick to take offense, crafty, over-
emotional, and frequently brutal and callous toward those around him, especially
those he may love. Much of the latter, ol course, is attributable to the very
marked guilt complex which is typically developed.

Types of Alcoholics. It is important to consider first of all how alcoholics
differ from the much larger number of persons who drink but are not alcoholics.
As Bacon' has indicated, there are many reasons for drinking such as to fulfill
a religious ritual, to be polite, to have a geod time, to make [riends, to experi-
ment, to show off, to get warm or cool, to quench thirst, to go on a spree, or to
flavor food. He states however:

None of these is the purpose of the alcoholic, although he might claim any or all
to satisfy some questioner. The alcoholic drinks because he has to if he is to go on
living. He drinks compulsively; that is, a power greater than rational planning brings
him to drinking and to excessive drinking. . . . Most alcoholics hate liquor, hate
drinking, hate the taste, hate the results, hate themselves for succumbing, but they
can’t stop. Their drinking is as compulsive as the stealing by a Kleptomaniac or the
continued hand washing of a person with a neurosis about cleanliness. . . . It is
useful to think of their drinking behavior as a symptom of some inner maladjustment
which they do not understand and cannot control. The drinking may be the outward,
obvious accompaniment of this more basic hidden factor.*

As many psychiatrists have pointed out, if the alcoholic did not drink, unad-
justed he would consciously or subconsciously seek some other outlet for his
unresolved conflicts and tensions. In addition, there is some evidence that certain
physical causes [or alcoholism exist. Some feel that the problem drinker may
have some abnormal psychological and physiological reaction to alcohol that
others do not have.14

The frank alcoholic is intensely introspective and is disinterested in any-
thing except himself and his problem. He has few if any diversional interests
such as hobbies, entertainment, or social activities. A very large proportion are
socially unattached to family or social group. This introspection and social iso-
lation presents a particular difficulty to persons, programs, or agencies which
may try to relate meaningfully to them in order to assist them. Sometimes, part
of the difficulty derives from the sense of failure and guilt which the alcoholic
commonly feels and which may even result in a willful rejection of attempts
to help. Alcoholics may reject help on the basis that they deserve to be miserable
because of their real or imagined failings and because of the compulsive drinking
pattern itself, which they developed in relation to their conflicts and failings.

Generally speaking there are two main types of problem drinkers. The
first or primary type is the individual who was maladjusted to begin with,
that is before he embarked upon compulsive drinking. He was what is com-
monly referred to as neurotic, that is, subject to a sense of constitutional psycho-

*Bacon, S. D.: Alcoholism, Nature of the Problem, Federal Probation 11:No. 1, 1947.
576 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

neurotic inferiority. Usually his personality was developed improperly from
early childhood with gradual realization of vague and constant feelings of anxiety,
apprehension, inadequacy, or inferiority. Very often he feels he is “licked before
he begins anything,” and that he will be unsuccessful in school, in courtship,
in work, and in society. He fears such situations and, if at all possible, wants
to avoid them. Occasionally such a person finds that indulgence in alcohol brings
a sense of release and gives some degree of confidence and apparent success.
Perhaps more than anything it makes it possible to forget temporarily his own
feeling of inadequacy and dissatisfaction with himself. What is more logical
than to repeat the experience? The problem is compounded however when the
effects of alcohol wear off. There are unpleasant memories or, worse, uncertainties
about behavior while under the influence of alcohol providing additional feelings
of anxiety and guilt. This leads to the additional use of alcohol, often the
morning after, to overcome the postalcoholic sense of guilt, and a vicious circle
is established.

The second type of compulsive drinker begins as an apparently well-adjusted
person. He is not neurotic, his personality has not been improperly developed,
and in fact he appears to get along well in his family, in his work, and with
the group. If anything, he may tend to be an extrovert. He becomes involved
in situations and with groups, in connection with either or both his social or
work life, which lead to considerable drinking. He participates with enthusiasm
but is not yet an alcoholic. He is in fact indulging himself without any par-
ticular feeling of compulsion. However, the continued use of more alcohol grad-
ually lowers his senses of discrimination and responsibility. He becomes less
efficient, careless, and begins to put things off or “let things slide” in order to
meet the preferred “social” demands. Almost imperceptively at first his relation-
ships and behavior at home, on the job, and in society begin to deteriorate.
This becomes noticeable to those around him, he becomes aware of it and
because of fear or worry drinks more. Meanwhile, his family, [riends and em-
ployer, usually indulgent or tolerant at first, become impatient. There occurs
a mutual loss of regard and blunt words are exchanged. Because of arguments
at home, perhaps a demotion or loss of a job he begins to feel that everyone
is down on him, and with increasing self-pity blames it all on the misunder-
standing and intolerance of others or on just plain “hard luck.” The only thing
which provides escape, jacks up the ego, is the very thing which began the pro-
cess—alcohol. Hence again, a vicious circle is begun. As times goes by and
the situation becomes worse, he appears on the surface more and more like the
primary type ol alcoholic. However, because his alcoholism is not superimposed
upon a basic inferiority, his chances of recovery and rehabilitation are decidedly
better. Fortunately from society's viewpoint, the larger proportion of alcoholics
appear to fall into this category.

What Can Be Done. Until not long ago, and even yet in far too many
places, the approach to the alcoholic was to tolerate him if possible; “dry him
out” periodically, either in jail, a public hospital, or a private sanatorium; or, if
he were beyond recovery, to provide him with some type of refuge in “skid row”
or elsewhere in which he could subsist on handouts [rom [riends, strangers,
ADDICTIVE DISEASES 577

 

missions, or other charitable organizations during the intervals between employ-
ment at usually undesirable types of work. With the relatively recent acceptance
ol the condition as a disease and on the basis ol an increasing amount of social,
medical, and psychiatric study and research, a growing number of programs
are being established with increasingly fruitful results. Much is still on the
basis of trial and demonstration. This is as it should be.

It is interesting that the real impetus arose from within the group affected.
This took the form of the organization in 1935 of Alcoholics Anonymous. It
considers itself “a fellowship of men and women who share their experience,
strength, and hope with each other that they may solve their common problem
and help others to recover [rom alcoholism.” It states that “the only require-
ment for membership is an honest desire to stop drinking”; that it is “not allied
with any sect, denomination, politics, organization, or institution; does not
wish to engage in any controversy, neither endorses nor opposes any causes.” The
primary purpose of its members “is to stay sober and to help other alcoholics
to achieve sobriety.”* Since its foundation, A.A. has helped more than 250,000
men and women in the United States, Canada, and a large number of other
countries. These people constitute the core of the membership and the nucleus
to which others in need of help may relate. There are now more than 5,000 groups
throughout the world. The organization operates on a lew simple but sound
and effective premises. Participation must be voluntary—there can be no check-
ing up or compulsion. An alcoholic can never indulge in controlled drinking;
either his drinking will become progressively worse or he must abstain com-
pletely from alcohol and develop a new pattern ol constructive living. Belief
and faith in God is a fundamental source ol strength in the attempt toward
recovery. A recovered alcoholic can best understand the problems and motivations
ol the alcoholic and is therefore in the best position to be of assistance. Group
meetings for group therapy and open discussion of problems are valuable in
obtaining an understanding of the underlying causes ol one’s alcoholism. In-
dividual anonymous assistance in the form of moral support is instantly available
by visit or phone at all times. The process ol trying to help other alcoholics in
itsell is an important aid to staying sober one’s self. Members do not swear
off alcohol for life or for any other period in the future, they merely concentrate
on the twenty-four hours of today. Contributions toward recovery and rehabilita-
tion by other groups such as the medical profession and social agencies are
recognized, and members are referred freely as indicated.

Meanwhile, over a number of years, an ever increasing amount of knowledge
about the psychological and physiological causes and effects of alcoholism has
been accumulated. One result is the development in effect of three schools of
thought with regard to explaining and handling the problem, i.e., the social,
the psychiatric, and the medical or physiological. More and more, it is recognized
that the three are not conflicting but to the contrary that they are complemen-
tary—each approach contributes to the over-all solution of the problem. It was

*For various publications contact Alcoholics Anonymous, P. O. Box 459, Grand Central
Annex, New York 17, New York.
578 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

not until very recently that attempts were made to apply knowledge as it be-
came available. In 1944, the Laboratory of Applied Physiology at Yale University
established two public clinics in Connecticut, one at New Haven, the other
at Hartford, to attract and guide alcoholics and to bring to bear the various
resources and approaches to their treatment. Shortly afterward, the Yale Sum-
mer School of Alcohol Studies for training of workers in the field was begun
and a journal, The Quarterly Journal of Studies on Alcohol, devoted exclusively
to the subject appeared.’ The success of the Yale clinics led to the establish-
ment in 1949 of a pilot program by the Western Electric Corporation which
now estimates that about 70 per cent of their recognized alcoholics are reha-
bilitated.? Since 1949, the number of companies with planned programs for
the recognition and treatment of alcoholics is rapidly increasing. For companies
without programs, assistance in the form of consultation and information is
available through the numerous local committees of the National Council on
Alcoholism.

Until 1945, no state had a program for alcoholism. In that year, largely
as a result of the success of the Yale clinics, Connecticut began the first state
program under an independent commission.’® During the following ten years,
a total of thirty-four states established programs. Thirteen are in independent
commissions, ten are units of state health departments, two are related to state
welfare departments, three are in state mental health agencies, and two in de-
partments of institutions. The programs carried on are various combinations
of educational, research, and treatment activities. * Federal interest in the problem
is concentrated in the Community Services Branch of the National Institute ol
Mental Health which with the Bureau of State Services ol the United States
Public Health Service provides consultation and grants for research and demon-
strations to states and through them to localities.!?

On the local level, numerous communities have recently begun programs.
Often these programs consist essentially of treatment clinics only. However, there
is a trend toward broadening the base of the approach by utilizing more effectively
and extensively the resources and contributions of all fields.'s 1 Considering
the magnitude of the problem, none of the existing programs is adequately
financed. It is often proposed that an additional surtax be levied on alcoholic
beverages, the revenue from which could be devoted entirely to programs to
combat alcoholism. Similarly, one hears the not totally illogical suggestion that
the Alcoholic Beverage Industry support the program. It is significant in this
light that the industry has already established a foundation for research into the
causes and treatment of alcoholism.

Content of Programs. Quantitatively the problem is so vast and so complex,
with multiple causes, different types of cases, and numerous agencies of potential
value, that no standard program is possible or even desirable at this time. Cer-
tainly, as Vogel" has stated:

Treatment of the alcoholic is not the sole province of the psychiatrist, internist,
sociologist, minister, or any scientific or lay discipline. Recognition of this is funda-

*For example see Alcohol Studies and Rehabilitation in Virginia by Lee.
ADDICTIVE DISEASES 579

 

mental. . . . A total push is necessary and mobilization of all methods and facilities
is necessary to improve results and make help available to more alcoholics. The
nonspecificity of present day treatment should not result in therapeutic nihilism, which
is often used by physicians and others as rationalization to avoid this important
problem. There are definitely ways to treat the alcoholic. *

Basically there is no reason why the approach to the problem of alcoholism
should not follow the general principles of epidemiology and program planning
which have been so successful in many other areas. This should include the
gathering of data by survey, reporting, or other means to determine the extent
of the problem in the area under consideration. The data should be analyzed in
order to pinpoint problem areas and problem groups, existing or incipient, and
to determine places and circumstances in which alcoholism is or tends to be-
come a problem. Early case finding should be carried out by enlisting the par-
ticipation of public health and visiting nurses, police, clergy, institutional staff,
and many others. Since about one hall of the problem drinkers are in the pre-
addict stage, special effort should be made to reach them as early as possible
for attempts at prevention of progression. Another 30 per cent of problem
drinkers are in the early acute addict stage. This group probably represents
the combination of the most accessible and potentially most susceptible to re-
habilitation. Treatment centers, providing a spectrum of therapies utilizing the
services of Alcoholics Anonymous, internists, psychiatrists, sociologists, and others
as needed, should be available especially for those in the early acute addict
stage. Provision should be made for individual counseling, group therapy, medi-
cal treatment as required, and hospital referral if indicated. Increasing use
has been made of the drug Antabuse (tetracthylthiuram disulfide) which taken
orally produces no effect unless alcohol is subsequently used. In such an event,
acetaldehyde is formed and such severe nausea, vomiting, increased pulse rate,
and decreased blood pressure. This should always be prescribed and used under
medical attention and, if at all possible, should be combined with psychotherapy.
Concurrent with the treatment of the individual, steps should be initiated for
the other aspects of his rehabilitation, i.e., social, familial, religious, economic,
and the like. In the process, the patient's family, especially the spouse, should
not be overlooked. The occasional importance of this has been emphasized by
Lewis,?! formerly consultant for the National Institute of Mental Health, in the
following terms:

When the wife of an alcoholic remarries, she very often remarries an alcoholic.
We often see reciprocal relationships between the alcoholic and his spouse, and as an
alcoholic improves the adjustment of the spouse deteriorates. Strange as it may seem,
the spouse is often ambivalent about her alcoholic husband’s recovery; she frequently
derives neurotic satisfaction, which may be unconscious, from his alcoholic binges.
The inadequacy of her husband makes her feel needed and more adequate . . . . Wives
often resent their alcoholic husband's therapists whom they see as threatening their
control of their husbands. A part of this psychological mechanism between husband

and wife is the nagging and the pressure which the wife puts on her alcoholic husband,
making him feel more inadequate and thus less likely to stop drinking.t

*Vogel, S.: Psychiatric Treatment of Alcoholism, Ann. Am. Acad. Political and Social
Sc. 315:99, Jan. 1958.
tLewis, J. A.: Alcoholism, Am. J. Nurs. 56:433, April 1956.
580 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Suggestions for meeting this situation are to align oneself with the spouse's
positive motivations, to urge her to join Alanon, a group ofl spouses of A.A.
members, or if possible to try to get her to accept some psychiatric consultation
in order that she might better understand her husband’s problem and her re-
lationship to it.

Prevention. The development ol most cases of alcoholism is so insidious and
the causative factors so complex and often so buried in the past that prevention is
difficult. Experience has shown that prohibition of alcoholic beverages by law is
impractical. Even if it could be achieved, the maladjustments and inferiorities
which give rise to alcoholism, in the presence of alcohol, would still be there. In
a utopian world the elimination of these underlying factors might be anticipated,
but under existing conditions this is far too much to hope for. Nevertheless, in-
creasing attention to mental health, the greater equalization of social and eco-
nomic opportunity, and more understanding parents may make some inroads.
In the practical sense, however, it would appear that the best chance for preven-
tion still lies along the path of education. This should have as its goal a willingness
on the part of all to regard, discuss, study, and deal with alcoholism and its pre-
cursors frankly, dispassionately, and intelligently toward the ends of combatting
the development of the precursors and of seeking in the face of their existence
patterns of behavior other than hiding behind the screen of an alcoholic haze.
Education in the school can be important, but as Bacon®? has stressed, “only if
(a) the lesson to be taught is realistic, understandable, meaningful to the student,
(b) the community is largely in agreement with what is taught and (c)
the teachers themselves are taught and properly equipped.” It is utterly pointless
and farcical for an uninformed teacher to utter prohibitory preachments to stu-
dents about drinking, when they know that he as well as their families and friends
and society in general partake of alcoholic beverages to some extent. Far better
for an informed teacher to face and present the realities of living and upon that
basis to discuss its risks and why and how they may be avoided.

Earlier it was stated that one of the most important needs is to recognize al-
coholism for what it really is—a disease. Paradoxically, an area in which this is
still lacking to a considerable degree is in the medical profession itself. Surpris-
ingly few schools of medicine teach to any consequential extent about alcoholism.
The average physician and, indeed, the average public health worker still wrinkles
his nose anachronistically on a sensory rather than an intellectual basis, and re-
gards the alcoholic as a socially undesirable misfit who refuses to pull himself
together. If the physicians and public health workers cannot face the problem
honestly and properly, how can anyone else? A few recent events serve to empha-
size the point. Only within the past few years have some hospitals begun to take
alcoholics on their general wards. Only within the past few years have hospitaliza-
tion insurance organizations begun to pay for hospitalization due to alcoholism.
Even yet only about one half of such organizations do so and benefits vary widely.
Indeed, it was only in the early part of 1958 that the House of Delegates of
the American Medical Association unanimously passed a resolution stating that
alcoholism is a disease and that it should be treated by a physician in a hospital
setting when necessary. To its credit, the Association is now prepared to move ra-
pidly. Its Committee on Alcoholism has prepared a manual on alcoholism23 to be
ADDICTIVE DISEASES 5681

distributed to all physicians, is urging the development of uniform legislation deal-
ing with alcoholism based upon scientific fact, is urging hospitalization insurance
organizations to allow hospital benefits for alcoholism and most important of all,
with its Committee on Professional Education is working toward the much needed
improvement in the teaching of alcoholism as a disease in the nation’s medical
schools. It is to be hoped and expected that schools of nursing and schools of pub-
lic health will follow suit with regard to improved instruction on the subject.

Drug Addiction. Here again, as in the case ol chronic alcoholism we are deal-
ing with a condition and with a situation which appears on the surface to be
something quite different from what it really is. Whereas the typical attitude
toward the alcoholic is that he is a weakling, lacking in self-control and self-
respect, the narcotic addict is usually regarded as an essentially depraved person
and a criminal. One might construct an equation to illustrate the typical social
and unfortunately all too common medical attitudes, that would state something
like this: alcoholism is to tuberculosis as narcotic addiction is to leprosy!

Definition. Drug addiction lends itsell somewhat more easily to definition
than does alcoholism because fewer people regularly use these drugs, and because
ordinarily they are obtained and used clandestinely. Furthermore, the addiction
which results from their use is more clear cut and appears within a relatively
short time. The World Health Organization’s Expert Committee on Addiction-
Producing Drugs®* believes that it is important to distinguish clearly between
drug habituation and drug addiction. It defines drug habituation (habit) as “a
condition resulting [rom the repeated consumption of a drug,” and lists its char-
acteristics as (1) a desire (but not a compulsion) to continue taking the drug for
the sense of improved well-being which it engenders, (2) little or no tendency to
increase the doses, (3) some degree of psychic dependence on the effect of the
drug, but absence ol physical dependence and hence of an abstinence syndrome,
and (4) detrimental effects, il any, primarily on the individual. The majority of
affinities to synthetic drugs fall in this category.

On the other hand, the Committee defines drug addiction as “a state ol peri-
odic or chronic intoxication produced by the repeated consumption of a drug
(natural or synthetic),” and lists its characteristics as (1) an overpowering desire or
need (compulsion) to continue taking the drug and to obtain it by any means,
(2) a tendency to increase the dose, (3) a psychic (psychological) and generally
a physical dependence on the effects ol the drug, and (4) detrimental effect upon
the individual and a society. The continued compulsive use of the narcotizing
alkaloids and of certain synthetic drugs are included herein. For purposes of
orientation it should be pointed out that the World Health Organization con-
siders alcohol as intermediate between the addiction-producing and the habit-
forming drugs. It points out that alcoholism and drug addiction have certain
similarities but also certain important differences. Thus the severe symptoms
which occur on withdrawal of alcohol can be more dangerous to the individual
than those which occur when morphine, of example, is withheld. On the other
hand, it takes much longer to develop dependence upon alcohol than to develop
dependence on narcotics. Also, up to the present time, treatment of alcoholism is
much more possible and successful than is treatment of narcotic addiction.2?
582 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Extent and Cost of the Problem. There are known to be about 35,000 persons
addicted to narcotics in the United States. However, an additional 25,000 are
estimated to exist making a total of about 60,000, a prevalence of about 3.3 per
10,000 of the population. This is a considerable decrease over previous prevalences
which were estimated to be 25 per 10,000 in 1909, 18 per 10,000 in 1914, and 10
per 10,000 in 1920. This is in line with both production and seizure figures. The
World Health Organization notes that world-wide licit production of heroin has
dropped from 839 kilograms in 1948 to 132 kilograms in 1954. Similarly, seizures
of illicit morphine by the United State Federal Bureau of Narcotics in 1956 was
only 4,000 ounces in contrast to 75,000 ounces in 1922, despite the increased num-
bers of inspectors and investigators in recent years. The amount of addiction or
habituation to non-narcotizing drugs is impossible to estimate. Some indication
is obtained by production figures. Thus, in 1948 the total production of barbitu-
rates in the United States amounted to three hundred thirty-six tons or approxi-
mately twenty-four doses of 0.1 gram for each individual. Much, of course, was
destined for export. Even when that was subtracted the remainder far exceeded
our needs for legitimate purposes.

It is impossible to make even a crude guess as to what drug addiction costs
society. Included should be the loss or decrease of production by those afflicted,
the costs of hospitals, enforcement agencies, prisons, losses due to crime stimulated
by the search for money with which to purchase drugs, the costs of accidents and
illnesses rising out of their use, and the cost of the drugs themselves. With regard
to the latter it has been estimated that it costs a narcotic addict a minimum of
from $5 to $15 per day to maintain his habit. The illegal sale of narcotics is well
known to be highly lucrative hence its attraction to the criminal classes of society.
Thus a single kilogram (2.2 pounds) of heroin now costs about $1,000 in Turkey,
but by the time it passes through various dealers and peddlers who dilute it and
package it and sell to individual addicts, it may easily bring a total of one million
dollars. This of course is why illicit dealers so frequently encourage free trials, in
order to get additional sure customers “on the hook.”

Effects of Narcotics. Each narcotic produces certain characteristic effects. Gen-
erally speaking, however, they all cause a general stimulation, euphoria, and con-
tentment with release from pain or concerns that arise from worries, neuroses,
and conflicts. Various sensory manifestations occur such as a tingling of the skin,
hallucinations, and feelings of ecstasy. All of these pleasures of course are ofl
temporary and short duration for which the addict pays a high price in continued
and progressive misery. Contrary to popular opinion, while these substances act
generally as stimulants, they depress certain functions, notably the sexual urge.
Their continued use produces a marked loss of appetite resulting in weight loss
and nutritional disorders. Thus the typical addict is thin, wan, and under-
nourished. Severe constipation is common as is marked itching. The addict suffers
from nervousness, insomnia, and depression, and suicidal attempts are not
uncommon especially during the typical postjag depression. Because of the anx-
iousness of the addict to experience the drug and because dilution by those who
sell it is so common, the addict frequently does not know how much he is actually
taking. As a result, serious toxic reactions and even death may occur from over
ADDICTIVE DISEASES 583

 

dosage. Another serious aspect of addiction is in relation to infections and other
illnesses. Because of lowered resistance, the addict is much more susceptible
than the average person to many infectious and organic diseases. Furthermore,
one effect of the drug is to dull awareness to pain, fever, and other symptoms.
Infections are not infrequently circulated among drug addicts, as a result of the
use of common materials, especially unsterilized hypodermic needles. Prominent
among these are syphilis, malaria, infectious jaundice, and blood poisoning. All
told, life expectancy is markedly shortened.

The most unfortunate effect of narcotics is what they do to the morale,
morals, and social behavior of those so unfortunate as to become addicted to
them. The typical narcotic addict lives only for the next time that he can ex-
perience the drug. Nothing else really matters. As a result, in order to obtain
the drug, he will forfeit anything, job, social position, family, self-respect. He
will beg, borrow, or steal in order to satisfy his craving and, considering the
combination of lowered ability to earn and the high daily cost of the required
drugs, much petty crime results. Male addicts commonly turn to picking pockets,
shoplifting, burglary, dishonest gambling, and pandering. Women and girls
frequently become prostitutes. Very frequently the addict becomes a willing
“pusher” of the drug, the riskiest link in the delivery chain, in order to as-
sure his own supply. In effect the unfortunate addict literally does not own his
soul.

Causes of Drug Addiction. The causes of drug addiction are essentially the
same as in the case of alcohol. In fact, not infrequently individuals are found
who have passed from alcoholism to drug addiction because they felt that alcohol
no longer provided the sought for “lift.” Yost®¢ has classified drug addicts into
the three following groups to which a fourth may be added:

I. Emotionally well-adjusted individuals who take addicting drugs on medi-
cal advice for treatment of pain, sleeplessness, and the like. After pro-
tracted use, they find they cannot get along without them. (This type
constitutes only 5 in 1,000 of those hospitalized at the United States
Public Health Service Hospital at Lexington, Kentucky.)

2. Neurotics who turn to drugs because drugs make them forget their feel-
ings of inadequacy, fear, and the like, make them feel better and more
normal, either physically or mentally, or both. (These addicts constitute
the largest group.)

3. Psychopaths who take drugs in a deliberate search for thrills and “kicks.”
(These addicts are probably the smallest group numerically.)

4. Otherwise relatively normal individuals, usually adolescents, who “try
narcotics in order to maintain face with the group. (This would appear
to be a variable group, its numbers depending considerably upon varia-
tions and fluctuations in group behavior, and fads, and upon the extent
of law enforcement and availablity of supplies.)

’

Yost applies the apt phrases of “addiction prone” to the second and third
categories (neurotics and psychopaths) and of “accidental addicts” to the first
group. As might be expected and in line with the experience with alcohol, the
584 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

first and fourth catergories of addicts present the least important and least difficult
part of the problem and are much more susceptible to rehabilitation because
undersirable underlying personality problems are generally absent. The second
and third categories, neurotics and psychopaths, present the core of the problem
of addiction in terms of numbers and presence of personality insufficiencies, hence
difficulty of cure.

With regard to the type of person who is apt to become an addict, a study
in 1951 of two hundred sixty boys and girls admitted to Bellevue Hospital in
New York City is illuminating. It was concluded that there was a striking un-
iformity in personalities and backgrounds ol the boys. The subjects were all non-
aggressive and used passive techniques which gave a superficial appearance of
ease and poise. Their interpersonal relationships were very weak and superficial
with the notable exception of their relationships with their mothers. They had
many acquaintances but few friends, but their relationships with their mothers
were extremely close. Often they were their mother’s favorite. Many had chosen
definitely domestic types of occupations such as cooking or tailoring.

Epidemiology. As with alcoholism, the problem of drug addiction may be
approached from the epidemiological point of view. This has been well illustrated
by Jacobziner®" in connection with the program during recent years in the New
York City School Health Program.

An epidemic of narcotic addiction must be studied in the same manner as any other
outbreak of a communicable disease. The agent, host, and environment and their impact
and interrelationship must be studied and investigated. In an epidemic of narcotic
addiction the agent is perhaps of far lesser significance than the host and environment.
It should be emphasized that drug addiction is not a primary disease entity, but merely
symptomatic of an underlying deep-seated disturbance: narcotic addiction being only
one of many forms of social and maladjustment. Narcotic users are not definitely psycho-
pathic, but in the main, products of an unhealthy and an unhappy environment. There-
fore, the underlying causes and motivations must be investigated, discovered, and under-
stood. It is not the process of addiction which is important to know, but what causes
an adolescent to use a drug or to become socially maladjusted. . . . Two factors are needed
for the production of addiction: There must be a vulnerable soil—the individual or
host must suffer from a psychological or emotional disturbance—and the drug or agent
must be capable of resolving the conflicts, tensions, and anxieties of the maladjusted
individual .*

From the standpoint of epidemiological analysis it is interesting to note a
predilection for earlier ages than with alcoholism. The most susceptible age
group is from 15 to 25 years of age? and about 30 per cent of addicts become
addicted before their twentieth year. Although the number of males addicted to
drugs exceeds the number of females, they do not nearly predominate to the
extent observed with alcoholism. Again most cases are found in the upper and
lower socioeconomic thirds of society tending to spare the middle class some-
what, and again, as would be expected, concentration in urban centers is ob-
served. However, a major proportion of the problem in the United States is
concentrated in the New York City, Chicago, and Los Angeles areas.

*Jacobziner, H.: Investigating Narcotic Addiction in School Children, Am. J. Pub. Health
43:1138, Sept. 1953.
ADDICTIVE DISEASES 585

Approach to the Problem. Any program designed to attack the problem of
drug addiction must be multipronged and must involve the understanding and
cooperation of many disciplines, i.e., medicine, psychiatry, social work, nursing,
religion, law and law enforcement, and teaching, to mention only the most
obvious. The most logical first step is case finding. Police and other law en-
forcement personnel are the primary sources of case findings; physicians are the
secondary source. In addition to these, public health and visiting nurses and
social workers occasionally learn of addicts from those close to them. Regardless
of the circumstances, on discovery the addict should be regarded primarily as an
ill person and not as a criminal. Instead of being dealt with in a punitive fashion
he should be admitted promptly to a hospital or other suitable institution for
treatment. It is not possible to treat a confirmed narcotic addict on an outpatient
basis. If local facilities are not available or suitable, arrangements can be made
for prompt admission to one ol the two Public Health Service hospitals which
are specially equipped to handle this type ol case; one is located in Lexington,
Kentucky, the other in Fort Worth, Texas.

As to chances of cure, on the basis of studies of patients after discharge
[rom the Lexington, Kentucky hospital, 7 per cent had died, 13 per cent were
cured, 40 per cent were using drugs again, and the true status of the remaining
40 per cent was unknown. Usual experience is that three out of every four addicts
relapse at some time. Frequently the road to ultimate cure involves a number
of relapses on the way. Thus at Lexington in 1955 there were 3,724 admissions
ol which about two thirds were readmissions. There were some who returned
as many as six times. However, Kolb*? who has been associated with that hos-
pital feels certain that the majority of addicts want to be helped and would
endure almost anything if they thought cure was possible. However, as the Ex-
pert Committee of the World Health Organization points out, this does not
mean that the average addict will commit himself willingly to an institution for
the relatively long period of months necessary. The Committee?” feels that some
legal provisions are necessary because “most addicts require some degree of
coercion—preferably civil committment for medical treatment—to involve them
to desist from what is to them often a pleasurable experience.”

The high relapse rate points to the most difficult part of the problem, i.e.
rehabilitation and follow-up. An important part of the treatment is to make
the addict aware of the underlying reasons for his addiction and to help him
rehabilitate himself psychologically and socially. Jacobziner*? stresses the im-
portance ol qualified field personnel, public health nurses or social workers, who
may obtain pertinent background information about the patient, his family, and
his environment. He suggests the importance of repeated visits to the home and
environment by such personnel not only before and alter the discharge of the
patient, but also prior to the patient’s admission for treatment. In addition to
the patient, the family and the community need to be re-educated and prepared
for the return of the patient. With special reference to the adolescent, Jacobziner
emphasizes that “The importance of good parent-child relationship must be
stressed and parents must be made to understand that a poor quality of parent-
child relationship is responsible for many forms of social maladjustment.” Those
580 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

close to the patient should be forewarned of the possibility of a relapse and
warned not to castigate the patient if this should occur but to contact the ap-
propriate persons or institutions as soon as possible. Attention should be called
to the formation several years ago of an organization known as Narcotics Anony-
mous, patterned after Alcoholics Anonymous. This could develop into an in-
valuable adjunct in rehabilitation. Since a sense of inadequacy and failure often
plays an important role, efforts should be made to assist the discharged patient
in obtaining employment so that he may develop a feeling of fulfillment and
confidence. Much remains to be done toward development of a willingness on
the part of most potential employers to give the ex-patient an opportunity and
to give him encouragement wherever possible.

A point of considerable controversy at the present time is the advisability
and value of the so-called British system wherein drug addiction is handled
primarily by the medical profession and there is controlled legal distribution of
drugs to those who use them. The premise is that by removing the profit motive,
there is no temptation to resort to crime in order to obtain the drug and there
is no incentive to create new addicts. Kolb® advocates strenuous attempts to
cure the addict during periods of hospitalization but feels that when after several
such attempts it is found that the patient is not amenable to cure but will get
along well with a minimum amount of narcotic (excepting marijuana or cocaine)
he should be given this for the rest of his life under medical supervision. He
feels, on the basis of his experience, that the majority of such addicts “would
work, support themselves, and create no public problem.” This approach is
followed in a number of European countries as well as England and is now
advocated by the New York Academy of Medicine. Many object to this procedure
on the basis that it removes the incentive for real cure.

The Study Group on Treatment and Care of Drug Addicts? called by
the World Health Organization in November, 1956, discouraged this approach
saying that “while complete withdrawal of the drug of addiction might be de-
ferred in certain circumstances, the maintenance of drug addiction is not treat-
ment.”

Toward the goal of prevention, a number of things should be considered.
First of all, certain legislation is needed (a) to control strictly the importation,
production, distribution, and sale of all drugs which potentially may cause
addiction, (b) to provide adequate organization and financing for carrying out
the foregoing and other activities, (c) to provide for severe punishment of
those found guilty of the illicit importation, handling, and sale of narcotics,
and (d) to allow for addicts who are apprehended to be turned over to suitable
institutions for mandatory treatment without court action. More adequate edu-
cational activities are indicated in order to bring about better understanding
and cooperation on the part of all those in society who may play a role in at-
tacking this problem. This applies to physicians, nurses, public health workers,
teachers, clergy, police, welfare workers and many others. Most authorities,
however, believe strongly that direct propaganda to young people on the sub-
ject of narcotics is not only of no value but is actually dangerous. Thus Dr. H. J.
Anslinger,* United States Commissioner of Narcotics believes that it may only

*In The Bane of Drug Addiction by Yost.*®
ADDICTIVE DISEASES 5687

 

serve to awaken the interest or stimulate the curiosity of potential adolescent
addicts. Similarly, R. N. Artis, supervisor of the Chicago office of the United
States Bureau of Narcotics has stated:

We do not recommend or promote direct education on narcotic drugs. In this con-
clusion, we agree with the conclusions of the 68 nations of the United Nations who passed
a resolution on this subject. Narcotic education is open to controversy and great objec-
tions. We prefer to educate at the parent-teacher level .*

Beyond the activities of adequate legislation and education, it is to be
anticipated that, as in the case of alcoholism, increased and improved methods
in mental health and their wider availability and acceptability will play a
significant part in the prevention as well as in the amelioration of the narcotic
problem. Added to this are the benefits which are sure to result from constantly
improving and equalizing social conditions and opportunities. These, in the
long run, may remove some of the underlying factors which lead some to escape
unpleasant realities through the insidious medium of narcotics.

REFERENCES

1. Addiction-Producing Drugs, Chronicle of the World Health Organization 11:81, March 1957.

2. Alcoholism in the United States, Ann. Am. Acad. Political & Social Sc., vol. 315, Jan. 1958.

3. Jellinek, E. M., and Keller, M.: Rates of Alcoholism in the United States of America, Quart.
J. Stud. Alcohol 13:49, 1952.

4. Clark, G. A.: The Doctor and the Alcohol Problem, Pennsylvania M. J. 58:790, Aug. 1955.

5. Moore, P. A.: Western Electric's Program on Alcoholism, Chicago, Western Electric Co.,
Industrial Relations Department.

6. Report of the American Public Health Association Task Force, Arden House Conference,
Oct. 12-15, 1956, Am. J. Pub. Health 47:218, Feb. 1957.

7. Jellinek, E. M.: Phases in the Drinking History of Alcoholics, Quart. J. Stud. Alcohol 7:1,
1946.

8. Trice, H. M.: Work Accidents and the Problem Drinker, I.L.R. Research, New York State
School of Industrial and Labor Relations, Cornell University, 3:2, March 1957.

9. Loomis, T. A., and West, T. C.: The Influence of Alcohol on Automobile Driving Ability,
Quart. J. Stud. Alcohol 19:30, 1958.

10. McFarland, R. A.: The Role of Preventive Medicine in Highway Accidents, Am. J. Pub.
Health 47:288, March 1957.

11. United States Injury Estimates, July-Dec. 1957, Am. J. Pub. Health 73:581, July 1958.

12. Alcohol as a Drug, Chronicle of the World Health Organization 8:144, April, 1954.

13. Bacon, S. D.: Alcoholism, Nature of the Problem, Federal Probation 11: No. 1, 1947.

14. Hirsh, J.: The Problem Drinker, New York, 1949, Duell, Sloan & Pearce, Inc.

15. McCarthy, R. G.: Public Health Approach to the Control of Alcoholism, Am. J. Pub. Health
40:1412, Nov. 1950.

16. Lee, K. F.: Alcohol Studies and Rehabilitation in Virginia, Pub. Health Rep. 67:474, May
1952.

17. Lewis, J. A.: Summary of Federal and State Alcoholism Programs in the United States, Am. J.
Pub. Health 45:1417, Nov. 1955.

18. Johnston, M.: Adult Guidance Center, San Francisco, Pub. Health Rep. 68:590, June 1953.

19. Zappala, A., and Ketcham, F. S.: Toward Sensible Rehabilitation of the Alcoholic, Pub.
Health Rep. 69:1187, Dec. 1954.

20. Vogel, S.: Psychiatric Treatment of Alcoholism, Ann. Am. Acad. Political & Social Sc.
315:99, Jan. 1958.

*Artis, R. N.: In Grigg, W. K.: Prevention and Control of Addiction of Narcotics, Am. J.
Pub. Health 42:1295, Oct. 1952.
588

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

21.
22,

Lewis, J. A.: Alcoholism, Am. J. Nurs. 56:433, April 1956.

Bacon, S. D.: Alcoholism, Its Extent, Therapy and Prevention, Federal Probation 11: No. 2,
1947.

Manual on Alcoholism, Chicago, 1958, Committee on Alcoholism of Council on Mental
Health, American Medical Association.

Drug Addiction and Drug Habituation, Chronicle of the World Health Organization 11:165,
May 1957.

Alcohol and Alcoholism, Chronicle of the World Health Organization 9:177, June 1955.

Yost, O. R.: The Bane of Drug Addiction, New York, 1954, The Macmillian Co.

. Jacobziner, H.: Investigating Narcotic Addiction in School Children, Am. J. Pub. Health

43:1138, Sept. 1953.

. Grigg, W. K.: Prevention and Control of Addiction to Narcotics, Am. J. Pub. Health 42:1295,

Oct. 1952.
Kolb, L.: Narcotic Addiction—An Interview, Spectrum 5:136, March 1957.

. Treatment and Care of Drug Addicts, Chronicle of the World Health Organization 11:323,

Oct. 1957.
chapter 2 5

Chronic diseases and adult health

 

Emergence of the Problem. The form and substance of the practices of both
medicine and public health have been undergoing considerable change during
recent years. Not the least of the reasons for this is the spectacular shift which has
occurred in the relative age distribution of the population. This shift may be at-
tributed to three factors: (1) the decrease in immigration, (2) a temporary de-
crease in the birth rate, and (3) an increase in the life expectancy and the ac-
companying rise in the average age at death. Of the three, the last has been of
greatest significance and has been largely the result of prior activities in preven-
tive medicine and public health. Up to the present time, these activities have
been designed, of convenience or necessity, to benefit primarily infants and chil-
dren, with relatively little attention paid to those in the older age groups. That
this has been true is not so surprising. In one sense, it has been a case of first
things first. In another sense, it is characteristic of a young, virile, growing nation
that most attention be focused upon the younger age groups so necessary for the
development of that kind of nation.

However, our population has matured, as far as its age distribution is con-
cerned. The extent to which this is true is shown in Figure 38, which indicates
the shift that has taken place in the age distribution of the population since the
middle of the last century, and the distribution anticipated by the end of the
twentieth century. It will be noted that in 1860 only 13 per cent of our people
were 45 years of age or over, in contrast with an expected proportion of 40 per
cent by the year 2000. Similarly, in 1860, 51 per cent of the population were
younger than 20 years ol age, in contrast with an anticipated 25 per cent by the
end of the twentieth century. Considering a shorter and more recent interval, in
1900 only 13 million persons, or 18 per cent of the population of the United
States, fell in the age group over 45. At the present time, the corresponding fig-
ures are about 43 million persons or about 30 per cent.

When a population ages, many other changes necessarily occur. The relative
need and demand for diapers and baby carriages necessarily decreases, whereas
the need and demand for canes and wheel chairs increases. Similarly, the need
and demand for certain types of public health and medical care must be ex-
pected to change. With the increased control of the acute communicable diseases,

589
590 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

the number of beds needed for patients being treated for these diseases has neces-
sarily decreased. At the same time, the need and demand for facilities for the care
of chronic diseases and the aged has increased. By like token, private physicians
and public health workers must expect to devote more and more attention to
problems of a geriatric and gerontologic nature.

Although chronic and metabolic diseases are by no means restricted to the
older age groups, the fact remains that it is that period of life in which they
most commonly occur or become evident, and cause disability and ultimate death.
As a result of the population changes which have occurred, many more persons
are now surviving to ages which in our time are characterized by a high incidence
of cardiovascular-renal diseases, cancer, diabetes mellitus, arthritis, rheumatism,
gout, and the mental and physiological changes associated with the climacteric.
That this has occurred is emphasized by a comparison of the leading causes of
death in the United States in 1900 and in 1956 (Table 40).

 

% OF TOTAL : % OF TOTAL
POPULATION os awoover POPULATION
10.4 —_

45 TO 64
35.7
20 TO 44

35.8 TTT

 

 

 

5 TO 19 Ea
_—
54 onven 5 veans
1 1 1 1 1 1
1860 1900 2000 AD.
Fig. 38. Change in age distribution of the population in United States, 1860 to 2000 A.p.

The over-all picture may be summarized by stating that while at the begin-
ning of the century 61 per cent of deaths were caused by infectious and parasitic
diseases and only 28 per cent by degenerative diseases, the situation is now more
than reversed with 80 per cent of deaths caused by degenerative diseases and
only 7 per cent by infectious or parasitic diseases.

Extent of the Problem. It is obviously impossible to determine with any
degree of accuracy how many persons are affected at a particular time, to any de-
gree, by the various chronic noncommunicable diseases. The insidious nature
of most of them results in delayed diagnosis which, not infrequently, is made
first at the time of death. In 1943 it was estimated that 25 million people in the
United States, or one out of every five, suffered from chronic ailments. These
CHRONIC DISEASES AND ADULT HEALTH

Table 40. The Twelve Leading Causes of Death, United States,

591

 

 

 

 

 

 

 

1900 and 1956
1900 1956

Death Rate Death Rate

Per 100,000 Per 100,000

Cause Population Cause Population
Influenza and pneumonia 202.2 Diseases of heart v 360.5
Tuberculosis 194 4 Cancer 147.9
Diarrhea and enteritis 139.9 Cerebral hemorrhage 106.3
Diseases of heart 137.4 Accidents 56.7
Cerebral hemorrhage 106.9 Diseases of early infancy 38.6
Nephritis 88.7 Influenza and pneumonia 28.2
Accidents 72.3 General arteriosclerosis 19.1
Cancer 64.0 Diabetes mellitus 15.7
Diseases of early infancy 62.6 Congenital malformations 12.6
Diphtheria 40.3 Cirrhosis of liver 10.7
Simple meningitis 33.8 Suicide 10.0
Typhoid and paratyphoid 31.3 Chronic nephritis 9.1
All causes 1719.1 All causes 935.4

 

 

 

cause an estimated annual disability rate of one billion man days, and result in
approximately one million deaths each year. The National Health Survey of
1935-1936, which provided a more detailed analysis, brought to light the num-
bers of persons who suffered from eight particular chronic diseases (Table 41).

Of these diseases, only one, tuberculosis, may be considered to have de-
creased since the time of the survey. The annual incidence of chronic disease or
permanent impairment for all ages was found to be 177 per 1,000 population.
Table 42, which presents the incidence of chronic invalidism by age groups, em-
phasizes the increasing tendency to be affected as one grows older. Although half
of the persons with chronic diseases or impairments are below 45 years of age,

Table 41. Persons Suffering From Eight Particular Chronic Diseases,
National Health Survey, 1935-1936

 

 

Arthritis and rheumatism
Heart disease

Hay fever and asthma
Chronic bronchitis

Nephritis and kidney disease
Nervous and mental diseases
Cancer

Tuberculosis

9,700,000
3,700,000
3,450,000
1,700,000
1,550,000
1,450,000

930,000

680,000

 
592 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 42. Invalidism from Chronic* Diseases per 1000 Population, by Age
Groups, United States, 1935-19367

 

 

Rate Per Rate Per
1,000 Persons Percentage 1,000 Persons Percentage
Age in Years | in Each Age Distribution Age in Vears in Each Age Distribution
Group Group

All ages 177 100.0 35-44 221 19.9
_— 45-54 274 18.8
Under 5 34 1.4 55-64 344 14.2
5-14 68 6.6 65-74 466 10.8
15-24 83 8.4 75-84 522 4.1
25-34 159 15.3 85 and over 557 0.7

 

 

 

 

 

*Chronic refers to illnesses the disease symptoms of which have been observed for at least
three months before the day of visit.

tAdapted from Britten, R. H., Collins, S. D., and Fitzgerald, J. S.: The National Health
Survey; Some General Findings as to Disease, Accidents, and Impairments in Urban Areas,
Pub. Health Rep. 55:444, March 1940.

the risk within each age group increases consistently with age until past 66 years,
when one out of every two persons is affected.

The prevalence of specific chronic diseases or impairments by sex and age
at that time is presented in Table 43. Among the interesting facts which it brings
out are the consistent increases in the older age groups and the higher preva-
lence which occurs in most age groups for females in contrast with males. This
is surprising, considering the significantly greater expectation of life for females.

It is estimated that there are now 51% million persons affected by chronic
long-term disabilities that are serious enough to require some kind of care. Of
these, 1,400,000 are under 45 years, 1,800,000 are between 45 and 64 years, and
2,100,000 are 65 years ol age or older. The respective prevalencies by age are
1.3 per cent under 45 years, 5.8 per cent between 45 and 64 years, and 17.1 per
cent over 65 years of age.”

Are Chronic Diseases Increasing? There is no denying that many more peo-
ple suffer from chronic diseases now than formerly. An important question, how-
ever, is whether the increase is real or apparent, absolute or relative. The use
of crude morbidity and death rates in the evaluation of health problems is fraught
with considerable danger. Unfortunately, because of the ease and convenience
of their calculation and use, most of the information which is available to and
discussed by the healing professions as well as the public is of this nature. Since
the age groups in the population that are most prone to develop chronic ailments
have increased so markedly, it is only natural that the crude morbidity and
death rates from these causes should have increased. Thus, the crude death rate
for diseases of the heart increased from 137.4 in 1900 to 360.5 per 100,000 in
1956, and the rate from cancer during the same period increased from 64.0 to
147.9. These represent increases of more than 100 per cent for both diseases dur-
CHRONIC DISEASES AND ADULT HEALTH 593

 

Table 43. Prevalence (per 1,000 Persons) of Specified Chronic Diseases or
Impairments, Disabling and Nondisabling, Among Adults 20 to 64 Years
of Age, Classified by Sex in Two Age Groups*

 

 

 

 

Male Female
Disease or Disease Group Total 20-34 35-64 20-34 35-64
Years Years Years Vears
Major chronic diseases and impairments:
Rheumatism and allied diseases 47.5 12.4 62.2 21.4 84.2
Cardiovascular-renal diseases 39.3 &.7 49.6 17.0 72.7
Orthopedic impairments 21.7 20.0 52.4 5.8 14.0
Deafness 10.6 4.0 18.7 3.6 15.2
Asthma 9.0 4.6 15.8 4.6 11.0
Nervous and mental diseases 9.0 3.7 09.1 7.1 14.3
Goiter and other thyroid diseases 8.1 1.3 2.6 10.9 14.2
Blindness, one or both eyes 5.1 3.0 11.3 1.1 5.5
Cancer and other tumors 4.7 .8 2.4 3.9 9.9
Gall bladder and liver diseases 4.4 3 3.5 1.9 10.3
Diabetes mellitus 4.1 1.0 5.1 .8 8.6
Ulcer of stomach 2.8 2.2 6.5 .0 2.3
Tuberculosis (all forms) 1.0 1.5 3.1 2.0 1.2
Minor chronic diseases:

Hay fever 14.3 11.6 16.4 13.8 15.0
Hernia 13.7 10.6 40.7 1.4 6.3
Varicose veins 13.2 2.0 9.8 6.6 20.6
Hemorrhoids 12.4 4.7 20.5 7.3 15.9
Bronchitis 8.9 3.4 13.1 5.5 12.3
Sinusitis 8.3 6.2 9.5 7.3 9.6
Diseases of female genital organs 4.9 9.7 7.5

 

 

*From Hailman, D. E.: Health Status of Adults in the Productive Ages, Pub. Health Rep’
56:43, Oct. 1941.

ing the intervening forty-five years. Quite a different picture is obtained, how-
ever, by a more careful analysis by means of age specific standardization of rates.
In briel, this procedure consists of the calculation of a series of death rates, one
for each age group of the population, instead of a single crude rate for the entire
population. These age-specific death rates are then applied to the present popu-
lation as it would appear if distributed by age in a manner similar to some
standard or previous population such as that of 1900. Thus, when this procedure
was applied to industrial policyholders of the Metropolitan Life Insurance Com-
pany, the surprising fact was brought out that during the third of a century, be-
tween 1911 and 1945, the death rate standardized for color, age, and sex de-
creased 29 per cent for diseases of the heart, arteries, and kidneys, and had in-
creased only 8 per cent for cancer. The observation was made that the slight in-
crease recorded for cancer was rather less than might be expected from improve-
ments in diagnosis.*
594 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Aging Versus Senescence. Information such as presented here is not meant
to imply the inevitability of chronic illness and disability in the adult and aging
population. Aging is not necessarily synonymous with chronic illness or senes-
cence. This has been pointed out by many writers. One of them, Widmer,? having
studied one hundred persons past 90 years of age, summarized his conclusions
in the forceful sentence, “The old people of sixty are all ill, the centenarians are
healthy.” He described his patients as taut, lean, and dry. None of them were
invalid or bedridden and all were rather young in appearance.

Rejoicing is heard on all sides for the consistent lengthening of the life
span which it has been the privilege of recent generations to experience. For
many, it would appear to represent a matter of scorekeeping in a contest with
fate. If the increasing numbers of persons achieving advanced ages did so physi-
cally and mentally fit, there would be real reason to rejoice. The brutal fact re-
mains that despite any mathematical readjustments that may be made, in-
creasing numbers of individuals, not rates, are not only growing old, but sick
and senile as well. As Piersol® has opined, “Longevity marred by an accompani-
ment of a disabling disease and suffering has little to commend it; it is a distinct
liability rather than an asset.” He therefore considers that the most important
responsibility of medicine and public health today is prevention or delay of the
development of the degenerative diseases in order that the potentialities of elderly
persons may be more widely developed and utilized.

The Solution of the Problem. Much attention is currently being given to
steps that may be taken by the individual, the medical profession, and society
in general to meet successfully the problems posed by the aging of the population
and the accompanying increase in chronic diseases. The voluntary health agen-
cies provided the first organized attack in the form of associations concerned
with heart disease, cancer, arthritis, diabetes, and other chronic ailments.

The ultimate hope, of course, is for prevention. There are two kinds of pre-
ventive medicine: the community type as represented by the typical public
health approach, and the private type represented primarily by the individualized
service rendered in the offices of private practitioners of medicine. Community
or public health preventive medicine is inapplicable to most problems of preven-
tive geriatrics. The physical condition of the older segments of the population
cannot be improved by the turning of a valve or the injection of an antigen. Nec-
essarily, therefore, the predominant role must be played by private physicians.
Geriatrics will undoubtedly pattern much of its thinking and development on
the concepts and experiences of pediatrics. As a matter of fact, paradoxical as it
may appear on the surface, pediatricians probably have been more conscious of
the factors involved in aging than any other physicians. The problems that
must be faced, however, are somewhat different. As pointed out by Stieglitz?
in his discussion of the social urgency of research in aging, “Whereas the
commoner diseases in youth have acute and florid onsets, obvious symptoms
and, being of infective origin, tend to be self-limited and self-immunizing, the
disorders frequent in later years are characterized by insidious and asympto-
matic onsets, slowly progressive course and endogenous, or at least non-specific,
etiology.”
CHRONIC DISEASES AND ADULT HEALTH 595

 

Handicaps to Solution. Fundamental as it is to the solution of the problem
of adult hygiene and chronic diseases, the personal approach of the private
physician is not without its limitations and handicaps. Not the least of these are
the expense and inadequacy of facilities for adequate early diagnosis and treat-
ment. The inequalities in the distribution of members of the healing professions,
and of auxiliary aids such as hospitals, is the subject of discussion in Chapter 30;
also discussed is the inability of a large proportion of the population to meet
the mounting costs of medical care. The average person can usually afford the
fee for the first physician seen but in many instances finds is difficult to meet the
costs of consulting physicians, diagnostic aids, hospitalization, and surgery.

Another handicap is the difficulty encountered in the prevention of chronic
diseases in a direct sense. While some might deny the possibility of prevention
of chronic diseases, it is nevertheless possible to a significant but indirect extent.
The successful approach to the prevention and treatment of the communicable
diseases of early life precludes the development of much tissue damage and foci
of infection which, if permitted to occur, would be manifest later on as syphilitic
or rheumatic hearts, nephritis, arthritis, or other chronic conditions. Careful ob-
stetrical management, with the avoidance of cervical tears and the proper repair
of those that occur, is certain to prevent many future cervical carcinomas. The
increasing precautions taken by industry for the protection of its workers not
only prevent many disabling injuries but, for some processes, also remove poten-
tial hazards that might lead to bronchitis, silicosis, occupational cancers, and
other chronic diseases. These are but a few of the potential preventive measures
that may be taken against chronic illness. The point to be realized is that the
benefits should not be expected to become evident immediately, any more than
the effect of the injection of an antigen is expected to produce immediate and
obvious beneficial manifestations.

A most serious handicap is the insidious nature of the development of the
majority of chronic illnesses. Their onsets tend to be asymtomatic and they often
progress slowly with little or no pain or discomfort in the earlier stages. This
encourages the person afflicted, even when he suspects the condition, to delay
in seeking medical advice and care. One of the most fundamental handicaps,
therefore, is the difficulty of getting persons to protect themselves, to obtain peri-
odic medical examinations and, if necessary, early and adequate treatment.
Stieglitz” has aptly stated that “the privilege of longevity carries with it the obli-
gation of personal effort toward health maintenance.!* This, in consideration of
the inherent frailties of human nature, is the seat of much of the problem. A num-
ber of psychological blocks must be counteracted. The individual must overcome
a considerable amount of inertia and do something which is not of immediate or
apparent benefit, much less pleasure. For many, a truly complete and adequate
physical examination represents a decidedly unpleasant and embarrassing experi-
ence. Furthermore, it not infrequently requires time off from gainful work. Fear
of a positive diagnosis serves as a deterrent for some, and others rebel at the
thought of potential restrictions upon their personal habits and pleasures. The
only weapon available against these deterrents is increased and persistent educa-
tional measures. The ultimate goal should be the establishment of periodic
596 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

medical examinations as part of the accepted cultural behavior of our civiliza-
tion, as has occurred to a considerable degree with regard to the immunization of
children against many communicable diseases. This is an instance in which the
role of the health department begins to become evident.

The Role of the Health Department. For a long period it was considered
that chronic diseases and adult health were not the concern of official public
health agencies. This attitude has been undergoing change, slow though it may
appear to many. Interestingly enough, it is often overlooked that the more com-
monly accepted public health activities may play a most important, though indi-
rect, part in the eventual alleviation of many of the disease problems of ad-
vanced years. As pointed out previously, the reduction in morbidity from acute
communicable diseases not only is important in the prevention of early death
and in the prolongation of life, but also in the avoidance ol infectious foci and
structual changes which may give rise to chronic diseases. Maternal hygiene not
only eases the burdens and immediate risks of motherhood but prevents the de-
velopment of complications which formerly invalided many women in later life.
Most ol the benefits of services to children, such as well-child conferences and
clinics, school health programs, and medical examinations for the correction of
defects, are reaped in later life. Recognition should be given to the delayed bene-
fits of the present extensive use ol antibiotics, ataraxics, antihypertensives and
other drugs, and to recent nutritional improvements.

Good nutrition of the expectant mother and the child is said to contribute
more than anything to physiological and mental health in later life. Davis,® for
example, believes that “the involutional, biochemical processes which lead to
senescence may be influenced by all factors which in any way modily cellular me-
tabolism.” He lists the following factors as important in determining the onset
and relative severity of these changes: (1) heredity, (2) the health and nutrition of
the parents at conception, (3) the health and nutrition of the mother during preg-
nancy and lactation, (4) any illnesses that the individual may have had at any
time in his life, (5) the quantity and quality of the nutrition at all periods of life
and its relation to the individual needs, (6) the environment of the individual
during his past life, and his occupation, habits, and manner of living, and (7) any
gases, dust, chemical compounds, and drugs used at one time or another.

Official public health agencies should not be expected to assume the entire
burden of the attack against the diseases ol middle and older ages. As already
indicated, the predominant role must be played by practitioners of medicine,
and the place of the voluntary health and social agencies must likewise become
increasingly important. The necessary combination of workers is a three-cornered
partnership made up ol the medical profession, the social agencies, and the public
health agencies working together toward the amelioration and solution of the
problem. Such a partnership would not be new, having operated successfully for
many years in other fields such as maternal and child health, tuberculosis, and
venereal disease control. With the precedent well established, it is logical to vis-
ualize, for example, the establishment of diagnostic centers financed wholly or in
part by public funds, staffed by private physicians and consultants on any of
the acceptable bases of payment, with the educational and promotional work
CHRONIC DISEASES AND ADULT HEALTH 597

 

carried on by the public and voluntary health agencies, and the necessary social
service work performed by the appropriate agencies which exist for that purpose.
The impetus and leadership, however, may well be furnished by the official public
health agency, which may serve to correlate and integrate the contributions and
activities of all concerned.

Development of Public Programs. Chronic disease programs are being es-
tablished at an increasing rate. Up to this time, however, the chief focus of at-
tention has been on cancer. This was the first of the chronic diseases of later
life to receive recognition in the official public health program. In this country,
Massachusetts merits priority for the provision in 1919 of funds for the establish-
ment in its state health department of a program for the study of the prevalence,
prevention, and control of cancer. As far as can be ascertained, Detroit was the
first city to explore the problem, following a specific appropriation in 1928 to the
health department for this purpose. The objectives of the program were: first,
to get the factual information, i.e., the statistical background with regard to can-
cer in the community; second, to encourage physicians to diagnose and to treat
cancer, through the various channels of pregraduate and postgraduate medical
education; third, to institute a service for early case detection and the encourage-
ment of treatment; fourth, to institute a follow-up system for cases which received
surgical, radium, or x-ray treatment; and fifth, to educate the public in simple
terms and with frank statements with regard to the existing knowledge concern-
ing the early treatment of cancer.

Slow to develop, by 1950 every state had established a cancer program. Serv-
ices are provided by fifty state health departments, two state cancer commissions
(Arkansas and New Hampshire), twenty-seven state universities or medical col-
leges, nine departments of wellare, and three agencies of other types. A large
share of the total state-wide cancer programs is carried on by the state chapters
of the American Cancer Society, and by the state medical societies.” In most
states, the general ideals set [orth by the National Advisory Cancer Council are
more or less adequately approached. These include (1) statistical research to de-
termine the nature and extent of the cancer problem of the state and to evaluate
the results of activities, (2) educational activities for the public and all profes-
sional groups concerned in the detection, diagnosis, and treatment of cancer,
(8) activities to provide adequate detection, diagnostic, and treatment facilities
and services accessible to persons of all economic groups in all sections of the
state, including facilities for care of the terminal case either at home or in an
institution.

Progress has been much slower in relation to the other diseases and health
problems of later life. A few states are beginning to turn their attention to some
of the broader aspects of the situation. Here again, Massachusetts has long been
the leader, with Connecticut and New York not far behind. Already, a number of
public health programs include, in addition to the cytologic smear for detection
of cancer, the use of the clinitron for diabetes screening and the tonometer for
the detection of early glaucoma. Significant also is the beginning trend toward
expanding the programs for diagnosing tuberculosis into programs for diag-
nosing chest disease, which places greater emphasis upon certain cardiac condi-
598 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

tions, pulmonary carcinoma, and silicosis. The goal of all such programs is the
earliest possible diagnosis with referral to physicians and hospitals for prompt
treatment.

Content of a Chronic Disease Program. A complete program for chronic
diseases should probably consist of seven parts: (1) research, (2) early diagnosis,
(3) hospitalization and treatment, (4) follow-up, (5) rehabilitation, (6) education,
and (7) custodial care.

Research. At the present time, continued and expanding research is still
a fundamental necessity. In addition to the obvious need for the study of the
causes, diagnosis, and treatment of chronic diseases, research activities should in-
clude statistical studies of prevalence, incidence, and mortality in the various
component groups of the population, and administrative studies for the develop-
ment of satisfactory and efficient methods of implementing a community program.

Early Diagnosis. Early diagnosis is a primary step in controlling any chronic
disease, whether or not it is communicable. For some diseases, diagnosis is rela-
tively simple and inexpensive, whereas for many others it produces an economic
burden of considerable magnitude. Several approaches are possible in order to
overcome this aspect of the problem. Private physicians and hospitals may be
called upon to render an increased amount of free or reduced-fee medical care.
This, however, would be impractical and unfair to the profession and institutions
as well as undesirable for the public. One compromise that has been arrived at
and which has met with reasonable success is the plan of providing periodic ex-
aminations of limited scope in the offices of private physicians with the patient
paying the fee customarily charged for a general examination. Medically indi-
gent patients may be examined [ree or an agreement may be reached whereby the
physician is paid out of public funds.

Up to the present, this approach has been more or less limited to examina-
tion for signs of cancer. Studies have shown that more than 60 per cent of
cancer cases involve five readily accessible sites: the skin, lips, breasts, cervix, and
rectum. These sites can be easily examined by any well-trained physician in his
office without recourse to unusual equipment or procedures. The examination is
so relatively simple, brief, and inexpensive that both the patient and the physician
can afford its repetition every six months to a year. The only potential danger
of this approach is that the patient, on receiving a negative report from this lim-
ited examination, may feel that he is free of all types of cancer and of all disease.
Where this program is put into effect, it is of great importance, therefore, that its
limitations be stressed to the public.

Another approach has been specialized cancer detection centers. Generally,
these have not been economical and efficient, and if the idea were extended to
the establishment of similar special facilities for other chronic diseases, the cost
would be prohibitive and the program inefficient. The approach therefore should
be more general and should be concerned with broad aspects of the chronic dis-
ease diagnostic problem. Multiphasic screening programs have been developed
as one attempt to meet the need. In these, a variety of tests may be performed
quickly and efficiently for large numbers of people .
CHRONIC DISEASES AND ADULT HEALTH 599

 

Hospitalization and Treatment. The majority of patients who are diagnosed
as having a chronic disease are hospitalized for at least a period of several days
or weeks in order for a complete decision as to diagnosis, therapy, and prognosis
to be made. In addition, many hospital beds are needed for long-term care so
that certain patients may receive the surgical, medical, and nursing treatment
necessary to return them eventually to normal or near-normal existence. Here
again appear the problems of availability of sufficient hospital beds and the abil-
ity to pay for them. Private or public prepayment hospitalization insurance plans
provide a possible solution to the problem of payment. In addition, however,
there appears to be unanimous agreement concerning the need for large numbers
of additional publicly supported hospital beds for chronic diseases. Some of these
undoubtedly will have to be provided by additional appropriation and construc-
tion, such as are provided for by the Hill-Burton Hospital Survey and Con-
struction Act of 1946.

The need for more beds for patients suffering from chronic diseases provides
one answer, however, to a problem which public health administrators have al-
ready begun to be concerned with, i.e, what to do with the hospital beds avail-
able for acute communicable diseases and tuberculosis in the face of declining
incidences and shortened hospital stays. It would appear logical that many of
these beds might eventually be made available for the care of patients with
chronic noncommunicable diseases. It is interesting that the first public hospital
established for the care of cancer patients in Pondville, Massachusetts, was a
reconverted tuberculosis sanatorium.

Follow-up. The active follow-up of posthospitalized patients is a most im-
portant and expanding part of the chronic disease program. Often, the chronically
ill and aged patient is happier and mentally better off in his own home with
familiar surroundings and proximity to those he loves. It has been estimated that
about 70 per cent of such patients could be cared for satisfactorily in their own
homes if adequate auxiliary services, such as visiting nurse and housekeeper serv-
ices, were available, and if the other members of the family were given some
training. It is here that the public health nurse can make a significant contribu-
tion to the program for the care of the chronically ill and aged. The need has
already been made evident by the public in terms of demands for this type of
service. This constitutes a strong argument in favor of the more widespread and
more effective joining of the forces of the official public health nursing services
and the bedside nursing programs of the visiting nursing societies.

An example is provided by the Metropolitan Life home nursing service for
policyholders. In 1925, nearly 50 per cent of requests for service related to acute
and communicable conditions, most of which occur in early life, and only about
5 per cent for chronic diseases. In 1945, the figures were reversed to 14 per cent
and 28 per cent, respectively.!® In addition to rendering direct services in the
home, the visiting nurse may be of assistance in returning the posthospitalized
patient to the care of a private physician, providing him with information help-
ful in the handling of the case, and assisting the patient in putting the physician’s
suggestions into effect. Patients may also be aided in the use of outpatient clinics
and departments of general hospitals by patients residing in their own homes.
000 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Rehabilitation. A program of rehabilitation [or chronically ill and disabled
patients should be carried on concurrently with the other activities. The need
for this is indicated from two points of view. The most obvious is assistance to
enable patients to become partially sell-supporting, or at least to take care of
their own personal needs and to be less of a burden to their relatives and friends.
Many patients may be returned to their previous occupations, although often on
a reduced work-time schedule. Others may be guided into new endeavors more
suitable to their present capabilities. Further mention will be made of this in the
discussion of the role that industry may play in the adult health program (see
page 601).

Too frequently overlooked is the need for rehabilitation in the mental hy-
gienic sense. A not uncommon sight is the woman who, having undergone a
breast amputation or a hysterectomy, is returned to her home and family with no
psychiatric preparation and who spends the remaining years of her life feeling
incomplete, hall a woman, and perhaps unwanted. The same applies, although in
a somewhat different sense, to the man who is summarily directed to give up his
daily work, his sports, and other activities which made life worth the living. The
tremendous need for activity in this area represents as yet a vast virgin territory
and provides an area of great potential service by public health nurses as well
as medical and social service advisors.

Lducation. Great is the need for public education with regard to the chronic
illnesses of later life. On first consideration it appears incomprehensible that
large numbers of the population of the United States at this point in its appar-
ently advanced civilization are so utterly lacking in knowledge and have so
many misconceptions and superstitions regarding chronic ailments. However,
when the fundamental forces which motivate human thought and behavior are
considered, the result is not so surprising. Up to the present, this challenge has
been met almost single-handedly by the various voluntary agencies, and as a re-
sult it is they who deserve the major credit for the contemporary interest and prog-
ress that is taking place in this field. In the final analysis, it may well be that in-
creased public education in these matters would represent the single most im-
portant service that may be rendered by public health agencies.

Custodial Care. The final phase ol any program designed to serve those who
suffer from chronic diseases is the provision of custodial care. The extent of the
need for this type of care is the best measure ol the degree of defeat or failure of
the total program. A certain number of patients require custodial care of long
duration because of indigency and lack of family or because of progressive incura-
bility of their illness. What is needed here is not so much medical and hospital
treatment as mothering and the alleviation ol pain and discomfort during the in-
terval of life which remains. At the present time, relatively few facilities for this
type ol care are maintained at public expense. Dependence must be placed also
upon facilities established and operated by religious and fraternal organizations.
In addition, there are a large number of privately owned nursing homes through-
out the country—some excellent, and some abominable. The adequate supervision
of these institutions certainly is a justifiable public health [unction. Gradually, a
CHRONIC DISEASES AND ADULT HEALTH 001

 

few state health departments are being given the responsibility for the supervi-
sion of the sanitation and general operation of these institutions.

The Role of Industry. Industrial plants are key spots of great potential ad-
vantage to any program of adult health and chronic disease service and control.
They may be regarded as places where, because large numbers of adults are con-
centrated, adults may be conveniently and efficiently reached and served in the
same way that schools represent focal points for much of the public health pro-
gram designed for children. This is particularly significant when it is realized
that chronic illnesses are particularly prevalent among wage earners in the lower
and middle income groups. Thus Lawrence,'' in a study of 1,628 families in
1943, found almost twice as much chronic illness among those of moderate and
poor means as among the well-to-do. (Table 44.)

Table 44. Prevalence of Chronic Illness in Families, According to Socioeconomic
Status, 1943*

 

 

 

Numbers Percentages
Socioeconomic | oo So
Status
Total Well Ill Observed Expectedt Adjusted?

Total 1,010 585 425 42.1 42.1 42.1
Well-to-do 47 32 15 31.9 44.2 29.3
Comforta' le 123 74 49 39.8 44.6 39.8
Moderate 635 374 261 41.1 41.8 41.1
Poor 193 99 94 48.7 41.0 50.6
Very poor 12 0 6 50.0 41.9 44.0

 

 

*Lawrence, I>. S.: Chronic Illness and Socio-Economic Status, Pub. Health Rep. 63:1511,
Nov. 1948.

tRates that would prevail if chrenic illness and sociceconomic status were unassociated.

{Rates that would prevail if there were no age or family-size differences in the groups con-
sidered.

Modern progressive industries now realize that the promotion of the health
and education of workers represents a sound investment. There are many ways in
which industry may play an important role. An increasing number of businesses
and industries are establishing policies requiring the pre-employment and peri-
odic medical examinations of workers. Considering the many persons involved,
this serves as a fruitful means of diagnosing chronic illnesses in their early stages
and makes a large part of the population aware of the need for constant self-
surveillance. Many plants engage in praiseworthy programs of health education
for their workers. Reference has already been made to the potential preventive
effect of the removal of industrial hazards. Hospital and medical care insurance is
frequently an employment benefit. Rehabilitation programs work to the advant-
age of business and industry. World War II brought about a belated realization
002 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

that there exists in the population a large pool of industrial man power in the
form of persons only partially handicapped by chronic disease and disabilities. In
the face of serious shortages of man power, the contributions of such persons to the
national war effort was by no means insignificant and has been said by some to
have turned the scale on the production front. As a result, many industries have
continued their wartime policy of job placement of partially handicapped work-
ers on the basis of aptitude tests and a careful study of their physical capabilities.
This is the best possible type of rehabilitation, physical, mental, moral and eco-
nomic, and it should be done by more employers.

A very important contribution that may be made by industry is the develop-
ment of more reasonable and individualized retirement procedures. The picture
is all too familiar of an individual having to accept retirement at a certain age,
on the basis of chronology rather than physiology, with the result that the en-
forced idleness and apparent lack of purpose limit the remaining years of
life. We are less similar at the age of 65 than we are at birth. Productive poten-
tialities are subject to great individual variation until the end of life. Most men
are not promoted to positions of great responsibility and opportunity until about
the age of 50. This being true, it is important to find means to help the older
individual keep physically and mentally fit, and then to allow him to use his
fitness and ability. Tt would appear, therefore, to be highly inefficient as well as
illogical and cruel to attempt to place all persons in exactly the same retirement
mold.

Recent Events on the National Level. Vague as the total picture has been
up to the present, it now appears to be coming into focus. Not many years ago,
chronic illness and problems of adult health were subjects which tended to be
underemphasized in public health as well as in other circles. The situation has
rapidly changed during recent years, with the role of leadership being assumed
more and more by the national-level agencies. One may point to a number
of recent top-level meetings since 1947, such as the National Conferences for
Planning for the Chronically 111 with representation by the American Hospital
Association, the American Medical Association, the American Public Welfare
Association and the American Public Health Association’? and the National
Cancer Conferences beginning in 1949 sponsored by the American Cancer So-
ciety and the Public Health Service. Also, attention may be called to a significant
series of papers which represents the outcome of a symposium on problems of
an aging population held at the annual meeting of the American Public Health
Association in November, 1946,'3 and of the National Health Forum on Chronic
Disease in 1956.1* Of great value has been the work of the Commission on Chronic
Illness, a national voluntary group which carried out studies in the United States
between 1945 and 1956. On this basis, the commission has produced four useful
volumes on various aspects of the problem.!5

Finally, attention should be called to the flood of legislative bills, dealing
with a long list of chronic ailments and disabilities, including cancer, heart dis-
ease, arthritis and rheumatism, mental diseases, dental diseases, multiple sclerosis,
cerebral palsy, epilepsy, poliomyelitis, blindness, leprosy, and venereal diseases,
which have been introduced into the National Congress during recent years.
CHRONIC DISEASES AND ADULT HEALTH 003

 

Some of these already have been acted upon favorably, and have resulted in the
establishment of various National Institutes of Health. Also of interest are the re-
cent moves to include medical and hospital care benefits in the Social Security
provisions. Even the need for custodial care of the chronically ill and aged is
beginning to receive some attention from the Congress.

While the control of chronic diseases still appears difficult, the situation is
probably no different from that presented by communicable diseases a half cen-
tury ago. That problem has been largely conquered. In the light of recent trends,
we may well look forward to similar results in the field of chronic diseases with
the ever-increasing knowledge provided by persistent research and the coopera-
tion of the medical, public health, and social professions.

REFERENCES

1. Britten, R. H., Collins, S. D., and Fitzgerald, J. S.: The National Health Survey; Some Gen-
eral Findings as to Disease, Accidents, and Impairments in Urban Areas, Pub. Health
Rep. 55:444, March 1940.

Mayo, L. W.: Five Million People, Pub. Health Rep. 71:678, July 1956.

Hailman, D. E.: Health Status of Adults in the Productive Ages, Pub. Health Rep. 56:43,
Oct. 1941.

Statistical Bulletin, Metropolitan Life Insurance Company, 27:11, Nov. 1946.

Widmer, Charles: Die Neurzigjachrigen, Miinchen, Med. Wchnschr. 76:840, 1929.

6. Piersol, G. M.: Medical Considerations of Some Geriatric Problems, Arch. Ophth. 29:27,

Jan. 1943.
. Stieglitz, E. J.: The Social Urgency of Research in Aging; In Cowdry, E. V. (editor): Prob-
lems of Aging, ed. 2, Baltimore, 1942, Williams & Wilkins Co.
Davis, N. S.: Factors Which May Influence Senescence, Ann. Int. Med. 18:81, Jan. 1943.
9. Distribution of Health Services in the Structure of the State Government, Public Health
Service Publ. No. 184, Washington, 1953.

10. Dublin, L. I.: Problems of an Aging Population, Setting the Stage, Am. J. Pub. Health
37:155, Feb. 1947.

11. Lawrence, P. S.: Chronic Illness and Socio-Economic Status, Pub. Health Rep. 63:1511, Nov.
1948.

12. Planning for the Chronically Ill. Joint Statement of Recommendations by the American
Hospital Association, American Medical Association, American Public Health Associa-
tion, and American Public Welfare Association, Am. J. Pub. Health 37:1256, Oct. 1947.

13. Problems of an Aging Population, Am. J. Pub. Health 37:152, Feb. 1947.

14. National Health Forum on Chronic Disease, Pub. Health Rep. 71:675, July 1956.

15. Commission on Chronic Illness: I. Chronic Illness in the United States, II. Care of the Long-

Term Patient, III. Chronic Illness in a Rural Area, IV. Chronic Illness in a Large City,
Cambridge, 1957, Harvard University Press.

oo

SU os

<1

x
chapter 2 6

Occupational health and private enterprise

General Considerations. The existence ol a common ground of interest
between public health and private enterprise has only relatively recently been
realized in many places. Yet, even superficial study of the situation indicates many
points of common interest. Public health’s concern with private enterprise is
based upon a number of factors. A fundamental consideration is that health is
everybody's business. Perhaps the most obvious interest of public health agencies
in the affairs of private enterprise relates to products manufactured and sold.
Certain industrial products have far-reaching potential consequences for the buy-
ing public; therefore tax-supported public health agencies bear a responsibility.
The production, handling, processing, and circumstances of sale ol a large num-
ber of food products is well established as big business. It has long since become
necessary lor the paths of public health workers and private entrepreneurs to
cross during the supervision of the sanitary aspects of these products. This sub-
ject has been considered in Chapter 17.

Another obvious and early reason for public health interest in private enter-
prise relates to problems brought about by the conditions of work in industry.
Workers have been exposed to grievous physical and chemical risks. There are
four types ol recourse against undesirable conditions of work, i.e., strikes and
disability compensation, neither true solutions; labor-management arbitration;
and cooperative preventive planning and action by public health agencies, labor,
and industry. The latter has led to the development and use ol safety devices, and
provision for the diagnosis, treatment, and prevention ol occupational diseases
and injuries. It is this phase ol the problem which constitutes the chiel concern
of this chapter.

A further reason why public health agencies should be concerned with
private enterprise is the fact that a large segment of the population may be
reached and influenced lor public health purposes through their place of em-
ployment. This circumstance has been used to considerable advantage in pre-
service and inservice physical examinations, health education and nutrition
programs, mass diagnosis, and illness and disability surveys. As one authority!
has written, “people are employees and employers only part of the day. The
remainder of the time they are plain everyday citizens.” Their influence on com-

004
OCCUPATIONAL HEALTH AND PRIVATE ENTERPRISE 005

munity action is tremendous and worth consideration in planning and providing
community services essential to the maintenance of health. Hence, in any com-
munity planning for health, all groups should be represented. Moreover, this
planning should be for total community health and not for health services in
the place of employment alone. The greatest opportunity for life saving, and
the prevention of discase and disability lies, at the present time, in the age and
social class represented by the wage earner. The approach through industry and
business to the health of the wage earner offers the same administrative advan-
tages inherent in school health programs, namely, large numbers readily accessible
and, from the community standpoint, a group whose health is vitally important
and peculiarly at risk.

Finally, if proper relationships are developed, support of the public health
program of no small mangitude and significance may be obtained from those in
positions of responsibility and authority in private business and industry. The
nature of industrial hygiene activities requires accessible service and a close rela-
tionship between the publc health administrator and the industrialist. Through
an effective and profitable program of industrial hygiene and product sanitation,
the health officer is in a position to meet and favorably impress the industrialists
and businessmen ol his community on their own terms with the importance of the
total public health program. The health officer should always bear in mind that
businessmen and industrialists are citizens too, and that business and industrial
enterprises produce the economic lifeblood of the modern community.

Programs and activities concerned with the well-being of workers exist under
numerous labels in various times and places, i.e., industrial health, hygiene,
safety, engineering, welfare, or medicine, as well as the more confusing term
“environmental medicine.” As a result of the gradual coming together and
synthesis of the various interests implied by these designations and the ever-
broadening view of the many factors which are involved in the well-being and
efficiency of workers, there has come about a tendency to refer to the entire area
of interest as occupational health. In general, it appears that the label and defi-
nition given to the field has depended essentially upon the profession of primary
interest or background of the discussant. In this regard, Hussey? has very appro-
priately said:

This whole subject of occupational health and medicine is analogous to a three-legged
stool, one leg representing medical science, one representing engineering and chemical
science, and one representing the social sciences . . . . Up to the present we have been
trying to balance ourselves on two legs and in some instances on one leg. It is a very

uncomfortable position and one that cannot get us very far and certainly will lead, as it
has, to fatigue.*

With this in mind, the following definition by the Council on Industrial
Health of the American Medical Association? is presented:
Occupational Medicine deals with the restoration and conservation of health in
relation to work, the working environment and maximum efficiency. It involves pre-
vention, recognition, and treatment of occupational disabilities and requires the appli-

*Hussey, Raymond: In discussion of article by Hemeon, W. C. L.: Engineering in Industrial
Health Education, Occup. Med. 4:201, Aug. 1947.
000 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

cation of special techniques in the fields of rehabilitation, environmental hygiene, toxi-
cology, sanitation and human relations.*

Background. Ramazzini is usually considered to be the father of the subject,
his parenthood based upon the publication in the seventeenth century of his
Diseases of Tradesmen. Modern occupational health is an outcome of the in-
dustrial revolution in nineteenth century England. As a result of the rapid devel-
opment of deplorable work conditions and the exploitation of women and chil-
dren, numerous laws were passed for the protection of workers. Following a short
lag period, there came about what Legge! referred to as the “American Industrial
Renaissance.” During this period America profited by the events, researches, and
measures which had previously occurred in England, even to the extent of adop-
tion by some states of some of the earlier English legislation. The first compensa-
tion law in the United States was enacted in 1908 for the benefit of Federal
employees. At about that time, the report of the Wainwright Commission in New
York showed that only one out of every eight injured men was awarded any com-
pensation, and that he actually received only about a third of what was awarded.
The other two thirds went to insurance adjusters, legal advice and commissions.
As a result, in 1910 New York became the first state to enact a workmen's com-
pensation law. There followed an era of compensation medical service, and em-
ployers were made increasingly responsible for the medical and surgical care of
workers who became injured or ill at their jobs and for payment of accident and
disease compensation.

Meanwhile, increasing attention was being given to the identification, defi-
nition and diagnosis of occupational diseases, i.e., silicosis, plumbism, anthrax,
benzol and radium poisoning, and many others. There resulted a separate de-
velopment of occupational disease compensation laws; among the earliest were:
California and Wisconsin (1919), North Dakota (1925), Minnesota and Con-
necticut (1929). Unfortunately, many of these compensation laws were hastily
promulgated during a period of considerable public stimulation and concern
with the result that many were extreme, ill-advised, and impractical. Under the
circumstances, the extensive subsequent reaction and amendment is not sur-
prising.® At the present time, workmen’s compensation laws exist in all fifty states
and in all of the territories. Occupational disease is covered in forty-one of the
fifty states. In a few states, notably New York, the legislation has been broadened
so that coverage for occupational disease is all-inclusive.

The decade 1910 to 1920 saw the firm recognition of occupational health
as a specialty. In 1914 an Industrial Hygiene Section was established in the
American Public Health Association. In the same year, an Office of Industrial
Hygiene and Sanitation was created in the Public Health Service and about the
same time the United States Bureau of Mines came into being. Two of the most
significant events were the organization of the American Association of Industrial
Physicians and Surgeons, and the adoption of minimum standards for medical
service in industry by the Committee on Industrial Medicine and Traumatic
Surgery of the American College of Surgeons. Some years later, in 1937, the Ameri- |

*Medical Services in Industry and Workmen's Compensation Laws, rev. ed., Chicago, Am.
Coll. Surgeons, 1946.
OCCUPATIONAL HEALTH AND PRIVATE ENTERPRISE 007

 

can Medical Association created the Council on Industrial Health to coordinate
all medical efforts in the industrial health field. The Journal of Industrial Hy-
giene and the first courses on the subject were introduced in the schools of public
health at about the same time. All the schools now provide courses in the subject,
the University of Pittsburg and the University of Michigan giving it particular
attention.

Prior to the passage of the Federal Social Security Act of 1935, little progress
had been made by state health agencies in occupational health. Up to that time
only five states engaged in any activities designed for the benefit of industrial
workers, the first having been in 1913 in New York and Ohio. The Act made
available funds for the expansion of this as well as other forms of activity, with
the result that by 1950 all of the states and Alaska, Hawaii, Puerto Rico, and
the District of Columbia were carrying on some type of activity for the improve-
ment of the health and safety of workers in gainful occupations.® These are but
a few of the many landmarks in the development of this important field.*

Benefits. Serious attention to and support of occupational and public health
activities carry with them many benefits to private enterprise. Three of the
greatest items of expense to business and industry are labor turnover, absenteeism,
and liability compensation for occupational illness and injury. According to sta-
tistics of the National Salety Council for the year 1945, there were 16,000 fatali-
ties, 80,000 permanent disabilities, and 104,000 temporary disabilities charged to
industry. In addition to the liability compensation involved, this constituted a
loss to industrial production of 46 million man-days of work.®

Among the tangible profits ol good community and industrial health pro-
grams are remedies against these three sources of loss. A healthy worker is a
happier, more dependable worker with high morale and pride in his work. He
will tend to want to remain in his present position rather than to roam in search
of others. Thus, in one study of about one thousand plants that had instituted
industrial health programs, the National Association of Manufacturers found
that more than 20 per cent experienced a reduction in absenteeism. An average
reduction of practically 30 per cent was reported by 14 per cent of the plants.
Nearly 90 per cent of the plants showed a reduced labor turnover, a sample put-
ting their average reduction at 27 per cent. Significantly reduced incidences of
occupational injury and illness as a result of their industrial health programs
was reported by 92 per cent of the companies.”

Several factors are involved in such striking results from occupational health
programs:

1. Industrial health personnel has done much to control environmental haz-
ards, thereby providing “built-in” safety measures which in turn result in a
greater sense of security and employment satisfaction in the worker.

2. Industrial health personnel is more apt to make the worker realize that
his welfare and employment carcer are partly dependent upon his own sense of
responsibility for maintaining his health, safety, and working ability.

*For an excellent list of significant events, the reader is referred to Industrial Health and
Medical Programs by Klem and associates.”
608 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES a

3. A sound occupational health program makes possible a gradual and selec-
tive return to work consistent with the degree and speed of recovery.

4. Competent industrial medical and nursing personnel has had a desirable
persuasive effect upon patients and their physicians, which often results in the
seeking of early preventive and curative private medical care and in a demand
for private medical service of high quality.

5. Industrial health personnel has developed effective and appropriate tech-
niques for the detection and handling ol occasional malingerers.

6. Occupational health services form a link between the workers’ total health
problems and the community health and social services.

Other benefits to business and industry are a diminution in employee griev-
ances, improved employee relations and consequently improved public relations,
increased worker and community pride in the company and its products, and the
enhanced appeal and advertising value of a clean plant, healthy, contented em-
ployees, and a sanitary product. Out of 1,625 companies completing question-
naires concerning the value of industrial health programs, only five companies
failed to report to the National Association of Manufacturers that they considered
their health program “a paying proposition.”

The important point is that health problems and responsibilities are always
present in the plant or in the office, whether or not industry and business want
to recognize them, and whether or not they wish to do anything about them. If
they do accept these responsibilities, they not only perform an important public
service but, as already pointed out, may also turn that recognition and action to
their own financial advantage. On the other hand, if they refuse to recognize
their health problems and responsibilites, it automatically becomes incumbent
upon official public health agencies, acting in the public interest, to step in and
do something about the situation. However, from the standpoint ol official agen-
cies, there is much to be gained by interesting private enterprise in meeting their
own problems.

In the past, private enterprise, business and industry traditionally have been
looked up to by the public. Recently the public has also developed an intense
interest in matters ol personal and community health. This is indicated by the
findings of investigators at the University of Minnesota who have studied shifts
in social prestige occurring over the past three decades. They report the most
notable change to be the replacement of the banker and businessman by the
physican as the individual enjoying the highest prestige in America today. Here,
therefore, is a situation in which business and industry may work with another
high prestige group to mutual advantage, in providing valuable community
leadership and achieving even greater public esteem as well as efficiency in the
process. Many of the larger companies and industrial concerns have already
seen the value of following this line of action and not only are cooperating sin-
cerely and actively with official public health programs but, in addition on their
own initiative, are engaging in personnel health programs, plant safety, and
product sanitation activities ol considerable consequence.

In summary, therefore, occupational health programs bring many benefits—
to the employee, to the employer, and to the community. For the employee and
OCCUPATIONAL HEALTH AND PRIVATE ENTERPRISE 009

his dependents it means sustained earnings, lower personal medical and hospital
expenditures, increased and prolonged productive capacity, and the enjoyment
and security that comes with good health and job satisfaction. For the employer
it means decreased production costs because of lower labor turnover, less ab-
senteeism, fewer disability payments, lower insurance, and more capable and
more alert workers. It also brings higher worker morale and fewer strikes and
other labor difficulties. All of these result in diffused but extensive benefits to
the community in increased prosperity, decreased welfare costs, less labor strife
and in pressures for and support of high quality medical, hospital and public
health services.
Industrial Health Programs. 1t is appropriate to preface a discussion of the
objectives and content of industrial health programs by a pertinent comment
made by the Director of Industrial Hygiene of one of the world’s largest industrial
corporations.’ “Business,” he pointed out, “is conducted on a practical, or profit
and loss, basis and when losses equal or exceed profits, you do not stay in business
long. Industrial hygiene programs that are not basically sound are not likely to
survive the Test of Time.”
A good industrial health program is designed primarily for the benefit and
welfare of the workers. Its objectives, as listed by Cameron!! are:
1. The assessment of a worker’s physical and psychological assets, as well as his liabili-
ties, to facilitate proper selection and placement.

2. The prevention of occupational and non-occupational illnesses.

3. The provision of treatment, the type and extent of which depends on the policy of
the organization.

4. The fostering of a personal, physical, mental, and social ability to work and enjoy
life beyond the mere absence of disease or infirmity. *

The inclusion of psychological, mental, and social [actors merits particular
note. There are indications that up to 30 per cent of absenteeism is due to emo-
tional disturbances resulting from interpersonal problems in the plant, in the
home, and in the community.

Many factors influence the nature and extent of an industrial health program
which a business or an industry may carry out. Among these are the type of in-
dustry or business; the nature ol its product and of the ingredients and equip-
ment used in its manufacture; the disposition of the product; the size and location
of the establishment; the complex attitudes of top management, labor unions, the
community and its medical profession, public health agency, and government;
and the organizational status of the unit responsible for the activities. For these
reasons, it is obvious that a detailed standard pattern is impossible. To the con-
trary, each program must be more or less tailored to fit the needs and circum-
stances of the particular situation. It is possible, however, to state certain funda-
mental principles which should apply in general. Thus, the Council on Industrial
Health of the American Medical Association!? lists the objectives of an occupa-
tional health program to be: (1) to protect individuals against health hazards in

*Cameron, D. C.: Human Relations in Occupational Health, Pub. Health Rep. 67:686, July
1952.
010 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

 

their work environment, (2) to ensure and facilitate the suitable placement of
individuals according to their physical capacities and their emotional make-up
in work which they can perform with an acceptable degree of efficiency and with-
out endangering their own health and safety or that of their fellow employees,
and (3) to encourage personal health maintenance.

The statement goes on to describe in more detail the scope of services that
the Council considers should be provided by the medical department of an in-
dustry. They include:

I. Regular appraisal of plant sanitation.

2. Periodic inspection for occupational disease hazards.

3. Adoption and maintenance ol adequate control measures.

Provision of first aid and emergency services.

5. Prompt and early treatment [or all illnesses resulting from occupational
exposure.

6. Reference to the family physician of individuals with conditions needing
attention, cooperating with the patient and physician in every practical
way to remedy the condition.

7. Uniform recording of absenteeism due to all types of disability.

8. Impartial health appraisals of all workers.

9. Provision of rehabilitation services within industry.

10. The conduct ol a beneficial health education program.

Adequately expanded and developed, and adapted to the particular circum-
stances, these areas of activity would provide a satisfactory occupational health
program in most situations.*

Recently, an entirely new relationship has been introduced in the field of
industrial health. During the war years, when wages were more or less [rozen
as an anti-inflationary measure, organized labor took the opportunity to press
for other benefits in the form of group health and sickness insurance. An increas-
ing number of unions have succeeded in having benefits of this nature included
in the terms of their agreements with employers. It should be noted, however,
that in many instances this represents a substitution of union-administered plans
for previously existing employer-administered plans. In fact a number of con-
cerns have gone so far as to extend their industrial medical services to include
general medical care for their employees and in some instances for the families
of employees as well.1

Because of the large numbers of employees, the larger business and industrial
concerns find it worth while to conduct most or all of their employee health and
safety programs themselves. The great problem arises in connection with the
small plants and businesses, which are in the majority and which taken together
employ the major proportion, 60 per cent, of workers. Singly, they are usually
too small to afford or justily the employment of even a single full-time nurse,
much less a physician. Up to the present they have been largely left out of the
picture except for essentially token services rendered through the industrial hy-

*For detailed examples see Industrial Health and Medical Programs by Klem and associates.”
OCCUPATIONAL HEALTH AND PRIVATE ENTERPRISE 011
giene divisions of state and occasionally through local health departments. One
of the newest developments has been the joint employment, by a number of small
concerns in an area, of full-time industrial health personnel who devote the neces-
sary number of hours a week to each plant in the group. This plan has proved
itself of value in a number of locations. For the supervision of the environmental
hazards of small plants, various types of portable or mobile equipment have been
used to advantage.

The Role of Government. Since the occupational environment is part of the
total community to which the public health agency is responsible, it is to be ex-
pected that the latter have appropriate interest in the field. Reference has been
made to the relatively slow growth of occupational health programs in govern-
mental agencies, beginning with the initiation of activities in 1913 in New York
and Ohio. Activity and interest accelerated with the passage ol the Social Security
Act in 1935 and again during the period of the Second World War. In 1940, more
than a fourth of the state health agencies had no occupational health activities.
By 1950, however, all but eight had at least one professional employee assigned
to this field on a full-time basis. The over-all picture in 1950 was fifty-one state
and territorial health departments, forty-two labor departments, sixteen depart-
ments of mines, fifteen industrial accident boards or commissions, and a number
of other agencies, participating in some manner in occupational health activities.
In addition, an ever increasing number of local jurisdictions, especially those
of an urban nature, are engaged in occupational health activities to some extent.

In general, the function of government agencies includes industrial hygiene
surveys and field investigations of environmental conditions in industry; the col-
lection and analysis of data relating to occupational ills and injuries and to ab-
senteeism; the surveillance of atmospheric pollution by industrial plants; the de-
velopment of techniques for the detection of occupational disease, methods of
prevention and control, and the development of specific treatment. Health depart-
ments concentrate on the supervision of environmental conditions conducive to
employment-related illness. They suggest measures for control, promote in-plant
sanitation and medical services, provide advisory engineering and nursing serv-
ices, and conduct health educational activities. Departments of labor and mines
are primarily concerned with safety measures and the regulation of working con-
dititons. The industrial or occupational health units of these agencies, in addi-
tion to their specific functions, coordinate their activities and services with those
of units concerned with sanitation, health education, preventable and chronic
disease, thereby attempting to bring to industry a well-rounded health program.
In addition they usually maintain cooperative working relations with labor,
management, and various pertinent professional societies.

To varying degrees, state agencies are charged with the enforcement of laws
relating to the field of occupational health. It is interesting, however, that while
state health departments are the agencies most frequently responsible for general
industrial hygiene functions, labor departments are more often charged with en-
forcement powers.

On the basis of the considerable experience of the California State Depart-
ment of Health, Abrams'* warns that a governmental industrial hygiene agency
must observe certain basic principles if its work is to be successful:
012 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

I. It has primary responsibility to safeguard the health of workers.

2. Its technical work and its policies must be unbiased.

3. It must be able to speak authoritatively regarding health hazards and the adequacy
of measures for protecting the health of employees.

4. It must be able to interpret intelligently its program to labor and management and
to the health professions.

5. It should endeavor so to conduct studies that not only the plant's previous methods
and programs but also its own are improved thereby. *

It is of interest to compare these with the characterisics which a representa-
tive of industry says industry expects ol health agencies.’ They may be sum-
marized as follows:

Availability of services—speed, quality, and quantity balanced

Uniformity—of advice, standards, methods

Accuracy—evaluations based on technical data or mature experience

Clarity—clear reports with understandable terminology

Practicality—recommendations must be economically feasible

Palatability—couch recommendations in persuasive language

Tact—in the conduct of investigations to prevent fears, suspicion or mis-
understanding

Balance—representation of pertinent professions needed for an adequate pro-
gram

It is obvious that the problem of occupational health is large and complex,
much more so than, until recently, was realized. Furthermore, it is certainly des-
tined to become even more complicated and to require the services of still more
types of specialists including the nuclear-physicist. Because of its complexity and
its many ramifications, it is impossible for any one group or agency to supply
the solution. It can be solved only by sincere teamwork on the part of all groups
concerned. Thus management must accept moral and legal responsibility for
providing safe and healthy work conditions. Labor must accept the responsibility
of convincing its members that they should cooperate with measures taken in
their behalf. Industrial and public health workers fulfill their legal responsibility
to ensure a safe and sanitary environment for industrial workers. Finally, the
community must accept its responsibility to provide continuing and contiguous
safeguards and services for the nonindustrial environments and hours of the
worker. Winslow!6 has stated editorially:

There is no single perfect solution of this problem now in sight. There is rather a
challenge to the inventiveness of management, labor, the medical profession and the
public to find empirically the best plan that will fit a given local situation. For manage-
ment and labor, the need for cooperation in the meeting of a common problem is called
for rather than insistence on vested interests. For the medical profession, it seems certain
that the principles of group payment and group practice must be essential to any sound
solution. For the public health authorities, leadership in research, formulation of reason-
able standards of attainment, and assistance to small industries where desirable, would
appear to be the appropriate role.t

*Abrams, H. K.: Labor, Management, and the Official Agency, Am. J. Pub. Health 42:38,

Jan. 1952.
tEditorial: Administrative Problems of Industrial Medicine, Am. J. Pub. Health 37:1338,

Oct. 1947.
OCCUPATIONAL HEALTH AND PRIVATE ENTERPRISE 013

 

REFERENCES
1. Bloomfield, J. J.: Teamwork for Industrial Health, Am. J. Pub. Health 36:266, March 1946.
2. Hussey, Raymond: In discussion of article by Hemeon, W. C. L.: Engineering in Industrial
Health Education, Occup. Med. 4:201, Aug. 1947.
3. Medical Services in Industry and Workmen's Compensation Laws, rev. ed., Chicago, 1946,
Am. Coll. Surgeons.
4. Legge, R. T.: Progress of American Industrial Medicine in the First Half of the Twentieth
Century, Am. J. Pub. Health 52:904, Aug. 1952.
5. Waters, T. C.: Administration of Laws for the Prevention and Control of Occupational
Diseases, Am. J. Pub. Health 29:728, July 1939.
6. Distribution of Health Services in the Structure of State Government, 1950, Public Health
Service Publ. No. 184, Washington, 1954, U. S. Government Printing Office.
7. Klem, M., McKiever, M., and Lear, W.: Industrial Health and Medical Programs, Public
Health Service Publ. No. 15, Washington, 1950, U. S. Government Printing Office.
8. Hazlett, T. L.: The Value of Industrial Hygiene, Am. J. Pub. Health 37:1303, Oct. 1947.
9. Gray, A. S.: The Advantages of Adequate Health Service in Industry, Connecticut Health
Bull. 62:152, June 1948.
10. Patty, F. A.: The Industrial Hygiene Program in Industry, Am. J. Pub. Health 41:971,
Aug. 1951.
11. Cameron, D. C.: Human Relations in Occupational Health, Pub. Health Rep. 67:686, July
1952.
12. Council on Industrial Health of the American Medical Association: Scope, Objectives, and
Functions of Occupational Health Programs, J.LA.M.A. 164:1104, July 6, 1957.
13. Stern, B. J.: Medicine in Industry, New York, 1946, Commonwealth Fund.
14. Abrams, H. K.: Labor, Management, and the Official Agency, Am. J. Pub. Health 42:38,
Jan. 1952.
15. Newman, L. E.: What Industry Expects of the Official Industrial Hygiene Agencies, Am. J.
Pub. Health 43:330, March 1953.
16. Editorial: Administrative Problems of Industrial Medicine, Am. J. Pub. Health 37:1338,

Oct. 1947.
chapter 2 7

Accidents—a public health problem

 

Emergence of the Problem. In the discussion of the philosophy and content
of public health, its ever-broadening vista and the constant extension of its activi-
ties were described. It was pointed out that the modern public health agency is
interested in the well-being of the total individual and the total community
life. Accordingly it concerns itself wherever feasible with all factors which may
adversely affect any phase ol the physical and mental health of the community
and its population. As a result, we find ourselves involved more and more in what
to some might appear to be fringe activities. Actually, to consider them as such
is erroneous and misleading. Merely because certain types of problems require
joint action with other community agencies or groups, they are not necessarily
of a fringe or tangential nature. Indeed, it should be realized that joint or com-
munity action is the very essence of public health programs. Accident prevention
represents a good example of this type of activity.

If there is ever a tendency for any people at a particular time or in a par-
ticular place to consider disease fatalistically, such attitude is even more apt to
be applied to accidents. In fact, the average person in even the most advanced
societies tends to define the word accident as something due to chance, over
which the individual has very little, if any, control. This negative attitude ex-
plains to a considerable degree why so little concerted attention has been given
to the problem until quite recent years. Gradually, however, a number of factors
have captured the attention of certain groups in society. Each has attempted,
in its own way and for a variety of reasons, to explore approaches to solution and
some partial progress has resulted. The large life insurance companies were per-
haps the first to give attention to this problem. With a major proportion of the
population in the United States now covered by some type of life or disability
insurance, it has become increasingly important to the companies that everything
possible be done to decrease the extent of accidental disability or death. At the
same time it is of importance to the policy holder, not only from the standpoint
of avoiding suffering or death, but also in terms of lowering the costs of policies.
As a result, some of the best health education work and promotion of home salety
has been conducted by the large insurance companies. For somewhat similar
reasons, although companies which insure against losses due to fire have the re-

014
ACCIDENTS—A PUBLIC HEALTH PROBLEM 015

duction of material losses as their primary interest, they nevertheless have also
been involved in the prevention of fire injuries and deaths. Industries, particu-
larly the larger industries, have carried out safety programs of considerable mag-
nitude involving the installation of various safety devices and careful worker
selection, placement, and education. Increasing costs of tax-supported service for
fire prevention, emergency care, and hospitalization have caused public officials
to look for means of reducing the extent of accidents from all causes. Finally, as
mentioned above, public health workers have become aware of the ever-growing
threat of accidents to well-being and of the relationships of certain types of acci-
dents to various mental or physiological factors with which they were already
concerned. Gradually, therefore, the fatalistic attitude that accidents are events
that just happen has been changing. Increasingly, individuals and agencies have
been getting together to see il something positive could be done about the
problem.

Extent of the Problem. Currently, an average of 95,000 people are killed each
year by accidents in the United States. This amounts to about eleven deaths each
hour. The number of nonfatal accidents are more difficult to determine since
many of them never come to official attention. On the basis of reports, insurance
claims and the like, the National Safety Council has estimated that there are
about one hundred injuries for each [fatality or a total of about 9145 million.!
However, the National Health Survey? through its household interviews, deter-
mined a total of 46,919,000 nonfatal injuries of all types and degrees of severity
during the year July 1957 to June 1958. Slightly more than half or 27,614,000
restricted activity; 11,246,000 of these required convalescence in bed, 1,715,000
of which required hospitalization. These accidents resulted in 424,100,000 days
of restricted activity, including 113,700,000 days spent in bed at home or in a
hospital. All together, their cost in terms of lost wages, medical expenses, and
other factors has been estimated by the National Safety Council to amount to a
staggering total of about 11 billion dollars each year. While three fifths of all
the accidents involved males, there is an interesting sex variation by age. Male
accidental death rates exceed those in females in all ages except the most ad-
vanced. Rates for both sexes are high in infancy, but drop sharply to the fifth
birthday. Accidental death rates for males are only slightly in excess of rates for
females up to about the fifteenth year of lile alter which male accidental death
rates increase sharply and remain high from then on. By contrast, accidental
death rates for females remain low until about the sixty-fifth year, following
which it rises sharply and exceeds those in males at age 85 years.

The carnage occurs in all parts of our environment—in automobiles, on the
streets, in the home, at work, and on the farm as well as in the city. About five
eighths of nonfatal accidents are urban, two eighths are rural nonfarm, and one
eighth are rural farm. Because of their dramatic nature, accidents involving
public or private vehicles tend to monopolize the public attention. These, how-
ever, are only a part of a much larger problem. Analyses of accidental injuries
and deaths by place of occurrence present an interesting picture (Table 45).

Motor vehicle accidents rose sharply following World War I and have con-
tinued high. Annual deaths from this cause were about 11,000 in 1920 but by
616 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 45. Annual Distribution of Accidental Injuries and
Deaths by Location

 

 

Injuries
Location I Deaths Per
Activity Deaths 1000 Injuries
Total Restricted Hospitalized
Motor vehicle 4,702,000 3,004,000 890,000 40,000 8.5
Home 19,137,000 10,974,000 469,000 27,7C0 1.4
Work 8,150,000 4,228,000 123,000 11,300 1.4
Other 14,930,000 9,408,000 233,000 16,000 1.1
Total 46,919,000 27,614,000 1,715,000 95,000 2.0

 

 

 

1930 had risen to about $0,000. They have continued to climb more slowly but
constantly, except for the tire and gasoline rationing period of World War II.
During the same period of time, however, the death rate from motor vehicle acci-
dents per ten thousand motor vehicles registered has dropped markedly. Thus
in 1920 it was about 13.5 deaths per ten thousand cars registered, whereas it is
only about 6 deaths per thousand cars registered now. Nevertheless, both in terms
of absolute numbers of deaths and deaths per thousand injuries, motor vehicle
accidents are by far the most serious part of the problem.

Occupational injuries and deaths have been subjected to a considerable re-
duction. For example, in terms of injuries per million man hours, the frequency
in 1926 was thirty-two as against about seven now. Work-related accidents do not
appear to be as severe in terms of fatalities as do motor vehicle accidents, deaths
per thousand injuries for the former being about one sixth that of the latter.

Accidents in the home are particularly important because of their frequency
which approaches one half of all accidents. However, in terms of severity, as
measured by deaths per thousand injuries they are on a par with occupational
accidents. In recent years there has been considerable study of home accidents
which has brought out numerous facts of interest. Of social significance is the
fact that among females the highest home injury rate is in the income group
under $2,000 per year, whereas among males it is just the opposite with the home
injury rate in the income group $7,000 and over being twice the rate among males
in the income group under $2,000 per year. Strangely, the bedroom is the most
dangerous room in the house, and it is here that 53 per cent of all fatal home
accidents occur. Other fatal accidents in the home occur in living and dining
rooms, 15.5 per cent; in kitchens, 14.5 per cent; on stairs, 5.7 per cent and in
bathrooms, 5 per cent. By type of home accident, falls are the most frequent
cause of death and account for almost one half of accidental deaths. Fires account
for 21 per cent, suffocation for 13 per cent, and poisoning for 5.5 per cent.

Accidents should also be considered from the viewpoint of their relative
position as a cause of death. While more than 3,000 infants die accidentally each
ACCIDENTS—A PUBLIC HEALTH PROBLEM 017

 

 

year, there are numerous other conditions which contribute more to the infant
mortality. Once the first birthday is approached and passed, however, the picture
changes dramatically. Accidents constitute the leading cause of death in age
groups 1 to 4, 5 to 14, and 15 to 24 years. They are in second place in the age
group 25 to 44 years, in fourth place in the group between 45 and 64 years, and
in fifth place in the age group over 65 years. Certainly a problem of this magni-
tude cannot be ignored.

Reasons for Public Health Concern. There are a number of reasons why
public health agencies and workers should be concerned with the problem of acci-
dents. The absolute and proportionate magnitude of the problem which has been
described is, of course, one reason for concern, as is also its economic significance.
Beyond these, however, there are actually a great many activities of public health
agencies which do, or may be made to, impinge upon the problem.** Among
these are activities in the fields of public health statistics,”% health surveys and
studies, community health and safety education,” child health,%? industrial hy-
giene, housing, and mental hygiene.! The latter is mentioned specifically in view
of the growing body of knowledge about accident proneness and the development
of techniques for its determination.'.1213 Increasingly, workers in the fields of
public health and preventive medicine have been relating these general activities
or methods of approach to accident prevention. In a number of communities
accidental injuries as well as deaths are reported to the public health agency for
study and analysis to determine improved and more fruitful avenues of attack.
In many other communities, surveys have been carried out for the same rea-
son.1*.15.16 In still others the recording of and educational activities about home
accidents have been incorporated as part of the public health nursing function.!?
In the over-all sense, some excellent epidemiological studies have been made of
the problem.!82> Through the efforts of workers in the field of environmental
health, more and more accident prevention measures are being “built-in” to the
standards, specifications, and requirements for howe and city plans. Such meas-
ures coupled with persistent public educational measures form the core of the
attack on home accidents.26:27 Reference has been made to the significant decline
in occupational accidents. This has resulted in large part from activities in in-
dustrial health and safety programs, involving inspections and surveys, improved
plant and machine design, development and use of safety devices, pre-employment
examinations, and worker education. |

Many state health departments engage in some activities relating to accident
prevention at the present time. Accident prevention educational activities are
carried on by almost all state health departments. In addititon, many of them
are attempting to stimulate local accident prevention programs. Special con-
ferences, short courses, and workshops are held for local health department per-
sonnel and for representatives of other official and nonofficial local agencies.28
Also, various state health departments cooperate with other official state agencies
such as those concerned with mines, industry, labor, and traffic safety in carrying
out cooperative programs in those areas. |

In the final analysis, of course, the prevention of accidents depends upon
the individual, and efforts in order to be ultimately fruitful must take place on
018 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

the local level. No single satisfactory pattern has yet been devised or adopted.
It is certain, however, that there must be involved some of the basic epidemiolog-
ical approaches and techniques which have proved to be effective in many diverse
fields. Among these are: (1) the development and improvement of data on the
prevalence and incidence of accidents through reporting, surveys, and studies,
(2) education of the public through effective pertinent channels, (3) improvement
and extension ol salety devices in the home, public buildings, industry, vehicles,
and farm machinery, (4) inclusion of training in accident prevention in schools
ol public health, public administration, and architecture, (5) improvement ol
structural safety through the general inclusion ol accident prevention [actors in
building codes, (6) improvement of city planning, traffic studies, and highway
design, (7) improved driver training, education, and supervision with considera-
tion given to physical and mental factors that may indicate accident proneness,
and (8) improvement of the functional design of toys, houschold equipment,
and furniture with consideration given to the peculiar needs and behavior habits
of the very young and of the handicapped and elderly.

Only through the cooperative efforts of many community agencies, one of
which is the health department, in attacking along all of these and many other
fronts, will the toll of accidents be lessened eventually. In the process, because
of its all-embracing interest in all aspects ol safe and healthful living, it is the
official public health agency which is best fitted to serve as a catalyst and rallying
point.2

Poison Control. A special type ol accident hazard is presented by the ex-
tensive and increasing number of toxic materials to be found in the modern
home.?® In recent years, industrial chemists and pharmaceutical research have
developed many wonderful products which have contributed greatly to our way
of life. Their widespread availability, however, has not been without danger. No
longer is it possible to use a “universal antidote.” The highly complex nature
ol many new pharmaceuticals and household products require a knowledge of
their chemical constitution in order that a quick and effective remedy may be
used in case of toxic ingestion.

During 1956, an estimated 250,000 persons in the United States accidentally
ingested poisons, and 1,422 died. This was more than the number of deaths from
rheumatic fever and about equal to the number of deaths from influenza. More
than one third were children under 5 years of age. The nature of the substances
ingested is of interest. In a study of accidental poisonings in children under 15
years of age in New York City, Jacobziner®! found the causes shown in Table 46.

Particular attention should be called to poisonings from lead. Most of these
occur in young children from low-income families who live in old housing, the
interiors of which have been painted with many layers of lead-containing paint.
The problem is complicated by the frequent casual attitude of many parents
who accept pica as normal behavior in young children and by the frequent ab-
sence of supervision of children in such socioeconomic circumstances.32

As a result of the growing concern over accidental poisoning, an increasing
number of communities have been developing poison control centers.33.3¢ There
are now over two hundred such centers in more than three quarters of the states.
To varying extents, they compile and keep up to date a readily usable file on
pharmaceutical, household, industrial, and other substances with data about
ACCIDENTS—A PUBLIC HEALTH PROBLEM 019

Table 46. Accidental Poisonings of Children Under 15 Years
of Age, New York City, 1956

 

Type of Poisoning Per Cent of Total
Aspirin, barbiturates, and other internal medications 26
Bleach, furniture polish, lye, and other household preparations 20
Lead 10
Iodine and other external medications 9
Insecticides 7
Turpentine and other solvents 6
Cosmetics 5
Rodenticides 3
Miscellaneous 15

 

 

their composition, toxicity and antidotes, they provide laboratory analytic serv-
ice, treatment, answer telephone requests for first-aid information, and carry out
educational activities for the professions and the public. Some provide follow-up
by means of public health nurses or other types of investigators or educators.

One interesting question that calls for more study is the relationship of
mental health to so-called accidental poisoning. Unquestionably, a certain num-
ber of such “accidents” actually represent either conscious or subconscious at-
tempts at suicide or homicide. With regard to the latter is the possible factor of
withheld or avoided supervision, warning, or prompt treatment by some parents,
older children, or spouses.?>

Sheet Plastic. Another special problem has resulted from improvements in
the packaging of goods. The development and inexpensive production of poly-
ethylene plastic has prompted its widespread use for packaging many types of
foods and household materials and equipment and for use as a protective covering
of clothing. Concurrent with its widespread use has been a rise in the number
of young children who have suffocated as a result of having their faces covered
by this material. Since the sheet plastic tends to build up a considerable amount
of static electricity, it is particularly apt to adhere tightly to the skin. Already,
a number of states and communities are exploring the possibility of limiting the
use of the material. Meanwhile, extensive programs are being conducted to edu-
cate parents concerning the potential dangers of sheet plastic.

REFERENCES

1. Accident Facts, National Safety Council, Chicago, 1957.

2. Health Statistics, Persons Injured by Class of Accident, U. S., July 1957-June 1958, Public
Health Service Publ. No. 584-B8, Feb. 1959.

3. Home Accident Prevention Text, For Use by Local Health Departments, Washington, 1957,
Public Health Service Publ. No. 564, U. S. Government Printing Office.

4. Iskrant, A. P.: Health Departments and the Prevention of Motor Vehicle Accidents, Pub.
Health Rep. 73:1021, Nov. 1958.

5. Service Statistics for Home Accident Prevention Programs, Pub. Health Rep. 72:494, June
1957.

6. Brightman, I. J., and others: Mortality Statistics as a Direction Finder in Home Accident
Prevention, Am. J. Pub. Health 42:840, July 1952.
620

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

7.

8.

10.
11.
12.

30.

31.

32.

33.

34.

Zindwer, R.: An Educational Project in Childhood Accident Prevention, Am. J. Pub. Health
45:438, April 1955.

Jacobziner, H.: Home Safety and Accident Prevention in a Child Health Conference, Am.
J. Pub. Health 44:83, Jan. 1954.

. Dietrich, H. ¥.: Clinical Application of the Theory of Accident Prevention in Childhood,

Am. J. Pub. Health 42:849, July 1952.

Bock, J. K.: Driver Behavior and Accidents, Am. J. Pub. Health 47:546, May 1947.

Weinerman, E. R.: Accident-Proneness, A Critique, Am. J. Pub. Health 39:1527, Dec. 1949.

Webb, W. B.: The Illusive Phenomena in Accident Proneness, Pub. Health Rep. 70:951,
Oct. 1955.

McFarland, R. A., and Moore, R. C.: Human Factors in Highway Safety, New England J.
Med. 256:792, April 25, 1957; 256:837, May 2, 1957; 256:890, May 9, 1957.

Kent, F. S., and Pershing, M.: Home Accident Prevention Activities, Pub. Health Rep. 67:
541, June 1952.

. Prothro, W. B.: Home Accident Preventiton, Am. J. Pub. Health 41:954, Aug. 1951.
- Robinson, T.: Gathering and Evaluating Accident Data with Respect to Farm People and

Farm Workers, Am. J. Pub. Health 39:999, Aug. 1949.
Phillips, E. C.: Home Accident Prevention, The Role of the Public Health Nurse, Am. J
Pub. Health 40:517, May 1950.

. Press, E.: Epidemiological Approach to Accident Preventiton, Am. J. Pub. Health 38:1442,

Oct. 1948.

. Gordon, J. E.: The Epidemiology of Accidents, Am. J. Pub. Health 39:504, April 1949.
. Armstrong, D., and Cole, W.: Persistent Hazards in the Home Accident Pattern, Am. J

Pub. Health 39:1434, Nov. 1949.

. Roberts, H., Gordon, J. E., and Fiore, A.: Epidemiological Techniques in Home Accident

Prevention, Pub. Health Rep. 67:547, June 1952.

Chapman, A. L.: Epidemiological Approach to Traffic Safety, Pub. Health Rep. 69:773,
Aug. 1954.

Beadenkopf, W. G., and others: An Epidemiological Approach to Traffic Accidents, Pub.
Health Rep. 71:15, Jan. 1956.

Braunstein, P. W.: Medical Aspects of Automotive Crash Injury Research, J.A.M.A. 163:
249, Jan. 26, 1957.

McFarland, R. A.: Epidemiological Principles Applicable to the Study and Prevention of
Child Accidents, Am. J. Pub. Health 45:1302, Oct. 1955.

. Kent, F. S.: Engineering Aspects of Home Accident Prevention, Am. J. Pub. Health 39:1531,

Dec. 1949.

Kent, F. S., and Pond, M. A.: Public Health Consideration on Housing Design and Home
Accident Prevention, Pub. Health Rep. 66:1461, Nov. 9, 1951.

Distribution of Health Services in the Structure of State Government, 1950, Washington,
1954, Public Health Service Publ. No. 184.

Accident Prevention—An Essential Public Health Service, Program Developed by Subcom-
mittee on Accident Prevention, Committee on Administrative Practice, American Public
Health Association, Am. J. Pub. Health 35:216, March 1945.

The Public Health Problem of Accidental Poisoning, A Symposium, Am. J. Pub. Health
46:951, Aug. 1956.

Jacobziner, H.: Accidental Poisoning Among Children, Am. J. Dis. Child. 93:647, June
1957.

Bradley, J. E., and Bessman, S. P.: Poverty, Pica, and Poisoning, Pub. Health Rep. 73:467,
May 1958.

Press, E., and Mellins, R. B.: A Poisoning Control Program, Am. J. Pub. Health 44:1515,
Dec. 1954.

Cann, H. M.: Control of Accidental Poisoning—A Progress Report, J.LA.M.A. 168:717, Oct. 11,

1958.
Schulzinger, M. S.: The Accident Syndrome, Springfield, 1956, Charles C Thomas, Publisher.
chapter 23

Mental health

 

Introduction. Mental health and illness form one of the newer frontiers of
public health, which has been the subject of considerable exploration and ac-
tivity during recent years. As a result of increasing attention in the public as
well as in the professional press, there has come about an acute awareness of the
relationship between mental illnesses of various types and degrees of severity on
the one hand, and of crime, juvenile delinquency, prostitution, addictions, accl-
dents, marital failures, work inadequacies, and a host of other undesirable social
phenomena on the other. Similarly, the public as well as the pertinent professions
have become conscious of the increasing mental stresses ol urban and especially
of industrialized life. Further, the large number of individuals in need of in-
stitutional care and the great cost of providing it have become matters of com-
mon knowledge and concern.

As with many other problems, preliminary social study and experimentation
in this field came about largely out of the interest of a few individuals and private
or voluntary groups or agencies. Until relatively recently, mentally ill persons
were incarcerated without treatment in filthy gaols and other institutions, often
in company with criminals and diseased persons; exhibited as curiosities or
sources of amusement; restrained at length in chains and straight jackets, beaten
unmercifully, and rendered stuporous by drugs. Their greatest and most courage-
ous champion in modern history was Philippe Pinel, who in the 1790's agitated
for reforms for their more humane treatment in France. His efforts to remove
their chains, to have them considered as victims of illness, and to transfer them
[rom prisons to hospitals were pursued in the face of strenuous opposition and
ridicule not only [rom the public but also from his fellow physicians. About fifty
years later, a similar movement got under way in the United States of America
due largely to Dorothea Dix. During the late nineteenth century, the foundations
of the related fields ol psychology and psychiatry were laid. These led gradually
to consideration of possible preventive and promotive approaches to the problem
which eventually crystallized in the form of the mental hygiene movement.

The mental hygiene movement, as such, may be said to have begun in 1908
with the publication of Clifford W. Beers’ now well-known book 4 Mind That
Found Itself.! It presented in dramatic and effective manner the author’s experi-

621
622 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

ences as a patient in a number of institutions for the mentally ill. The narrative
ended with a plea for drastic reform and public education in mental health.
Prompt encouragement and support enabled Beers to establish the first organiza-
tion of its type, the Connecticut Society for Mental Health. Its purpose was to
combat the widespread ignorance about mental illnesses and their causes. One
year later, in 1909, the National Committee for Mental Hygiene was organized.
Rapid growth occurred during the ensuing two decades as evidenced by the or-
ganization of nineteen state mental hygiene societies as well as societies in sixteen
different nations. In 1922, the International Congress for Mental Hygiene came
into being, and in 1930 it called the first International Mental Hygiene Congress
in Washington.

Meanwhile, a few local and state governmental units such as health depart-
ments began introducing activities in the field of mental health. Usually they were
frankly exploratory and experimental and often were integrated with some other
activities of the agency rather than identified separately. A great stimulus came in
1946 when the National Mental Health Act was passed by the Congress of the
United States. This Act made possible much of the expansion of thought and
action which since has occurred at all levels of government and to which sub-
sequent reference will be made.

Extent of Problem. In terms both ofl incidence and prevalence on the one
hand, and of social and economic implications on the other, mental illness is
one of the most compelling public health problems. So widely do problems of
this nature prevade all aspects of community health that one writer, a sociolo-
gist, has claimed: “If it isn’t mental health, it isn’t public health.” Each year in
the United States, over a million persons, including 4,000 children and youths,
are treated in mental hospitals. While only about 2 per cent of all hospital ad-
missions are for psychiatric disorders, about one half of the hospital beds in the
country are occupied by mentally ill patients. In addition, 1145 million adults
and children visit outpatient clinics and private physicians for psychiatric diag-
nosis and treatment each year. It has been estimated that about one hall of all
children and adults who consult private physicians for any reason have some
kind of emotional disorder. Similarly, it is estimated that of the 20 million
patients who go to general hospitals for physical ailments each year, about 6
million have illnesses caused by emotional disturbances. There is evidence that
at any given time, about one out of every ten persons in the country has some
form of mental or emotional disorder which needs treatment. Among the many
factors contributing to the increase in mental patients are the increased stresses
of urbanization and industrialization, a greater longevity, increased population,
improved and more acceptable diagnosis, and increased facilities for diagnosis
and care,

Among patients hospitalized for mental illnesses, schizophrenia is the most
common condition, accounting for 45.6 per cent of the total. The frequency of
other important conditions is: mental diseases of the senium, 12.2 per cent;
manic depression, 7.6 per cent; syphilitic psychosis, 6.7 per cent; and psychosis
with mental deficiency, 6.0 per cent. Alcoholic and involutional psychoses each
account for about 3.0 per cent of those hospitalized.
MENTAL HEALTH 023

The limitations of data restricted to hospitalization are obvious. Many in-
dividuals receive some psychiatric guidance through public and private medical
facilities other than hospitals, but the amount is unknown. Many more are in
need of varying degrees of assistance for relatively minor personality adjustment
and psychiatric problems but never receive it. In many ways, the latter represents
perhaps the greatest social and economic aspect of the total problem. It has been
estimated that the over-all annual cost of mental illness in the United States is
about 314 billion dollars.

Definition and Goal of Mental Health. Mental health represents a very
broad field and one which is difficult to define. Potentially, there are probably
very few areas of public health activity to which it cannot make a real contribu-
tion. The increased provision of facilities and the improvement of techniques
of treatment of the mentally ill for their own sake are not of course the funda-
mental interests or ultimate goals of the field of mental health. Rather, its pri-
mary concerns may be said to be improved and increased detection of psychiatric
and prepsychiatric conditions which may result in personal and social handicaps,
the study of their causes, and the initiation of efforts to eliminate, in so far as
possible, the factors which bring them about. Thus, the goal may be said to be
a more satisfying and effective life [ree of adverse mental deterrents for more
people or, to state it even more simply, the development of emotionally mature
people.

Some of the sub-goals involved have been presented by Bullis* in his descrip-
tion of the program sponsored by the Delaware State Society for Mental Hygiene
in which classes on human relations are taught in the public schools. This pro-
gram, he says, represents “a sincere attempt to help our boys and girls now in
school progress toward emotional maturity by developing their ability to make
decisions; to accept responsibilities; to learn from their own emotional mistakes;
to make and keep I[riends; to bring their fears out into the open; to carry on to
the best of their ability when emotionally disturbed; to accept themselves and
depend less on artificial entertainment; to face the past or future without fear; to
face up to unpleasant, fearful or distasteful events of the present; to look at un-
known future changes as interesting adventures to be faced.”*

Nevertheless, as indicated by Lemkau? in his excellent definition of the field,
the goals, hence the desirable program content, in mental health are two-dimen-
sional. He points out that the vertical or categorical dimension, consisting of early
diagnosis and treatment of existing mental ills, as in the case of tuberculosis
control, meets several needs: (1) the prevention of the development of more
serious and handicapping illness, (2) the removal of sources of stress from family
and social environments, and (3) the making available of the services of specialist
personnel to the broader horizontal aims of the mental health program. The
horizontal goals of mental health he visualizes in terms of the work of every
member of the public health department being influenced by mental hygiene
principles. The brief consideration of a few of the ways in which the latter may
be attempted is appropriate.

*Bullis, H. E.: Positive Mental Health Program, Am. J. Pub. Health 40:1113, Sept. 1950.
024 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Mental Health Programs. Because of the relative newness of the field and
amount of exploration occurring, it is not possible to state clearly what a mental
health program should include. However, a consideration of some of the activi-
ties which already have been attempted is of some interest. At the present time,
mental health services of some kind are being carried on by all states. In three
fifths of the states, the department of health is the responsible agency. In the
remainder, the program is the responsibility of a department of welfare, a de-
partment of institutions, as special board or commission, or an independent state
hospital or laboratory.® In these latter instances, and even in the cases of a numn-
ber of the state health department programs, the activities are largely limited to
diagnosis and psychiatric treatment with little or no effort toward prevention.

The National Mental Health Act, passed in 1946, provided for Federal
grants-in-aid to states for research, for training, and for assistance in the establish-
ment and development of community mental health programs, particularly for
the prevention and early treatment of mental and emotional disorders. Already,
significant progress may be noted in making other state public health personnel
aware of mental health and in integrating it into various parts of their programs
and activities. By 1950, specifically identified bureaus, divisions, or sections for
mental health existed in twenty-eight state public health agencies, and in several
others a consultant in mental hygiene served on the staff, usually of the bureau or
division of preventive medical services. At the present time, the functions of
these mental health units variously include: the maintenance of lists or rosters
ol mental health facilities; the gathering ol reports or data on mental health
needs and problems; the development of and assistance to state and local, lay and
professional educational programs; the direct operation of mental health clinics;
the promulgation of rules and regulations relating to mental health and the ad-
ministration of certain aspects of some of them; financial assistance to local agen-
cies, promotional, supervisory, and consultative services to local official and volun-
tary agencies and special surveys and research.”

As in the case of the states, mental health activities on the part of local public
health agencies have been of relatively recent origin. Up to the present, few of
the official city or county health agencies have endeavored to initiate and to carry
on such programs. Part of the reason for this has been the complexity of the prob-
lem, hence the complexity ol the approach to its solution. As a corollary, it has
been realized that the solution cannot and must not rest in the hands of one
group. This has been pointed out by Felix and Kramer,” who said: “Because of
the complexity of the problem, effective research on the community aspects of
mental illness must be interdisciplinary, combining the skills and knowledge of
the psychiatrist, psychologist, social scientist, public health physician and nurse,
psychiatric social worker, epidemiologist, and statistician.” This was also clearly
indicated in the report of the National Health Assembly!® which stated: “Clergy-
men, teachers, lawyers, social workers, nurses, recreation and group workers, law
enforcement officers, public health personnel, representatives of management and
labor, and many others, are constantly presented with opportunities for recogniz-
ing emotional problems.” A most important omission by each of these listings,
and perhaps the key group toward which the efforts of all of the others should
be primarily aimed, are parents—both actual and prospective.
MENTAL HEALTH 025

In 1954-1955, a total of 1,234 psychiatric outpatient clinics were reported
to be in operation in one hundred fifty-two local jurisdictions in the United
States. To be considered adequate [or reporting purposes, it was necessary that a
center be staffed at least by a psychiatrist, a clinical psychologist, and a psychi-
atric social worker. The clinics were located in all states and territories with the
exception of Nevada. However, more than half of the clinics were in the north-
eastern states which have one quarter of the total population. There were two
hundred four in the New York City area alone. State governments operated 41
per cent of the clinics, and another 23 per cent received some state aid; 5 per
cent were operated by the Veterans Administration.

The relationship between the stall of the mental health center or program
and the personnel of the official public health agency sometimes presents an ad-
ministrative problem. This involves especially the relationship between the psy-
chiatric social workers and the public health nursing staff. The obvious goal is
for the public health nurses and the psychiatric social worker to look upon each
other as sources of referral and as a resource for consultation, advice, and in-
service education. This can best be accomplished through joint planning, joint
conferences, and joint inservice training. Perhaps the key consideration to be
kept in mind by the nursing staff is that psychiatric social work is a specialized
field in itself. In turn, the very limited numbers of psychiatric social workers
must recognize that they are physically incapable of making all of the contacts
and of meeting all of the needs and that public health nurses have wide and
well-established contacts and entrée throughout the community. Beyond this, all
concerned, including the health officer and the director of the mental health
center, should bear in mind that the promotion and maintenance of smooth and
fruitful interpersonnel relationships is one manifestation of sound mental health,
and in turn is a prerequisite to the planning, development, and implementa-
tion of an effective community mental health program.

REFERENCES

1. Beers, Clifford, W.: A Mind That Found Itself, New York, 1908, Longmans, Green & Co.

2. Jensen, H. E.: Mental Health: A Local Public-Health Responsibility, Ment. Hyg. 37:530,
Oct. 1953.

3. St. J. Perrott, G., and others: Care of the Long Term Patient, Public Health Service Publ.
No. 344, Washington, 1954, U. S. Public Health Service.

. Bullis, H. E.: A Positive Mental Health Program, Am. J. Pub. Health 40:1113, Sept. 1950.

5. Lemkau, P. V.: Public Health Administration in Mental Hygiene, Am. J. Pub. Health 41:
1382, Nov. 1951.

6. Mountin, J. W., and Flook, E.: Guide to Health Organization in the United States, 1951,
Washington, 1953, Public Health Service Publ. No. 196.

7. Report of State Health Programs for Five-Year Period 1946-1950, Washington, 1952, Public
Health Service Publ. No. 236.

8. Distribution of Health Services in the Structure of State Government, 1950, Washington,
1954, Public Health Service Publ. No. 184.

9. Felix, R. H., and Kramer, M.: Research in Epidemiology of Mental Illness, Pub. Health Rep.
67:160, Feb. 1952.

10. America’s Health—A Report to the Nation by the National Health Assembly, New York,
1948, Harper & Brothers.

11. Bahn, A. K,, and Norman, V. B.: Outpatient Psychiatric Clinics in the United States, 1954-
1955, Washington, 1957, Public Health Service Publ. No. 538.
chapter 2 9

Rehabilitation

 

 

Introduction. It is only relatively recently that the concept of community
interest in and responsibility for the so-called acts of God, chance and Mars has
become a reality. One has to turn back but few pages in human history to find
an attitude of rather complete social irresponsibility even for disabled veterans
who were accorded their day of acclaim followed by a bitter lifetime of depend-
ency or outcast. Recent years, however, have brought an increasing amount of dis-
cussion of the problems of the handicapped and what might be done to make their
lives personally more satisfying and economically more fruitful. It is only in the
past few decades that the disabled began to be considered as fellow human be-
ings, subject as any other to sensitivity, pride and ambition, and as potential social
assets rather than liabilities.

On arriving at this point, not a small item of difficulty has been the definition
or determination of what is a handicap or a handicapped person. Adequate defi-
nition, of course, is fundamental to the determination and conduct of a compre-
hensive and satisfactory program of rehabilitation. As might be expected, at-
tention and effort were focused first upon the visibly most obvious physical de-
fects, i.e., the traditional lame, halt and blind. Gradually, other physical handi-
caps began to receive attention in the public consciousness. Tuberculosis was es-
tablished as an etiological entity and its physiopathology became understood. In
the absence of other means, intensive rest and supportive care were instituted as a
cure. Eventually it became evident that it was difficult to determine where cure
ended and rehabilitation began. At any rate, high relapse rates soon empha-
sized the importance of rehabilitation, at least in this and a few other diseases.
Such circumstances provoked further reconsideration and redefinition. There
came about a realization that there also existed such conditions as mental, emo-
tional, psychological or personality crippling which might be every bit as devastat-
ing to the individual and as costly to society as a physical defect. In addition, it
has come to be appreciated that mental or psychological handicaps and physical
handicaps are not infrequently related. So the present trend is to look upon
rehabilitation in very board terms, as a need applicable to practically all types
of ills and of as much concern to society as to the individual.

6206
MENTAL HEALTH 025

 

In 1954-1955, a total of 1,234 psychiatric outpatient clinics were reported
to be in operation in one hundred fifty-two local jurisdictions in the United
States. To be considered adequate for reporting purposes, it was necessary that a
center be staffed at least by a psychiatrist, a clinical psychologist, and a psychi-
atric social worker. The clinics were located in all states and territories with the
exception of Nevada. However, more than half of the clinics were in the north-
eastern states which have one quarter of the total population. There were two
hundred four in the New York City area alone. State governments operated 41
per cent of the clinics, and another 23 per cent received some state aid; 5 per
cent were operated by the Veterans Administration.

The relationship between the staff of the mental health center or program
and the personnel of the official public health agency sometimes presents an ad-
ministrative problem. This involves especially the relationship between the psy-
chiatric social workers and the public health nursing staff. The obvious goal is
for the public health nurses and the psychiatric social worker to look upon each
other as sources of referral and as a resource for consultation, advice, and in-
service education. This can best be accomplished through joint planning, joint
conferences, and joint inservice training. Perhaps the key consideration to be
kept in mind by the nursing staff is that psychiatric social work is a specialized
field in itself. In turn, the very limited numbers of psychiatric social workers
must recognize that they are physically incapable of making all ol the contacts
and of meeting all of the needs and that public health nurses have wide and
well-established contacts and entrée throughout the community. Beyond this, all
concerned, including the health officer and the director of the mental health
center, should bear in mind that the promotion and maintenance of smooth and
fruitful interpersonnel relationships is one manifestation of sound mental health,
and in turn is a prerequisite to the planning, development, and implementa-
tion of an effective community mental health program.

REFERENCES

1. Beers, Clifford, W.: A Mind That Found Itself, New York, 1908, Longmans, Green & Co.

2. Jensen, H. E.: Mental Health: A Local Public-Health Responsibility, Ment. Hyg. 37:530,
Oct. 1953.

3. St. J. Perrott, G., and others: Care of the Long Term Patient, Public Health Service Publ.
No. 344, Washington, 1954, U. S. Public Health Service.

4. Bullis, H. E.: A Positive Mental Health Program, Am. J. Pub. Health 40:1113, Sept. 1950.

Lemkau, P. V.: Public Health Administration in Mental Hygiene, Am. J. Pub. Health 41:

1382, Nov. 1951.

6. Mountin, J. W., and Flook, E.: Guide to Health Organization in the United States, 1951,
Washington, 1953, Public Health Service Publ. No. 196.

7. Report of State Health Programs for Five-Year Period 1946-1950, Washington, 1952, Public
Health Service Publ. No. 236.

8. Distribution of Health Services in the Structure of State Government, 1950, Washington,
1954, Public Health Service Publ. No. 184.

9. Felix, R. H., and Kramer, M.: Research in Epidemiology of Mental Illness, Pub. Health Rep.
67:160, Feb. 1952.

10. America’s Health—A Report to the Nation by the National Health Assembly, New York,
1948, Harper & Brothers.

11. Bahn, A. K,, and Norman, V. B.: Outpatient Psychiatric Clinics in the United States, 1954-
1955, Washington, 1957, Public Health Service Publ. No. 538.

ot
chapter 2 9

Rehabilitation

Introduction. It is only relatively recently that the concept of community
interest in and responsibility for the so-called acts of God, chance and Mars has
become a reality. One has to turn back but few pages in human history to find
an attitude of rather complete social irresponsibility even for disabled veterans
who were accorded their day of acclaim followed by a bitter lifetime of depend-
ency or outcast. Recent years, however, have brought an increasing amount of dis-
cussion of the problems of the handicapped and what might be done to make their
lives personally more satisfying and economically more fruitful. It is only in the
past few decades that the disabled began to be considered as fellow human be-
ings, subject as any other to sensitivity, pride and ambition, and as potential social
assets rather than liabilities.

On arriving at this point, not a small item of difficulty has been the definition
or determination of what is a handicap or a handicapped person. Adequate defi-
nition, of course, is fundamental to the determination and conduct of a compre-
hensive and satisfactory program of rehabilitation. As might be expected, at-
tention and effort were focused first upon the visibly most obvious physical de-
fects, i.e., the traditional lame, halt and blind. Gradually, other physical handi-
caps began to receive attention in the public consciousness. Tuberculosis was es-
tablished as an etiological entity and its physiopathology became understood. In
the absence of other means, intensive rest and supportive care were instituted as a
cure. Eventually it became evident that it was difficult to determine where cure
ended and rehabilitation began. At any rate, high relapse rates soon empha-
sized the importance of rehabilitation, at least in this and a few other diseases.
Such circumstances provoked further reconsideration and redefinition. There
came about a realization that there also existed such conditions as mental, emo-
tional, psychological or personality crippling which might be every bit as devastat-
ing to the individual and as costly to society as a physical defect. In addition, it
has come to be appreciated that mental or psychological handicaps and physical
handicaps are not infrequently related. So the present trend is to look upon
rehabilitation in very board terms, as a need applicable to practically all types
of ills and of as much concern to society as to the individual.

626
REHABILITATION 027

 

Source of the Problem. There are many reasons why rehabilitation should
command attention at this time. For a long period of time it was ignored or over-
looked because of the magnitude of other problems, many of which have been
eliminated or abated, thereby allowing more time and effort for attention to
other things. With the development of possible social and medical tools, there
occurred a tearing away from the complacent fatalistic attitude that there were
many conditions for which nothing could be done. The results of examinations
for eligibility in the armed forces at the beginning of World War II came as a
shock to most people and spotlighted the enormous numbers of ills, mostly
chronic, among the supposedly most healthy segment of our population. Despite
our high standard of living, it was found that 40 per cent of selectees had to be re-
jected because they could not meet standard physical requirements. With the en-
suing man-power shortage, it became necessary to draw upon the reservoir of dis-
abled persons who were not eligible for the armed services. This brought out the
surprising fact that many of all types of handicapped persons were capable of
making very real and significant social and economic contributions if only they
were given an opportunity to readjust themselves and their disability to the de-
mands of working and living situations. In other words, the rehabilitation needs
of the nation and its communities represented a vast but diffuse frontier of pre-
ventive, therapeutic, and promotive medicine and community action which was
waiting to be discovered.

Beyond this, however, is the [act that the number and proportion of dis-
abled persons have increased considerably in recent years. Our society has become
more keyed up, more centralized, more industrialized, more complex and faster
moving, with an accompanying increase in accidents, cardiac and hypertensive
disease, and mental illness. Recent wars have involved more and more people
and have been more and more devastating, directly and indirectly, to the peo-
ple on both the battle and the home fronts. Crippling diseases such as multiple
sclerosis and, until recently, poliomyelitis, have increased. Finally, and de-
spite the foregoing, the average life span has increased remarkably during the
past half-century. As a result, our population has been aging, with many more
people reaching advanced years with accumulations of handicapping effects of
chronic diseases, many of which had their origins in preventable illness earlier in
life. While all these events and changes were occurring, certain sociological and
cultural changes were coming about. Especially pertinent was society's gradual
assumption of the responsibility for doing something about the needs and prob-
lems of the handicapped, which heretofore were considered to be essentially pri-
vate burdens, responsibilities of the individual and his family. In the presence of
such a vast vacuum, assistance to individuals began to be given by the many
voluntary and philanthropic agencies which sprang up, often on the basis of very
personal motivations. In recent years, however, governmental agencies have grad-
ually entered more and more into the picture.

The various events and revelations to which reference has been made neces-
sitated the re-examination of existing concepts of physical fitness, disability, and
rehabilitation. It has been realized that the term physical fitness must refer not
only to the physical ability and endurance of the man in combat but also to the
028 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

ability of the worker to perform productive and continuous work. It is a key
word to the correct understanding of the whole problem of the crippled and dis-
abled. False concepts of physical fitness have had an important influence on our
social, economic, industrial, and military life. Fitness, disability, and rehabili-
tation are now recognized to be terms with many political and economic im-
plications. Vague and unsatisfactory standards and definitions have often been
created, sometimes by law, which have in effect branded those with physical
defects as unproductive and socially useless and have committed them to the bleak
outlook of permanent dependency.

Numerous attempts have been made to describe and define the field of
rehabilitation. Rusk! refers to it as the third phase of medicine, saying:

We now talk about the third phase of medical care, the first being obviously pre-
vention, the second, definitive medicine and surgery, and the third, that phase between
the bed and the job, what you do after the fever is down and the stitches are out to
allow the chronically ill or the physically disabled person to live a self-supporting, self-
respecting life with dignity. *

Sensenich,? viewing the field in terms of what should be done, says:

The problem of rehabilitation of an individual involves a twofold effort—on the
one hand, to lessen and minimize through medical treatment his physical handicap,
and on the other, to help the individual develop his strength and his abilities so that
he is better equipped to meet and live on comfortable terms with the physically able
of the community. t

A group? which recently studied the field developed a succinct but useful defi-
nition:
Rehabilitation is the process of assisting the individual with a handicap to realize
his potentialities and goals, physically, mentally, socially and economically.f

Magnitude of the Problem. One strange aspect of the problem of the dis-
abled is that the reaction of the public often appears to be that of seeing but not
comprehending. This is to say that, while in the majority of instances the dis-
abled are visually very much in evidence, the public tends not to react by grasping
the total significance to society of the implications of vast numbers of disabled
individuals. Perhaps the reason is that to many the thought of disability is un-
pleasant, so they thrust it out of their consciousness. Yet even a cursory analysis in-
dicates forcefully the great magnitude of the problem and the enormous economic
loss to society which it entails.

In terms of impact upon the public mind, probably the most effective pic-
ture of national disability resulted from the National Health Survey of 1935-36.
Information was secured on illnesses which were present during the preceding
twelve months in a sample of 800,000 families in eighty-three cities and twenty-

*Rusk, H. A.: America’s Number One Medical Problem, Proc., 42nd Annual Meeting of Life
Insurance Assn. of America, Dec. 9, 1948, p. 57.

tSensenich, H.: Team Work in Rehabilitation, Am. J. Pub. Health 40:969, Aug. 1950.

Van Riper, H. E.: Rehabilitation Interests of a Voluntary Agency, Am. J. Pub. Health
44:744, June 1954.
REHABILITATION 0629

 

three rural areas of nineteen states. From the findings which had been demon-
strated to be reliable, national estimates were developed. For our purposes, the
following findings® are pertinent:

4.4 per cent were disabled on the day of the survey visit.

1.2 per cent were disabled the entire preceding twelve months.

17.7 per cent were reported as having a chronic disease or impairment.
1.1 per cent of workers (15 to 64 years of age) were reported to be “un-
employable” by reason of disability.

Leo =

Two more recent surveys of the prevalence of disabling illness were carried
out in February 1949 and September 1950.6 These surveys reported on the num-
bers of persons between 14 and 64 years of age who were unable to carry on
their usual activities because ol some illness or other medical condition. For the
February survey the figure was 4.6 million and for the September survey it was
8.6 million. Most of the difference was due to disabilities of short duration, one
month or less, many of which were probably seasonal. On the other hand, the
number of persons who, at the time of the survey, had been disabled for more
than three months was not greatly different from the corresponding number in
February 1949. The estimate [rom the earlier survey was 2.3 million and from the
later survey 2.2 million.

Rusk and Taylor” have prepared a concise summary of the extent of the
problem based upon a review of recent literature. They report about 2,600,000
persons with orthopedic impairments of which 341,000 are incapacitating; ap-
proximately 900,000 amputees, almost one half of which are major; almost
400,000 registered crippled children; an estimated 336,000 persons with cerebral
palsy; and somewhere between 500,000 and 114 million cases of epilepsy. Among
additional impairments they call attention to between 9 million and 10 million
persons suffering from diseases of the heart and arteries; an estimated 2 million
diabetics; approximately 300,000 clinically significant, active cases of tuberculosis
plus 150,000 convalescents who would benefit from rehabilitation services; and
an estimated 2,400,000 persons in need of hearing aids, only one third of whom
have them; and about 230,000 blind. These figures substantiate the statement
that 88 per cent of all disabilities is due to disease, 10 per cent to accidents, and
2 per cent to congenital conditions.®

With specific reference to children, Lesser and Hunt? call attention to
500,000 under 18 years of age suffering from rheumatic fever or its effects; about
64,000 with cleft palate or cleft lip or both; at least 60,000 with visual handicaps
so serious as to need special educational help (with facilities for only 8,000);
from one-quarter to one-half million children with serious hearing loss; and
about 11% million children between 5 and 20 years of age with speech handicaps
that are unrelated to hearing, cerebral palsy, or cleft lip or palate, and of which
about one half are functionally serious.

Disability related to military service is dramatic and tends to attract atten-
tion more readily than handicaps from other sources. However, it is important to
realize that they constitute only a minor proportion of the problem. During
World War II there occurred about 17,000 amputations in the United States
030 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

Army. During the same period, there were 120,000 major amputations in the
civilian population attributable to disease and accidents. It has been estimated
that there are about 2 million civilian men and women of working age in
the United States so severely disabled by physical or mental impairments that
they cannot support themselves or their families. Furthermore, the total number
of disabilities grows at the rate of about 250,000 per year because of accidents,
illness, or congenital causes.1®

Economics of the Problem. Certain general economic aspects ol illness and
death will be discussed in Chapter 30. It may be pertinent to add here some
comments on the economic implications of disability and what may be gained
by rehabilitation efforts. Society pays in many ways for its failure to prevent and
to care for disabilities among its constituents. A few of the more obvious ways
are through insurance payments and therefore higher rates, wage losses, produc-
tion losses, employees’ disability compensation, and a significant part of the re-
lief load. If we consider the labor force alone, estimated at about 60 million people
fully employed, the loss due to compensable disability during a recent year has
been estimated at 1.8 billions dollars. Add to this the production loss of about
twice the lost wages and the total is a staggering 5.5 billions dollars per year. This
sum is more than the total capital funds of all the national banks in the United
States and is about one half again as great as the total fire losses in the country
during the ten years 1937 to 1946. It must be recognized of course that much of
this loss is due to temporary, self-eliminating disability and that it is dependent
upon fluctuating employment opportunities, strikes and similar factors. However,
a great deal of it represents, without question, needless and stupid loss.!!

To approach the premise from the positive direction, the results of some of
the limited efforts at rehabilitation of the handicapped are available. During 1948,
successful rehabilitation services were made available under joint Federal-state
sponsorship to 53,000 persons.’? Of these, 13 per cent had never been employed
and an additional 74 per cent were not employed when they began rehabilitation;
7.7 per cent had been in or eventually entered professional or semiprofessional
work; 37 per cent in managerial, clerical, sales or service activities; 7.9 per cent
in agriculture; 30.9 per cent in skilled or semiskilled work; 9.3 per cent in un-
skilled work; and 7.2 per cent in family work or housewifery. Many had been on
public assistance at a cost of $400 to $700 per year as compared with an average
cost for rehabilitation of $460 per case—a single rather than an annually recurring
expenditure. Their average annual wage after rehabilitation was $1,623 in con-
trast with $321 before. This small group of 53,000 persons rehabilitated in 1948
increased the national purchasing power by 69 million dollars and paid over
5 million dollars in Federal income taxes in addition to state and local taxes.
It has been shown that for every dollar spent by the Federal government on re-
habilitation, the average rehabilitated person will eventually pay ten dollars in
Federal income tax. This is based on the rate of earnings at completion of re-
habilitation and on employment for only 85 per cent of the individual's work life
expectancy.

An analysis of handicapped people rehabilitated during 1955 showed that
they have since increased their earnings from 15 million dollars to 105 million
REHABILITATION 031

 

dollars per year and have added more than 100 million man hours to the nation’s
productive effort. Almost 20 per cent or about 11,000 of those rehabilitated had
been receiving public assistance which amounted to 11 million dollars annually.
These rehabilitated persons are now paying about 81% million dollars each year in
Federal taxes. At this rate, within three years they will have repaid the total
investment of 25 million dollars made in them. In terms of their working life
expectancy, it may be considered that, on the average, they will pay ten dollars
in Federal income taxes for each dollar spent for their rehabilitation.

It has been computed that considering 50 per cent successful rehabilitation
of the million handicapped persons between the ages of 15 and 54 who have
never worked, at an eventual weekly income of $35, about 900 million dollars a
year would be added to the purchasing power and tax paying power of the
nation.

Employment of handicapped workers, therefore, is far from a charitable
proposition. It has been shown!> that many of the physically or mentally handi-
capped are able to perform efficiently about 3,500 different jobs or tasks and in
general have better volume of production, higher attendance rates, better safety
records, and better stability and dependability than nonhandicapped workers.

Program Needs and Goals. Many communities already have many rehabilita-
tion services available for their handicapped citizens. Most of these, however, are
scattered throughout many public and private agencies and often are unrelated.
They have developed as part of the community-wide social services, beginning
usually as isolated entities, e.g., as programs for special handicaps or diseases or
as services to particular age groups. As might be expected, more often than not a
state of confusion in the field of rehabilitation, with some difficulty and in-
efficiency and a lack of services for certain types of cases or individuals, has
resulted. Thus, in one large city where I studied the problem preparatory to
efforts toward coordination, there were thirty-seven agencies which were signifi-
cantly active in some phase or other of rehabilitation. This did not include the
various businessmen’s service clubs or many of the church groups.

Rehabilitation is actually a complex of many component parts of which the
physical or medical aspects of the handicap is only one phase. The individual's
emotional acceptance or rejection of the handicap must be taken into account and
treated, and his home and job environment, his mental attitude, his vocational
skills, aptitudes and training, must also be considered. Attention must be given
to all of these and other factors on a coordinated interrelated basis with respect
to the total individual in order that he might become self-reliant and fill a
useful place in society.

This philosophy requires a unified approach if it is to serve adequately
the needs of all types of handicapped persons. It is just as important for the res-
toration of a patient with multiple sclerosis as for a double amputee. It applies
equally to the less severely and to the more severely handicapped. It brings all
the skills of a number of professions to bear upon a common effort to restore the
individual to a position of maximum usefulness and satisfaction in his society.
It places each phase of the approach in its relationship to every other
phase of treatment or education. The develc i ilagephy is so recent

  
    
032 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

that not many really adequate centers have yet been established. Some, such as
those at the Bellevue Institute of Rehabilitation and Physical Medicine, the Cleve-
land Rehabilitation Center, and the Gallinger Hospital (Washington, D.C.)
provide excellent comprehensive rehabilitative care on an inpatient basis. By
following this approach of broad training for sell-care, these institutions have con-
clusively demonstrated the achievement ol considerable economies in addition
to far more successful patient care. Thus during the year prior to the formation
of the new department ol rehabilitation at the Gallinger Hospital, orthopedic pa-
tients spent an average ol fifty-five days in the hospital. After the new program
was instituted, the hospital stay of similar patients was reduced to thirty-three
days, a saving of $122,000 [or orthopedic patients alone.'¢

The challenge which faces at least the moderate to larger-sized communities
was indicated by Taylor!'? in a study he carried out in one ol the major cities. He
concluded:

The greatest need . . . is the development of a single large center with sufficient

staff and facilities to furnish rehabilitation services to all persons with physical disabili-
ties regardless of the medical condition which has caused those disabilities. *

He suggests that patients be referred to this community rehabilitation center
from any physician, whether in private practice, industry, public agency, or else-
where, and that the primary medical responsibility for the patient should remain
with the referring physician. Following evaluation, if the patient is accepted,
the medical director of the center could assume the primary responsibility for
the prescription and supervision ol the physical medicine and rehabilitation serv-
ices only. Such a procedure is similar to that customarily followed in the referral
of patients for specialized care in other areas of medicine. A center of this type
should have facilities for inpatients as well as for outpatients. In fact, Taylor
suggests that eventually a large proportion of the hospital beds in a city might
gradually be allocated for convalescents and patients being rehabilitated, up to a
level of one bed for each thousand of the population. This could be accomplished,
at least in part, by the decreasing need for beds for communicable diseases and
as a result of shortened hospital stays for many conditions.

The community rehabilitation center should operate under the leadership of
a physician whose training qualifies him for certification by the American Board
of Physical Medicine. The Baruch Committee on Physical Medicine recommends
the organization ofl such a center under two primary divisions, i.e., a medical
services division and a vocational services division. The medical services division
should include a physical medicine branch with an occupational therapy section,
a physical therapy section, and a physical education section; and a psychosocial
branch with a clinical psychological section and a social service section. The
second of the primary divisions, that dealing with vocational services, should
provide branches for vocational testing and guidance and for special educa-
tion. In addition, in order to meet the graded needs of various degrees of dis-
ability, the vocational services division should conduct a sheltered workshop
program, a curative worksh rogram, and a homebound program.

   
  

ealth Council of the Council of Social Agencies
REHABILITATION 033

 

Sponsorship and support should be looked upon, especially at this stage, as
variable. In many communities the rehabilitation center may undoubtedly begin
as a result of the initiative of a forward-looking public health agency in focus-
ing attention on the total problem, drawing together all interested groups and
perhaps providing the basic care of the center to which the others may make ad-
ditions. There are few fields in which it is as easy to contemplate true community-
wide interest and action involving public agencies, voluntary agencies, industry
and labor. It should be realized however that there is no single pattern that will
be acceptable and successful everywhere. In the absence of a community re-
habilitation center, a few communities have developed central rehabilitation diag-
nosis and referral centers. This has usually been done under the sponsorship of
health and welfare councils, for instance in Philadelphia. The purposes are to pro-
vide preliminary screening and diagnosis, sometimes elementary therapy, social
service, and referral and follow-up. Other aims are to ensure that the patient
neither gets lost among the several agencies that may contribute to his rehabilita-
tion, nor gets “captured” by any single one. The best of these agencies have
multidisciplinary staffs available for the consideration of the various aspects of
the patient's problem.

Commendable rehabilitation centers have been instituted and operated ex-
clusively by voluntary agencies, industrial concerns, insurance companies, and
labor unions. The goal of course should be a truly cooperative well-integrated
and comprehensive program which serves all components of the community and
for which all parts of the community have a responsibility and concern. It is in
this regard that the official public health agency can bring into play its important
role of catalyst. If many public health workers have not considered it, workers
in other fields have. After considering the many community agencies interested in
the handicapped, the director of a prominent voluntary agency'® comments:

Some place major responsibility for leadership in community organization for re-
habilitation on the hospital-medical school, others on the Bureau of Vocational Re-
habilitation. The Health Department might logically be asked to exhibit leadership even
in an area of health concern where its current services are minor. A more realistic
approach would seem to be one of accepting leadership where one finds it. This jibes
with the nature of rehabilitation, a drawn-out process which uses many professional
skills as it shifts emphasis from the original medical to the later vocational aspects.*

In a somewhat similar vein Notkin!? says:

In recent years, vocational rehabilitation and public health groups have been widely
expounding both their ideas and the scope of their operations. Although autonomous
operation is probably still desirable at this stage of progress, it may be wise to start
thinking of vocational rehabilitation as part of the broader concept of public health
which is prevalent today.t

So it would appear that here is a public service frontier calling for effective
coordinating leadership which some people outside of the field believe might well

*Wenkert, Walter: Community Planning for Rehabilitation, Am. J. Pub. Health 42:782,
July 1952.

tNotkin, H.: Vocational Rehabilitation and Public Health, Am. J. Pub. Health 41:1100,
Sept. 1951.
034 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

be provided by a community’s official health agency. Whether this frontier will be
developed or lost by default will be interesting to watch and will be of inti-
mate concern to many thousands of disabled persons who are waiting for an op-
portunity to live their lives properly.

REFERENCES

I. Rusk, H. A.: America’s Number One Medical Problem, Proc., 42nd Annual Meeting of
Life Insurance Assn. of America, Dec. 9, 1948.

2. Sensenich, H.: Team Work in Rehabilitation, Am. J. Pub. Health 40:969, Aug. 1950.

3. Van Riper, H. E.: Rehabilitation Interests of a Voluntary Agency, Am. J. Pub. Health
44:744, June 1954.

4. The National Health Survey, List of Publications, Pub. Health Rep. 57:834, May 29, 1942.

5. Britten, R. H., Collins, S. D., and Fitzgerald, J. S.: The National Health Survey, Some
General Findings as to Diseases, Accidents and Impairments in Urban Areas, Pub.
Health Rep. 55:444, March 15, 1940.

6. Woolsey, T. D.: Estimates of Disabling Illness Prevalence in the United States, Washing-

ton, 1952, Public Health Service, Publ. No. 181.
Rusk, H. A., and Taylor, E. J.: Physical Disability: A National Problem, Am. J. Pub.
Health, 38:1381, Oct. 1948.

8. Hearings Before Subcommittee on Health, of the Committee on Labor and Public Wel-
fare, U. S. Senate, 83rd Congress, 2nd Session, on “President’s Health Recommenda-
tions and Related Measures,” March 30, 1954.

9. Lesser, A. J., and Hunt, E. P.: The Nation’s Handicapped Children, Am. J. Pub. Health
44:166, Feb. 1954.

10. Number of Disabled Persons in Need of Vocational Rehabilitation, Washington, 1954,
Rehabilitation Service Series No. 274, Office of Vocational Rehabilitation.

11. Strow, C. W.: The Extent and Economic Cost of Disability, Research Council for Eco-
nomic Security, Chicago, 1947, Publ. No. 23.

12. Brass Tacks, Office of Vocational Rehabilitation, Washington, June 1949.

13. Annual Report—1955, Washington, 1957, U. S. Department of Health, Education, and

~1

Welfare.

14. Allan, W. S.: Rehabilitation, A Community Challenge, New York, 1958, John Wiley & Sons,
Inc.

15. Editorial: Public Health Workers and Rehabilitation, Am. J. Pub. Health 38:1455, Oct.
1948.

16. Rusk, H. A.: Rehabilitation in the Hospital, Pub. Health Rep. 68:281, March 1953.

17. Taylor, E. J.: Unpublished Study, 1950, Health Council of the Council of Social Agencies
of Metropolitan Detroit.

18. Wenkert, Walter: Community Planning for Rehabilitation, Am. J. Pub. Health, 42:782,
July 1952.

19. Notkin, H.: Vocational Rehabilitation and Public Health, Am. J. Pub. Health 41:1100,
Sept. 1951.
chapter 3 0

Public health, the private physican,

and medical care

 

This subject is one which has been somewhat controversial up to the present
and which will undoubtedly continue to be so for some time to come. It is not
considered within the province of this book to discuss the details of the many
bills and proposals of the past and present. Events have been moving so rapidly
that any such discussion would be out of date at the moment of its writing. The
intention, therefore, is to attempt to paint the picture of the general problem and
the development of attempts at its solution with primary colors and in broad
strokes and to do this in as unbiased a manner as possible.

Relationship Between Public Health and Private Medicine. Public health
activities cut across a great many other phases of community life and involve con-
tact with the members of most businesses and professions. Among these relation-
ships, perhaps the most intimate is with the members of the medical profession.
There are many reasons for this. In the first place, most of those engaged in
public health work are themselves either members of the medical profession or of
some other profession closely related to it such as nursing. Public health workers
and private practitioners of medicine are concerned with the same ultimate
goal, health. Furthermore, many of the programs sponsored by health agencies
require the active cooperation and participation of private physicians. In fact, the
opinion is increasingly heard that every private physician is in effect a deputy of
the health officer and that each physician's office should represent, for the families
he serves, a branch of the health department. The expressed hope that some day
all preventive and promotive as well as therapeutic medicine will be obtained
from the private practitioner seldom meets with argument. Finally, private medi-
cal practice and public health activities have a considerable effect, one upon
the other. Modern public health programs depend greatly upon coincident effec-
tive private practice. Every health officer realizes that the scientific practice of
medicine is the foundation of public health. In turn, many public health activi-
ties such as laboratories and health education operate to the assistance of private
practitioners.

635
036 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

In order to undestand adequately the significance of this relationship, which
in the light of recent trends is certain to become even more intimate, it is well
to review briefly and jointly the development of these two fields, especially as re-
lated to and affected by the development of our modern industrial economy and
social organization.

Evolution of Modern Medicine and Society. Generally speaking, it is ad-
vantageous to consider these developments in three time periods: the period
preceding the so-called Industrial Revolution, the period from about 1750 to
1850 during which the Industrial Revolution took place, and the time that
has elapsed since. Before the Industrial Revolution which is usually consid-
ered to have begun about 1750, the social and economic structure of the
civilized western world was relatively simple. Few large cities existed and the
economy was essentially agrarian. Economic and social life was limited to the small
local community or neighborhood, and while these aspects of life were quite
stable, they were on a rather low scale in comparison with the present and in-
volved relatively little personal freedom. Social classes were rigidly stratified and
adhered to by custom from one generation to the next. Only with great difficulty
could a son pursue a way of life different from that of his father. Industry in the
present sense of the word simply did not exist. The family was the unit ol produc-
tion, usually making for itself whatever goods it needed. Manufacturing, to the ex-
tent that it did exist, was carried on either through guilds which provided for the
continuous training of a limited number of apprentices by skilled craftsmen, or
by means of the “putting-out system.” This latter consisted of putting raw ma-
terials into the hands of individuals who, with all of the members of their fam-
ilies, worked on them on a piece basis. Thus, the individual craftsman was re-
sponsible for the entire process of manufacture and usually was personally ac-
quainted with the source of his materials and the ultimate consumer of the prod-
uct of his labors.

During this era the practice ol medicine was at one of its lowest ebbs. The
scientific viewpoint was generally underdeveloped. Medical procedures were
based largely upon speculation and superstition, and but little experimentation
or planned observation was engaged in. There were no standards of medical edu-
cation or practice, and healers and physicians were often sell-designated. Many of
them were charlatans, often unworthy of trust not only with regard to competent
medical care but also in terms ol private possessions. Since surgeons worked with
their hands and often performed surgery as an adjunct to barbering, they were
held in particularly low esteem. Treatment consisted chiefly of the use of purga-
tives and leeches and considerable attention was given to various aspects of cos-
metology. The relatively [ew hospitals were essentially pesthouses, consignment to
which usually signified impending death. At any rate, the average member of
society had little if any contact with physicians, since the latter, if not vagrant
itinerants, were usually attached to the households of the noble and wealthy
classes. They seldom received fixed payments for their services, usually depending
on gratuities.

The provision of medical service in a public sense was in its most embryonic
form. Social controls and requirements relating to the practice of medicine were
~ PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 637
either elementary or nonexistent. It is true that during the late Middle Ages, the
professional behavior and avarice of physicians in some urban centers occasionally
led to the legal fixing of fees and to requirements that some arrangements be
made for the care of the sick poor. At best, however, these requirements were
rare and sporadic and of a very unsatisfactory nature. As early as the thirteenth
century, a few European towns employed town surgeons. Town physicians, on the
other hand, are not encountered historically until the sixteenth century. From the
fourteenth century on, it became not uncommon to require surgeons and later
physicians to submit public reports of all injuries they treated as well as cases of
certain diseases, notably leprosy, plague, and syphilis. Very gradually physicians
became concerned with sanitation and other aspects of public health.

Whatever care, medical or otherwise, was provided for the sick, poor, aged,
and homeless had the Church as its source. Charity by this time had become a
dominant manifestation of acceptable Christian behavior, and medical, nursing,
and hospital care became a major interest and activity of many monastic orders.
Later, during the sixteenth, seventeenth, and eighteenth centuries these responsi-
bilities gradually began to shift from the Church to the state. As pointed out by
Shryock, however; “This humanitarianism, like the clerical form of earlier
centuries, largely expressed the benevolence of the upper classes rather than any
demand for reform from below.”

The Industrial Revolution, when it came, brought with it tremendous
changes not only in methods of manufacturing but also in the modes of transpor-
tation and facilities for the communication of ideas and information. Manufactur-
ing was fractionated into component processes and the laboring class became con-
centrated in industrial centers of population and organized to work in large
factories for the greater profit of management. A new economic and political
power came about in the form of the industrialist and economic royalist. To such
a height did the desire for high profits soar that all consideration for human wel-
fare and decency was forgotten. No longer were goods made by skilled guild mem-
bers or craftsmen with pride in their workmanship. No longer was the consumer
personally acquainted with the producer. The personal face-to-face relationship
between employer and employee disappeared as well. Articles were now produced
through the combined efforts of a great many individuals. As might have been ex-
pected, the social and economic center of gravity shifted from the agrarian to the
urban scene. Rural areas themselves were directly affected. The populations of
industrial cities were not self-maintaining because of their appalling death rates.
They therefore required continuous replenishment from the rural population.

Interestingly enough, it was during this period of cruel industrialization and
economic interdependence that the search for scientific knowledge received a
necessary impetus. While it is true that the primary incentive was the development
of new techniques for greater economic gains, the results were ultimately bene-
ficial to society. The character of the practice of medicine began to undergo
some improvement. A trend toward logical experimentation and observation de-
veloped. A system of medical training by apprenticeship came into vogue and the
physician changed his locale from the highway and the manor to take his place
as a private enterpreneur in competition with other physicians. For a while this
038 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

competition resulted in many abuses which led eventually to the necessity for the
re-establishment of a long-dormant code of professional ethics.

With some exceptions, diseases were not considered as distinct entities but
were classified in terms of their manifestations, such as swellings, fevers, and in-
flammations. The equipment of the physician was still simple and his only adjunct
was the pharmacy, which in most instances he operated himself. Hospitals more
than ever were pesthouses because of the tremendously increased incidence of
communicable diseases for which the filthy centers of population served as breed-
ing grounds.

During the nineteenth century, the idea of corporate structures developed
and resulted in the monopolistic control of each industry and not infrequently of
several industries together. The intent, of course, was to achieve still greater in-
dustrial efficiency and, not incidentally, the ultimate in profits from the smallest
possible cost or investment. Entire geographic regions as well as the workers them-
selves became specialized in function and the social distance between producer
and consumer was widened even more. Abuse of the laboring class became so fla-
grant that by 1850 a social reaction began to set in and slowly to swing the pendu-
lum in the opposite direction. Notable in this respect were a number of prominent
persons imbued, for that or for any period, with an unusual spirit of humanitari-
anism. A few among those who might be named were Edwin Chadwick, Robert
Owen, Southwood Smith, John Stuart Mill, and Lord Ashley. These and others
like them did their utmost to bring into the public consciousness an appreciation
of the conditions under which the laboring classes were forced to live and work.

Gradually many social reforms got underway; these reforms dealt with work-
ing conditions, poor welfare, housing of the working classes, the care of orphans
and the insane, education, and sanitary conditions. Scientific and technological
investigations which had formerly been conducted largely from the point of view
of industrial development now began to be pursued for their own sake and for the
benefit of humanity as a whole. Despite these trends, economic welfare was still
insecure. More than ever, workers “earned” a living instead of “making one.” By
this time, the greatest handicap to industrial expansion was the fact that tech-
niques of distribution ol goods lagged far behind techniques of production. The
subsequent solution of this was dependent upon the invention of the steam loco-
motive, the internal combustion engine, and the construction of paved, all-weather
roads.

During this period of social revolution, tremendous gains began to be made
in the field of medicine, particularly in relation to scientific research and educa-
tional standards. There came about a great eagerness for new medical knowledge
which eventually led, among other things, to the conclusive prool of the bacterio-
logical causation of many diseases. Spectacular discoveries followed one another
at a breath-taking pace. One result of this was the foundation of preventive medi-
cine and sanitary science. Medical education became formalized with the estab-
lishment of schools with increasingly higher standards. While the general prac-
titioner was still the prototype, many medical specialties began to appear. The
construction and use of hospitals was expanded and they gradually came to be
looked upon as places for the restoration of health rather than houses of death.
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 039

 

Furthermore, they began to take their place as centers for teaching and research.
Professionally trained nurses and scientific laboratories entered the ranks of
auxiliary facilities upon which both the public and the medical profession gradu-
ally became more and more dependent.

On the economic side of the practice of medicine, some interesting changes
were coming about. The itinerant physician became a thing of the past and groups
of physicians began to band together to form group practices or private clinics.
Medical care was now offered to all components of the population on a competi-
tive fee-for-service basis with a sliding scale as a means of adjustment for varying
abilities to pay. A growth of [ree medical service in hospital wards appeared as one
manifestation of the medical prolession’s acceptance of responsibility for the
public welfare. In this manner, medicine finally came to be regarded as a social
science. Thus, in 1847 Dr. Solomon Neumann of Berlin published his book Public
Health and Property in which he stated that medicine is fundamentally a social
science, and that as long as it does not correspond to this reality, we cannot taste
its fruits and must content ourselves with the rind. A year later Rudolph Vir-
chow declared that physicians were the councilors of the poor, and that, to a great
extent, medicine was the key to the social question.? Perhaps the most outstand-
ing evidences of the influence of the changing social and economic structure on
the form of medical practice were the widening of the breach between the dis-
covery ol medical knowledge and its application, and the ever-rising cost of medi-
cal care resulting [rom the increased capital outlay required for medical educa-
tion and the rendering ol modern medical services by skilled physicians and their
auxiliary assistants.

It is interesting that, despite the remarkable medical discoveries of the late
nineteenth century such as improved diagnostic and therapeutic techniques, the
development of anesthesia, antisepsis and asepsis, and the study of cellular physi-
ology and pathology, to mention but a few, medicine as practiced by average phy-
sicians was still scientifically backward. Until the close of the century, it was still
common to consider illness as fevers, dropsy, inflammations, and the like, and
treatment still consisted for the most part of blood letting and the evacuation of
“ill humours” by physicking, sweating, diuretics, vomiting, and the formation of
blisters. Calomel, the leech, and the lancet were still the important contents of the
physician’s bag. In fact, leeches were used literally by the hundreds of thousands
each year.

Characteristic of the American physician of this period was Dr. Hiram Buhr-
man, who practiced in small towns in Maryland and Pennsylvania in the 1870's.
His regulation fee was twenty-five cents for an office call. This included medicines
unless expensive drugs were necessary. A house visit within the township was fifty
cents without medicine, seventy-five with medicine. The doctor compounded his
own prescriptions. In case of death, there was a three-dollar fee, for which he did
most of the work ofl the present-day mortician. Ail obstetrical cases, regardless of
the length of labor, were five dollars, as were abortions, while miscarriages were
billed at one dollar and a half. A search through his account books showed that
in all but two instances he made only one house visit after delivery and this on
the following day. The fee for setting and caring for a fractured clavicle, includ-
 

040 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

 

ing all material used in the dressing, was five dollars, whereas a fractured thigh
cost ten dollars. Lancing an abscess or a felon was filty cents. Dr. Buhrman also
functioned as a dentist. A tooth extraction cost twenty-five cents, except when
several in a row were removed at the same time in which case the fee per tooth
was reduced. When chloroform was used for extractions the total charge was two
dollars. These were the charges but they were not always collected. When money
was needed, the doctor set out in person as a collector of outstanding accounts.

As did other doctors of his day, to visit his patients he traveled on horseback
with saddlebags or in a gig or buggy and carried a limited supply of fever medi-
cine, sulfur and molasses, obstetric forceps, and a bag of instruments for emergen-
cies. His major expenses, other than those of his home, involved the stabling and
feeding of the horses and the purchase of saddles, horse collars, fly nets, and
halters. In this unspecialized small town practice, conducted with few instruments
and drugs, on a limited number of diseases, the hospital did not enter into the
picture at all.3

As a matter ol fact, as late as the 1890s much of the most advanced practice
was usually carried on in an office which had as its equipment a medicine cabinet,
a sofa or an examining table, and a table which could be used as a laboratory.
The technical equipment consisted of a thermometer, a stethoscope, a prescription
pad, and a sufficient amount of chemicals to determine the presence ol albumin
and sugar in the urine. A few particularly advanced practitioners had microscopes
and still fewer were able to examine a specimen of blood to determine the leuco-
cyte count and the presence or absence ol malarial parasites.

With the beginning of the twentieth century, the practice of medicine began
to mature as a science and as a result became much more effective. The speculative
theories and traditional practices ol the physician of the nineteenth century had
failed to win the confidence of the public and, as a consequence, many medical
cults flourished. With the acceptance and application of the newer scientific
knowledge by the orthodox physician in practice, and as a result of more wide-
spread public education and understanding, the medical profession has since risen
high in the public esteem.

Unlortunately, this has not occurred without accompanying complications.
Improvements in diagnosis and treatment have required at the same time the de-
velopment of highly trained specialists and costly diagnostic and therapeutic tools
with a corresponding increase in the cost of medical care. Robinson* has empha-
sized this by comparing two patients admitted to the same hospital with the same
heart condition, one in 1913, the other twenty-five years later in 1938. The first pa-
tient was cared for by a visiting physician, an intern, and one specialist the path-
ologist-bacteriologist. The completed record covered two and one-half pages. The
second patient was observed and described by three visiting physicians, two resi-
dents, three interns, ten specialists, and fourteen technicians, a total of thirty-two
individuals, and although the record ol the case was still incomplete, it already
covered twenty-nine pages. He concluded that the more recent case, in its sharp
contrast with medicine of the past, presents one of the major social problems
facing contemporary medical practice.
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 041

Economic Factors Influencing the Need for Medical Care. Pertinent to the
ability to obtain medical care are a number of related economic factors concerned
with the distribution of wealth and its effect on the need for medical care and
the distribution ol medical facilities. It is obvious that the economic level of a
community plays a significant role in determining the degree of its health and
illness and in the extensiveness of its facilities to care for them. Since wealth is
nowhere distributed equitably, it naturally follows that the state of health of a
community or of a nation cannot be uniform. In a very literal sense, health and
the treatment of illness are purchasable, but the ability to purchase them is not
always present. The use of average figures to depict the purchasing power of a
community of people tends to be greatly misleading.

Table 47. Distribution of Families by Total Money Income,
United States, 1957*

 

 

 

 

 

Total Money Income Thousands of Families Percentage
Under $500 1,300 3.0
$500 to $999 1,600 3.4
$1,000 to $1,999 3,900 8.5
$2,000 to $2,999 4,400 9.6
$3,000 to $3,999 5,400 11.8
$4,000 to $4,999 6,400 14.1
$5,000 to $5,999 6,000 14.5
$6,000 to $6,999 4,200 10.3
$7,000 to $9,999 6,700 16.3
$10,000 to $14,999 2,600 6.5
$15,000 to $24,999 600 1.4
$25,000 and over 300 0.6

Total 43,400 100.0

 

 

 

*Adapted from Current Population Reports, Series P-60, No. 29, June 1958, Consumer
Income, Bureau of the Census, U. S. Department of Commerce.

Thus, while the mean family income in the United States is high, about
$5,000 in 1957, there is considerable variation by region, degree of urbanization,
and other factors. For example, while the mean family income for urban and rural
nonfarm families in 1957 was $5,232, for rural farm families it was only $2,490.
Table 47 presents the distribution of families by total money income, before
taxes, in 1957 in the United States. It indicates, for example, a variation of from
3 per cent of families with annual incomes less than $500 to 2 per cent of families
with annual incomes over $15,000. The lower quartile of families had annual in-
comes up to $2,999; the second quartile, from $3,000 to $4,999; the third quartile,
from $5,000 to $6,999; and the fourth quartile, over $7,000.

The inequity of the distribution of purchasing power is magnified still further
when the nation is considered in terms of its constituent parts. The relative eco-
042 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

Table 48. Purchasing Power and Medical and Dental Resources by Region,
United States, 1955-1957 *

 

 

 

Buying In- Population | Population | Population
Region Population comet Per Per Physi- | Per Dentist, | Per Hospital

(Estimated 1957) Capita, 1956 cian, 1955 1957 Bed,} 1955
Far West 18,483,000 $1,973 679 1518 352
New England 9,900,000 $1,866 0625 1490 330
Middle East 39,123,000 $1,853 627 1434 300
Central 44,317,000 $1,812 840 1731 312
North West 8,858,000 $1,513 800 1849 204
South West 13,373,000 $1,493 1036 2935 318
South East 34,753,000 $1,229 1066 2988 360
U. S. total 168,807,000 $1,681 728 1679 325

 

 

 

 

 

*Information taken from Perrott and Pennel,® Distribution of Dentists in U. S.,7 and Abbe. ®
tAfter taxes.
fAcceptable general hospital beds.

nomic standing of the various geographic regions of the nation varies from the
well-known disadvantageous position occupied by the Southeastern states to the
economically affluent New England and Pacific states. These economic inequities
have a marked effect on the distribution of personnel and facilities for the treat-
ment of illness. Table 48 presents the extent of medical, dental, and hospital
resources in the various regions of the United States. A direct relationship is
readily seen to exist between them and the purchasing powers ol the respective
regions. The New England states, with a per capita buying income in 1956 of
$1,866 have one physician for every six hundred seventy-nine inhabitants in con-
trast with the Southeastern states whose per capita buying income of only $1,229
attracts and supports only one physician for every 1,066 inhabitants. If the ages
and qualifications of the physicians were considered, these discrepancies would be-
come even more marked. Similarly, the more affluent New England states have
about twice the number ol dentists in relation to population as do the states of
the Southeastern region. With regard to the number ol acceptable general hospital
beds available, the same general picture holds true. However, a significant equal-
ization has been occurring in this regard during the past decade as a result of the
National Hospital Survey and Construction Act (Hill-Burton Act, of 1946).*
Another factor which accentuates both the need for medical and hospital care
and the disparities which exist among regional resources is the proportion of
older persons in the population. Persons 65 years of age and over require more
medical attention and hospitalization than any other age component of society.
For example, this age group uses about seven days of hospital care per capita per

 

*For a detailed review of accomplishments see The Nation's Health Facilities by Abbe and
Baney.*
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 043

year as compared with less than three days per capita for all other age groups.
Furthermore, this is a period of decreased or absent earning power, hence much
less ability to afford the needed care. Regionally, this works especially to the dis-
advantage of the New England, the Central, and the Northwestern states.

The unequal distribution of medical personnel and facilities would not be of
such serious consequence il the socioeconomic [actors causing it did not also have
an adverse influence upon the need for them. Numerous studies have shown that
the total illness experience ol a population follows a more or less definite pattern.
Although the average American suffers an injury or an illness about two and one-
half times a year, there obviously are some who go through the year unscathed
while others far exceed the average expectation. Accordingly, in any average cur-
rent year, out of each million American people 470,000 will suffer no serious ill-
ness, 520,000 will have one illness during the year, 140,000 will have two illnesses,
50,000 will have three illnesses, and 20,000 will have four or more illnesses.

For the general population is is possible to know in advance not only the
total amount of illness, but also the type. Numerous studies have been carried
out for this purpose during recent years. Among them, those ol Collins and his
co-workers!%:11 are particularly instructive. Some of the results of their analyses
ol five illnesses and household surveys in the United States are presented in
Figures 39 and 40. The charts in Figure 39 show annual days of disability, days in
bed, and days in a hospital by age and sex for the twelve predominant diagnoses.
The charts in Figure 40 show the incidence by age and sex of the most frequent
causes of surgery.

The over-all pattern of illness in the general population is predictable,
whereas the forthcoming experience of the individual cannot be foretold. How-
ever, it is known that the lower the individual is on the economic scale, the more
certain he is to experience one or more serious illnesses during any year. This is
not surprising since purchasing power determines the amount and quality ol
food consumed, the degree of exposure to or protection from the elements of
nature, and the ability to obtain many medical as well as other types of services.

Expenditures for Medical Care. The combined effect of the unpredictability
of illness in the individual and the influence ol economic factors on the probabil-

Table 19. Distribution of Medical Costs by Economic Group

 

Total Annual Charges Per Family Per Cent of Families Per Cent of Total Charges
Less than $60 58 18
$60-$250 32 41
$250 or more 10 41
a — -— _ EE
Total 100 100

*Adapted from Falk, I. S., Klem, Margaret C., and Sinai, Nathan: The Incidence of Illness
and the Receipt and Costs of Medical Care Among Representative Families, Chicago, 1933,
CCMC, Publ. No. 26, University of Chicago Press.
644

PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

ANNUAL DAYS OF DISABILITY
INFANCY 8 PRESCHOOL (Under Syears)(11,203) azar

   

 

   
  
 
  
  
   

ANNUAL DAYS IN BED
INFANCY 8 PRESCHOOL (Under Syears) (3138) 3/8/

 

 

 

 

     
  

 

 
 

 

73 -

ANNUAL DAYS IN A HOSPITAL
INFANCY 8 PRESCHOOL (Under S years) (646) 689
200

50 190 5

male0 0 _ Fon 290__
Congenital malformations 8 dis. of early |
94 infancy

all
| —— moni
47 A — 10,5 general dis |
20 Ne— 1 510101 olle1y
|
|

 

  

= “53 Tuberculosis (all forms) 44(86|
 — a mastoid diseases

58 xx Other digestive diseases

60 Mwy All accidents

67 hans Mental 8 neurological dis

22
27
23x Kidney a urinary diseases

Tonsillectomy

Skin diseases |

J
SCHOOL (5-14 years) (650) 1770
200.

og
ey Rr LA 1]
A A

6a C Infectious general diseases

90 ee Appendicitis

53 1 Tonsillectomy

16 Mrmr Other resp. 8 allergy

92 RARITY Other noninfectious gen. dis

36 NEE Al | occidents

16 Dis. of organs of locomotion
12 Influenza & pneumonia (all forms)
230 Eor 8 mastoid diseases

 

190 150
Meniol a neurological dis

 

 

[14
2293

YOUTH (15-24 years) (655) 2/89
75. 1Q0_15_ 130 175 200
Mental & neurological dis

 

   
 
     

Tuberculosis (ali forms) *
CITRIX YAppendicilis
|
|
|

2 | A — || oc cidents
 —\.c (10 of abdominal Cavity
~ —ceumotic fever

oe Infectious general diseases

34{SXxxw Other noninfectious general dis.

24 xy Kidney 8 urinary diseases

15 Tonsillectomy

15M All benign tumors

16 Influenza & pneumonia (all forms)

40 SXSXSXN Female genital a breast dis

486 NY ILLITE ITI
DeTveries, ShoronS B CoMPRCNIonS

 

aan, Vale A 0500 1000 1500 2000 2500 I a. Mole Fe eo 200400 600 oo sex
r \
1a81 1225 fh ys cough 384 413 354 Measles Lee
1288 1191 1387 Bronchitis fren 460 274 Pneumonio (all forms) | 94
1238 36 2060 ha QikWIELEl & nevrologicdl dis [srr soo zeal ronnie os
sia 974 853 Measles 259 202 297 x Influenza oe
615 597 634 Coryza a cold [169 161 178 Coryza a cold ©
538 524 594 Influenzo [185 191 nie Diorrhea 8 enteritis a2
523 638 405 None monio (oll forms) 130 216 43 Congenital malform dis of early inf. | a
454534 434 ERE Chchenson I 129 103 Tons | 5
464 506 330 NRE Aj occidents li07 6 154 Otitis media | 3s
375 a3 32 Tonsillitis | 106 102 109 Scarlet fever 25
366 341 293 Sore throot | so 70 13 Sore throat 18
358 449 264 Diarrhea 8 enteritis 90 77 104 All accidents "
HE — EE _-
SCHOOL (5-14years) (10634) //752 -14 years) (3339) 4457
0.500 10001500 2000 2300 3000 Yr 600 801000
1080 1707 409 m——II 17362983 278 5:0 8 > 9341698 | 117
as m7 996 Rheumatic fever 1263433(373 405 243 TIED 31107 se
846 714 907 N Lu Whooping cough 291 265 319
723 677 772 — Bronchitis 272 2m 273K e | 6
577 726 417 NSE 1 occidents 228 228 227 IEEE Bronchilis 57
570 585 554 Meosles 161 146 177 NUE, Scarle! fever | s3
569 503 640 x Influenza 147 174 17 All accidents | 1s
480 895 34 Cerebral hemorrhage, embolism, 120 122 121 Tonsillitis | aa
447 387 511 NER, Chickenpox 107 130 61 ME preumonia (all forms) 31
350 316 388 ME, Sore Ihroot 106 84 130 WE Coryza & cold 24
336 291 384 MER Scorler fever 103 44 166 Mey Appendicitis 20
YOUTH (15-24 years) (5496) 7028 YOUTH (I5-24years) (1957) 3489
250 500 750 1000 1280 1500 1750 Q _.1Q0 200 300  4Q0 50 _ 60
Other mental & neurological dis | Other mental & neurological diss,
653 379 930 REE odd) 20 24 33 (8 3 al
136 83 193 772( 433) EE =6964% °
539 780 295 KRY ms 162 225 Influenza | 93
377 334 420 [ARERR Influenza im 147 199 Rheumatic fever a8
321 353 289 150 49 226 Appendicitis 26
273 243 304 NER 87 130 43 J— | accidents —— 22
142 128 156 My Coryza & cold 47 31 62x Sore throat ole
NSremale
11 55 168 Mg Psychoneuross 40 32 40M; Coryza a cold CZER institutional 16
10 81 139 | 37 37 38RTonsillitis - 5
103 101 106 XY Diseases of the heart 36 27 ASP Pneumonialall forms) 15
89 78 101 M& Tonsillitis 34 29 40M Tonsillectomy 3
103 208 Female genital a ue dis | 59  - Tok “SXXX Female genital 8 breast dis. 20
me - 156 CULTLEINNTD 489 - 983 AF Easy 241
varies, Shomer: 8 compl conan: Deliveries, abortions & complications |
———— a PE SAE J
A.
Fig. 39, A and B. The twelve di

in cach of six age groups for days of

three household surveys with visits

full-time person-years of observation for white persons.

agnoses with the highest annual rates per 1,000 population

disability, days confined to bed, and days of hospital care—

at intervals of 1 to

3 months, covering a total of 37,988
(From Collins,

S. D., Lehmann, J. L.,

and Trantham, K. S.: Major Causes of Illness of Various Severities and Major Causes of Death
in Six Age Periods of Life, Washington, 1955, Public Health Service Publ. No. 440.)

ity ol illness and the distribution of medical facilities, therefore, causes a rela-
tively small proportion ol the population to bear the major share of the economic
burden due to illness at any given time. Furthermore, it is found that this un-
fortunate fraction of the population includes an unduly disproportionate number
ol those who are least able, because of their incomes, to meet the costs of ade-
quate care. This was brought out in the studies of the Committee on the Costs
of Medical Care between 1927 and 1932.12 It was [ound that among the 8,581 fam-
ilies studied by the Committee, 41 per cent of the total medical charges were
borne by only 10 per cent of the families, whereas 58 per cent of the families had
to meet only 18 per cent of the total charges. (Table 49.)
When the factors of low income and increased tendency to become ill are
considered together, it is found that the lower income groups not only have more
[requent medical bills, but they also must spend proportionately more of their
income for this purpose than the higher income groups; this is true despite their
Both Male
Sexes

409 439
840 1145
395 579
584 427
306 227
305 112
302 383
301 343
147 191
198 -
191 98
174 244

222
746

1003 1254
1666 1922
1618 2474
949 885
705 480
581 433
561 961
513 547
491 66
311 200
437 377
382 740

176 =

8818 8653
3838 3194
2444 2501
2070 1259
1699 1681
1592 1667
1498 479
1320 2772
1256 1341
855 146
853 662
816 618

ADULT (25-44years) (7524) 8808

PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND

ADULT (25-44 years) (2501) 3785

 

  

 

   
 
    
  
  
  
     
 

MEDICAL CARE

045

ADULT (25-44 years) (946) 2233

    

 

 

 

 

 

 

 

   
 
 
   
 

   

   
   
  
 

   
 

 

    
 
      

 

Fe- Both M - Both Male Fe-
maleQ 500 1000 1500 2000 Oth Male Feo o 200 a0 600 800 Sexes mole ©. 50100150 200 280 390
Other mental & newological dis neurological _dis.~ 0 ol
300 CREE 1333 (8% 03 6 198 231027 (138 120 42 196 A nor Ric]
3 P
53 ACRE Al csrtents 6 16 iene TS] a no Nm— FD un
215 R— Tuberculosis all forms) 693( 383/268 191 343] XN Influenza 79 129 20 NRWENNMSERION  enls |
739 NEE xy Influenza 165 192 138 All accidents | 62 53 70 NOES Appendicitis |
384 [121 92 150 Bronchitis 49 2 96 hess All benign tumors |
494 Booey Rheumatic fever | 37 46 32 57 Psychoneurosis 102.4 195] 30 71 Mem—enio of abdominal cavity |
222 KX Other dis. of organs of locomotion 89 45 132 Rheumatic fever 31 47 | NESE (hoc circulatory diseases |
260 [RECI™ Diseases of the heart 86 54 118 Appendicitis 28 50 7 |. |(e tious general diseases
103 NG 210{ 28 mm 1a Roe Bemgn tumors of female genital organs | 22 21 24M Other digestive diseases
393 Key Benign tumors of female genital organ: 64 76 52 Pneumonia (all forms) 22 12 31 gq Kidney a urinary diseases
284 Ry 58 47 68 Diseases of the heart | 20 18 22M Influenza & pneumonia (all forms) |
105 R= Acihritis & chronic rheumatism | 5a 36 72 Tonsillitis | 19 a2 ceils Thyroid diseases |
440 SSX Female genital 8 breast dis 79 - 157 Female genital breast dis | 37 = 73kesssxxw Female genital 8 breast dis |
148) KESSSNNNNNNNNY are - 227
Deliveries, abortions & complications Deliveries, abortions & complications. | Deliveries, abortions & complications |
: 3 \ ! Pilati hala tale lh Sadi har EE Paalhan: iL
MIDDLE AGE (45-64years)(13963) 15395 MIDDLE AGE (45-64 years) (2943) 4375 MIDDLE AGE (45-64 years) (850) 2282
200 400 600 800. 1000 0 50. 100 150 200 _ 250
2 min 7 ? = ? PF
|
757 05( 385 aa 59 20 1337 {1332
1415 35{ M9 25 a7 a pos
183. _
779 Diseases of the heart 265482] 9 180 yperiension & arteriosclerosis
1013 2) Tuberculosis (all forms) 258( 333 ss 70 10 ARR Ix Diseases of Ihe heart 93,8
925 Diabetes mellitus 06 EER; All accidents 77 96 55 REEERAEEN—— ||| occ dents |
te |246 168 on —— Influenza 69 57 5) EEE xy Malignant neoplasm |
169 enon 8 arteriosclerosis |215 141 2880 sayy Malignant neoplasm 58 50 6; EEE Diobetes mellitus |
{
Bronchitis 148 142 154 Bronchitis a6 15 76M wks Cholecystitis 8 calculus |
908 oxy Nephritis (all forms) 145 201 90 Hypertension 8 arteriosclerosis 39 44 30 gney a urinary diseases a0{ 47]
28 N yi A {34
420 Tuberculosis (all forms) aao{ 428 109 28 188 Bae Cholecystilis a calculus 37 6 eofaaeexssw All benign tumors |
“ Malignant neoplasm | 99 43 154 My Arthritis & chronic theumalism | 36 62 i N—G of obdominal cavity
Ulcer of stomach & duodenum | 95 57 133 MB sy Diabetes mellitus | 28 51 oo NEC) Gus general diseases
|
Female fs remae genial a ure a breast dis | 60 =~ 119KSXXN Female genital 8 breast dis 30 59 AXSNSNNY Female genital abre east di |
[Frome gent abrens a ee ae a a ——
OLD AGE (650nd over) (32,506) 3309/ OLD AGE (65 and over) (7477) 8062 OLD AGE (65 and over) (844) /430
0 2000 4000 6000 ___ 8000 10,000 0 500 1000 1500 ___2000 0 50 100 150 200 250 _
0__ 6000 8 50 00_ 1 On 0 5 9
Disegses of the heort Aero] 1 Diseases of the heart .
8961 RECTEERRR RY siege | 167 1375 1931 rm 1997 (33131 205 279 14 Tees 3 weigh
4394 | CRREEEEE Arthritis & chronic rheumatism 925 1359 545 NCR —. forms) oas{1353] 23 6 X $n 160{ {248
2397 REE Nephi tis (all forms) 2569(28 } Bas 673 994 RECEEEExxxy Malignant neoplasm [156 175 140 KR —— neoplasm
2170 (SxS Hypertension & arleriosclerosis 666 650 546 RREEERgm— Cerebral hemorihoge, Lobolism 1 go 11a 5) RCCRE— [| cients
1715 [EE Cerebral hemorrhage, embolism @ thrombosis | 495 24 902 kxsxwsssssxy Arthritis 8 chronic rheumatism 59 14 98 ME sas Diabetes mellitus
1527 ERE Malignant neoplasm 407 180 604 ME (xxx Hypertension 8 arteriosclerosis 45 20 66M xy All eye diseases
2379 Bxcxxy Other dis. of organs of locomotion 345 344 345 CCEA All accidents 44 81 | ESSSMMEINNN || cnzq a pneumonia (all forms)
66 Tuberculosis (all forms) 308 188 412 By Prevmonia (all forms) [gua 40 ~  75NESNSSNSNDis. of organs of locomation |
ez All accidents 27 177 352 Wy Influenza XN Female | 40 67 15 Ne— ena of abdominal Covily
i Institutional | a
1468 Diabetes mellitus 241 297 217 Em Bronchitis EEE Institut w ns Other circulatory dis.
1001 Bronchitis 165 32 279 kop Newrilis a neuralgia | Hypertension & arteriosclerosis
Cee ee (
390,
oc Ru nfvenco 2 1 2kzzm Other mental 8 neurological dis. 129 (p54 [eo els <All verign tumors
L L 1 L 1 1 1 L L :

 

Fig. 39 (cont'd). See opposite page for legend.

B.

greater tendency toward self-treatment or even total lack ol care. Thus, a study
by the National Resources Planning Board! brought out the fact that families

with incomes under $500 per year spend

7.1 per cent ol their small income lor

medical care, in contrast with 3.6 per cent spent [or that purpose by those in the
$5,000 to $10,000 annual income group (Table 50).
Considering the total picture for the moment, attention may be called to the
fact that the nation loses an estimated 10 billion dollars each year because of ill-
ness. This is made up of about 3.7 billion dollars spent [or medical care, about a
half billion dollars as the value placed upon the seven working days per year lost
by the average wage earner due to illness, and a capital evaluation of about 6
billion dollars placed upon the lives that are lost due to causes which in the light
ol present medical science may be considered preventable (see Chapter 4).
These seem like large sums, especially when the relatively small amounts of
money that would be required to avoid or at least reduce them is considered.
The amount necessary for adequate preventive care and the early diagnosis
and treatment of disease becomes almost insignificant when compared with the
040 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

  
  
  
  
   
  
 

oo SURGICAL CASES PER 1,000 POPULATION SURGICAL CASES PER 1,000 POPULATION
th Hos- -Non- Both Hos Non- !
Sexes pital hosp. INFANCY 8 PRESCHOOL (Under 5 years) (75.7) Sexes pital hosp. ADULT (25-44 years) (65.5)
0 5 10. 1» 20 2p | 15 20
7 i

   
 
  
  

 

 

    

 

 
 

 
  

      
    
  
    

  
 
  
  
       

1854 4.69 [2 519 12.03 :
2401 g70 67 Tonsillectomy 1271 Vey ge3 Accidents, except poisoning |
298 12.57 . S——
330 330 'Selk Accidents, except poisoning arr G3 182 pAEAIA Tonsillectomy
1060 as Ear 8 mastoid dis cas 407 © Appendicitis
221 2) Boils 8 skin abscesses p51 43 2.08 Benign tumors, exc. fem. genital
: : ,
21 1.4 50
ea Ze I33ES Lymphatic diseases A oan Boils & skin abscesses
1-28 130 781
1.84 g 10a 80 Kx | Sinusitis a nosal dis
76 oe ] sa 260 WAZ, 1ecnio, abdominal
i | 6 A
6 97 | 3 so L386 43 PZA Hemorrhoids
: RRRRRE reno 2 uf
54 22 ‘ J 13358 a0 man Other abdominal dis.
as 53 ar 2 33 Pedtonsillor abscess
: Female genital & breast dis.
15.58 2 Z1 a benign tumors
1199 2.16 SNNNNIIRINNINIRRNINN Deliveries, abortions, 8 compl.
1 1 LL 1 —
MIDDLE AGE (45-64 years) (44.3)
2 a 6 8 10 iz 14 ~
| i239 2.65 1031
3905 3 | 2.52
, 147
19.08 ccidents, 274 oer
ot poisoning ose 8
4.87 J) Cr wa ral
aa
175 2.63 213 J
453 133 293 Ear 8 mastoid dis 5.93 |
Bal 1.31 Bd 2.05 La7 |
er bh "ES Boils a skin abscess it
55 1 2.05 162 Malignant neoplasm
“72 "Se 22 Dis. of bones, joints, a locomotion 1.89 a
2.21 -
a4 55 1.98 — Other abdominal dis.
72 4s 2 g Sinusitis & nasal dis 1.73
Lo = . 1.82 _
66 5p Hernia, abdominal
Ba 66 1.82 39
so L133 Lymphatic diseases fe
| 1.60 2:06
se 42 ih Congenital malformations | 79 os
| 7.55 og Female genital 8 breast dis
| | | 8 benign tumors
1 1 1 1 { |
YOUTH (15-24 years) (58.7) OLD AGE (65and over) (43.4)
5 18 . ¢ ay 8 0 dz 14 1618
355 1335 ccidents, except ye 467 wore
11.44 TE ale Porkoning 1836 636 15.7
7.94 26 233
11:28 979 2.57 —— Tonsillectomy 426 Cg
456 - VZIZ 17
955 1429 CCIE SOOOOO000 Appendicitis 3.46 yo
asa 239 3
1.01 86 3:50
198 101 1.86 359
1.56 2 133 17
2.20 5 1.75
132 228 106 Tag
wroo= . .
91 oe roe ht CZ Cholecystitis & biliary calculus
a7 A ~ = 18)
58 3 106 | 1. ae Tonsillectomy |
- . BN 7 58 JS \oids
58 ae b Teeth 8 gum surgery 80 It 3 Hemorrhoids
449 BO ®CIFemale genital & breas! dis. 8 benign tumors | 642  — LZLZZZLLZZ Prostate diseases
1333 1.618 y=) Deliveries, abortions, & compli. | 245 - Ba Female genital breast dis. & benign tumors
| i! 1 i 1 1 1 1 1 Lo

1 Lh

Fig. 40. The ten most frequent causes of surgery per 1,000 males and females of five broad
age groups, and the ten diagnoses with the highest percentage of cases in the same age groups
that were treated surgically—white families canvassed periodically in five illness surveys covering
80,768 person-years of observation. (From Collins, S. D., Lehmann, J. L., and Trantham, K. S.
Surgical Experience in Selected Areas of United States, Washington, 1956, Public Health Service
Publ. No. 473.)

sums expended by the nation for other purposes. The nation finds it possible to
spend enormous amounts in time of war for the destruction of life. World War
II necessitated an average daily expenditure by America of 150 million dollars;
the total bill for the conduct of the war was slightly less than 300 billion dollars.
It is a commentary on our civilization that such expenditures are so willingly
made at the same time that appropriations to provide inexpensive immunizations
of children or examinations for cancer or heart disease are so often resisted.
Beyond the costs of waging war, expenditures for more routine needs and ac-
tivities offer an interesting contrast to the amount expended for medical pur-
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 047

 

Table 50. Average Annual Expenditures of American Families
for Medical Care*

| All Medical Per Cent of
Income Groups | Physician Dentist Other Care Income
Under $500 $9 $2 $1 | $22 7.1
$1,000-$1,250 16 6 25 47 4.2
$2,000-$2, 500 26 16 49 | 91 41
$3,000-$4,000 35 24 73 | 132 3.9
$4,000-$5,000 | 40 33 85 158 3.6
$5,000-$10,000 59 50 139 258 3.6
$10,000+ 77 106 284 467 2.1

All income levels 19 10 35 | 64 4.0

 

 

*National Resources Planning Board, Family Expenditures in the U. S., Washington, 1941.

Table 51. Personal Consumption Expenditures, United States, 1956*

Amount

$70,110,000, 000
36,113,000,000
32,841,000, 000

| 30,314,000, 000
27,017,000,000

Food and beverages (nonalcoholic)
Household operation

Housing

Transportation

Clothing, accessories, and jewelry

Personal business

Recreation

Medical, dental and hospital care
Alcoholic beverages

13,968,000,000
13,844,000,000
13,405,000,000
10,426,000, 000

Tobacco products and accessories

Religious and welfare activities

Personal care (non-medical)
Private education and research |

| 5,831,000,000

3,746,000,000
3,581,000,000
3,565,000,000

Foreign travel and remittances 2,399,000,000

*Adapted from Statistical Abstract of the United States, Washington, 1958, U. S. Depart-
ment of Commerce, Bureau of the Census.

poses. Table 51 presents a breakdown of savings and expenditures of the American
public during a recent year. It will be observed that the amount spent for recrea-
tion is greater than the amount devoted to all aspects of medical care and that
the latter sum is only twice the amount spent [or tobacco.!*

It should be noted that the relative expenditure for medical care has been
rising. Thus, in terms of percentage of all personal consumption expenditures, it
has increased from 3.7 per cent in 1929 to 5.3 per cent in 1957. However, as will
be seen, most ol this increase can be accounted for by the rising costs of
hospitalization.
648 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

How is the medical dollar spent? Figure 41 presents the proportionate
breakdown of medically related expenditures for the two years 1929 and 1957.1
While in absolute terms, the amount of money spent for all of the items has in-
creased, very significant shifts have occurred among them in relation to each
other. By far the most striking change has been in connection with the cost ol
institutionalization. While the proportions of the medical dollar devoted to pay-
ment of physicians and dentists have both decreased almost 50 per cent during
the past three decades, the proportionate amount expended for hospitalization
has almost doubled. This is especially evident il the proportions for insurance,
most of which represent hospitalization insurance, are added to the amounts
designated for hospitals. In fact, when this is done the proportionate expendi-
tures for hospitals and insurance combined show an increase from about one sixth
of the total medical dollar in 1929 to about one third ol the total medical dollar
in 1957. Also of interest is the fact that while a large number of complex and

Other Other
Professional Services Professional Services

 
 
   
 

  
    

Dentists

N.3¢ Physicians

24.5¢

   

Dentists Physicians
16.4c 32.6¢

 
 
    

Drugs
20.6¢

Hospitals
25.8¢

7

1957

Fig. 41. Composition of the medical care dollar in the United States, 1929 and 1957. (From
A.M.A. News, Jan. 12, 1959.)

   

  
  

    
  

  

Ophthalmic
and Orthopedic

  

Ophthalmic and Insurance |
Orthopedic 1929 nsurance

valuable new drugs and medicines have been developed and put to use during
this period, the proportionate expenditure for them has remained the same. In
fact, in relation to percentage of disposable personal income, expenditures for
medical drugs and sundries have actually declined from 0.87 per cent in 1939 to
0.66 per cent in 1956.16 Several other points are of interest in relation to certain
items not included in the figures. Expenditures for nursing are about one filth
of the amount paid to private physicians. Also, the estimated amount paid to
cultists is about equal to the per capita sum expended for public health work.

Attempts to Solve the Problem. By the end of the eighteenth century, il in-
deed not sooner, problems ol health and disease were recognized as subjects ol
social and political concern. In fact by that time it was beginning to be realized
that these problems were associated with and part of a social problem of much
greater magnitude, i.e., the emerging struggle for the expression of the rights of
the common man. This struggle was destined to become a main theme of political
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 049

 

appeal, and the health of the masses, particularly of the working classes, became
one ol the major talking points not only ol such humanitarians as Chadwick,
Southwood Smith, Shattuck, and others like them but also of the spokesmen for
the new political ideologies exemplified by Ingels and Marx. Thus, the stage of
recognition and orientation of the problem was reached. What to do about it,
how to solve it, was yet another problem, the solution of which was not to be forth-
coming for at least another century and a half if not longer.

In order to consider, as we certainly must, the preliminary attemps to find
an answer, it is necessary to retrace our steps to some extent. It has been seen that
the eighteenth and nineteenth centuries were characterized by a shift from a rural-
agrarian society to an urban-industralized society, a growing insecurity of personal
income, a great increase in the low-income population, a considerably increased
risk of sickness due to the social and economic changes, and constantly rising costs
of medical care. Rosen!™1% in his brief but concise discusion of the early attempts
to solve the problem, rightly highlights the propositions of three outstanding
social thinkers of the times: Defoe and Bellers in England and de Chamousset in
France. With the development ol statistical methodology and the increasing ac-
cumulation and analysis ol vital data, it became possible, at least in a crude way,
to calculate certain types of risks. Marine and fire insurance were fairly well es-
tablished and used. Life insurance companies were in the process of acceptance. It
is not too surprising, therefore, that even at a relatively early date some thought
was given to the possibility of applying this valuable social technique to the risks
ol illness. Daniel Defoe was apparently the first to make the suggestion, in 1697.
In an essay he proposed that the insurance principle be applied to the social
problems of the poor, including medical and institutional care and disability
pensions. Shortly afterward, in 1714, John Bellers suggested a rather detailed plan
for a national health service in England. He believed that the program should be
sponsored by government since “it is too great a burden to be left upon the
shoulders, or to the care of the physicians alone, no private purse being able to
bear the needful charges ol it. Especially considering the necessity of many and
the indifferency of others of that faculty, further than to procure a plentiful
substance for themselves: And how much it concerns every other person, there
is more reason to expect, the State should bear a good part of the expense of
it.”* He therefore proposed the establishment of governmental hospitals for
teaching and research, a national health institute, and a plan to provide medical
care to the sick poor. Going even further in his social thinking, de Chamousset in
1754 proposed a plan ol hospital insurance with a broader population base. Here
[or perhaps the first time is encountered a concern for others than the traditionally
dependent poor, i.e., a concern for the bulk of the population comprising the so-
called self-respecting middle class. He argued:

There are asylums available to the destitute, and that is a resource useful to those to
whom it is not humilitating to accept the free assistance which charity offers. (But there
is) the class of the greatest number of citizens, who not being rich enough to provide

sufficient aid at home or poor enough to be taken to an almshouse, languish and often

*Bellers, John, quoted by Rosen, George: In Galdston, Iago (editor): Social Medicine, New
York, 1949, Commonwealth Fund, p. 17.
050 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

perish miserably, victims of the propriety to which they are subjected by their class of
society. Such are the industrious artisans, merchants whose trade is limited, and in gen-
eral all those valuable men who live daily by the fruits of their labor, and who often
for that reason have no recourse to treatment when a disease becomes incurable. The
start of a disease exhausts all their resources; the more they deserve help, the less can
they bring themselves to profit by the only resources that remain to them, and to find
themselves in public asylums.*

Unfortunately little came of these suggestions. Eventually with no action
forthcoming from other directions, workers themselves in some parts ol England
and a few other countries began to inaugurate schemes at their own expense [or
protecting themselves against the risks of illness and injury. Trade benefit associa-
tions and societies were formed to contract with physicians and surgeons for the
care of the members ol the group, and each worker was assessed a fixed sum lor
annual dues or fees. How similar this is to recent events in this country. By the
beginning of the nineteenth century there had been formed in England nearly
10,000 societies of this type with a total membership of close to a million workers.
So common, in fact, had these plans become, that in 1773 and later in 1789 bills
were introduced in Parliament to provide sickness and old-age benefits for the
laboring poor. In both instances the bills were approved by the Commons but
rejected by the House of Lords. During the same period, there was much discus-
sion in England concerning the possibility ol requiring by law that all workers
join privately operated benefit societies, and suggestions were even made that the
government should bear part of the cost. Interestingly, such ideas and proposals
were vigorously opposed with many arguments similar to those heard much more
recently. Note the similarity between this idea and the third of the twelve points
of the program suggested by the American Medical Association in early 1949.1
It proposed that there be “further development and wider coverage by voluntary
hospital and medical care plans to meet the costs of illness, with extension as
rapidly as possible into rural areas. Aid through the states to the indigent and
medically indigent by the utilization of voluntary hospital and medical care
plans with local administration and local determination of needs.”

Meanwhile the medical fraternity was not entirely inactive. Many steps were
being taken to clean house by the development of standards, professional
licensure, and the improvement of medical education. Public health measures, in
the then ordinary but now narrow sense of state administration, of quarantine
and public sanitation were generally supported by the medical profession. Opposi-
tion to public provisions for vaccination, however, was not unknown. Support was
given to the extension of charity relief and medical care to the indigent. Beyond
this, except for rare instances, little was attempted by the medical profession to
solve the broader aspects of the medical care problem. Occasional private physi-
cians engaged in a certain amount of contract practice, whereby, for a fixed pre-
paid sum, they provided care to an individual or a family for a year or some other
agreed-upon period of time. Even this practice, however, was officially frowned
upon, as it still was in the United States only a dozen years ago.

The most significant attempt to solve the problem of providing adequate
medical care for a large population was made in Germany during the second

 

*de Chamousset, quoted by Rosen, George: In Galdston, Tago (editor): Social Medicine, New
York, 1949, Commonwealth Fund, p. 18.
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 051

 

hall of the nineteenth century. It took the form of a nationally sponsored and
administered plan for compulsory, comprehensive social insurance. Although
since frequently pointed to as an autocratic scheme to control the lives and be-
havior of a people and of the medical profession, it is interesting that the plan
was not instituted and enforced merely by Bismarck’s will. In all, the plan was the
subject of nine years of argument, debate, and struggle in the Reichstag and
when finally adopted represented a considerable compromise. It is also not with-
out interest that it met with relatively little opposition from German practitioners
ol medicine. The plan provided flor sickness, accident, and old-age benefits, sup-
ported by contributions from employees, employers, and the state. Despite its
past and present critics, so satisfactory was it to those involved that it was re-
tained long alter the downfall of the Bismarckian regime. In fact, when Germany
was defeated in 1918 and Alsace-Lorraine was returned to France, its population
insisted that the German social insurance system be continued for them. Eventu-
ally in 1928 a similar nationwide plan was instituted for the rest of the French
Republic.

Table 52. Dates of Enactment of Compulsory Health Insurance

 

 

1883 Germany 1922 Latvia

1888 Austria 1922 Japan

1891 Hungary 1922 Greece

1901 Luxemburg 1924 Chile

1909 Norway 1925 Netherlands
1911 Great Britain 1925 Italy

1911 Eire 1925 Lithuania
1911 Switzerland 1928 France

1912 Rumania 1933 Denmark
1917 Estonia 1936 Peru

1918 Bulgaria 1938 New Zealand
1919 Czechoslovakia 1940 Holland
1919 Portugal 1941 Costa Rica
1920 Poland 1943 Mexico
1922 U.S. SR. 1945 Brazil

1922 Yugoslavia 1948 England

 

 

Meanwhile, recognition of the problem and attempts to solve it spread not
merely throughout the European continent but beyond to some of the newer parts
ol the civilized world. One country after another adopted some [orm of compul-
sory health insurance, and at the present time practically every major nation has
some plan in operation. No two plans are identical, every major aspect of them
showing some variation, whether in comprehensiveness of service, population
served, type of administration and payment, or source of funds. Table 52 pre-
sents a listing of the years in which major compulsory health insurance plans
were enacted.

The National Health Service, which was initiated in England in 1948, has at-
tracted much world-wide attention. This plan, adopted by the government over
the strong opposition of the medical prolession, now claims 97 per cent enroll-
ment. From its inception it has been very comprehensive in its benefits and serv-
652 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

ices. This resulted in considerable difficulty in its early years because of the pub-
lic rush to remedy vast backlogs ol dental and visual defects. Although it is still
criticized on various counts by many outside as well as within the medical pro-
fession, there is quite general agreement that it has resulted in more widespread
and generally better medical and related services for more people. It is interest-
ing to note, however, that during the decade of its existence, membership in
voluntary health insurance plans has increased tenfold, from 84,000 in 1948 to
834,000 in 1958.

One basis ol difference and disagreement among the prepaid medical care sys-
tems which have developed in various countries is the method of payment of
physicians. As indicated by Evang,*® no generally accepted system can be found in
Europe at the present time, the following being currently in existence:

1. Payment on a capitation basis (panel system), as in England.

Payment on a cash basis, as in Germany.

Fee for service, as in Norway.

Fixed salaries, as in the U.S. S. R.

Basic salary combined with one of the types listed above.

SU we

Developments in the United States. The Western hemisphere, perhaps be-
cause of the tardiness of its discovery and development and because ol the usually
very localized type of society and government resorted to during its early history,
was slow to produce any specific thought or action with regard to the problem
of the adequate provision of medical care. Provisions for free medical services
were scanty and simple and restricted to the very poor. The pattern that was fol-
lowed varied from one town to another. In some instances, a private physician
would be engaged, perhaps because of a low bid, at a fixed stipend to provide
care to the sick poor. In others, stated fees were paid by the town treasurer when
bills submitted by a physician were authorized. Not infrequently the fee for each
particular case required a special vote. All of these three procedures are still
resorted to in certain communities in the United States.

From this beginning, there developed the provisions that are found at the
present time for public medical care in the United States. These provisions
are still essentially those of charity care of the sick poor, interrelated with and
often administered in conjunction with other social wellare benefits such as sub-
sidies for fuel, food, and housing. In most instances, the application ol a means
test is required. This not too stimulating experience necessarily adds considerably
to the cost ol administration. In contrast with this is the rather spectacular de-
velopment of public health measures in the United States. Of most pertinent in-
terest is the extent to which public health programs in this country have re-
peatedly found themselves in the position of having to assume responsibility for
activities that ordinarily might be considered part of the private practice of
medicine.

There is a lack ol interest on the part ol many physicians to render certain
types ol services. As Davis?! has stated, tax-supported medical care of the types
referred to, for the nonindigent,

... has been furnished for a variety of reasons, of which the following have been
most evident: (1) because, as in mental disease, only public funds can make the pro-
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 053

 

vision necessary for the large number of persons involved*; (2) because certain diseases,
as tuberculosis, hookworm, and trachoma, frequently involve, or lead to, incapacity for
self-support; (8) because only a public authority can provide care in a manner which
will protect the rest of the community; as in the case of acute communicable disease; (4)
because, as in poliomyelitis and some orthopedic conditions among children and in early
tuberculosis among young adults, the diseases if untreated, are likely to make permanent
dependents of those who, with proper care, could be self-supporting; (5) because, as
in eye, ear, throat, and dental defects among children, the education and the useful-
ness of future citizens are threatened unless these conditions are corrected; (6) because,
as with the diseases of babies and of the puerperal state, the widespread public interest
in maternity and infancy devolves some responsibility for them upon a public agency;
and (7) because as, in the case of syphilis or cancer, the relative costliness of diagnosis
or treatment renders many self-supporting persons unable to meet the expense.f

The public pressures upon public health agencies for more complete protec-
tion and promotion of the health of all of the people have resulted in greatly ex-
panded and more personalized programs. The evolution of this process has been
described in a statement of the Joint Committee on Medical Care of the American

Public Health Association and the American Public Wellare Association.22

Public Health has its historical roots in the long recognized necessity of invoking
governmental authority to protect the community against the spread of communicable
disease. From these limited beginnings, the increasing interdependence of individuals
living in a highly industralized and urbanized society has brought major advances in
both areas of governmental responsibility for individual well-being. . . . Public health
has also been undergoing a definite evolutionary trend toward a broadened concept of
governmental responsibility. Whereas its earlier functions were primarily concerned with
measures related to community sanitation and regulatory control of infectious diseases,
public health activities have increasingly entered the area of services directly concerned
with the personal health of individuals. With advances in medical science, the arbitrary
line between prevention and treatment has narrowed and the distinction between com-
munity and individual health has become less sharply defined. Society has increasingly
placed on public health an obligation to assure the availability of essential health
services. This trend has been translated into broadened programs of prevention, diag-
nosis, and treatment for the principal communicable diseases; programs for the protection
of the health of mothers and infants; school health programs; health education; and
programs for the prevention, detection, and correction of dental, visual, hearing, and
other defects.

Health Departments also provide an increasing range of services designed to
help control such chronic diseases as cancer, heart disease, diabetes, arthritis and rheuma-
tism, and to rehabilitate children crippled by orthopedic, cardiac, orthodontic, and
other conditions. Programs have been developed in the fields of mental hygiene; hospital
planning, construction and licensure; hygiene of the aging; as well as, in some states,
general medical care for needy individuals.t

In a brief but excellent review, Anderson? has traced the development of in-
terest and agitation for medical care insurance in the United States. He divides
it into three broad periods. The first, from 1910 to 1920 was notable for the

*Note that only 2 per cent of patients hospitalized for mental illness in the United States
are in private hospitals.

fDavis, M. M.: Public Medical Services, Chicago, 1937, University of Chicago Press, pp.
117-118.

tTax-Supported Medical Care of The Needy, Am. J. Pub. Health 42:1314, Oct. 1952.
054 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

activities ol the American Association for Labor Legislation which was instru-
mental in bringing about the widespread enactment ol workmen's compensation
laws. On achieving this success the Association selected medical care insurance as
its next cause. It established a Committee on Social Legislation which at first was
supported by and participated in by the American Medical Association. Eventu-
ally, when a number ol bills were introduced into state legislatures, many ol the
previously interested and cooperative groups including medical societies and
pharmaceutical companies, as well as insurance companies and cultists turned
against it. In 1920, the House of Delegates of the American Medical Association
enunciated a basic policy ol unequivocal opposition to any type of compulsory
contributory insurance against illness.

The second period, from 1921 to 1933 is described by Anderson as “a quiet
one devoted to the study ol basic facts and problems only superficially compre-
hended in the first period.” It saw the establishment of the Committee on the
Costs of Medical Care, financed by six foundations and consisting of forty-two per-
sons representing medicine, public health, institutions, economists and the gen-
eral public. Its many studies and reports between 1928 and 1932 resulted in a
final report, the conclusion ol which have been summarized by Falk*! in the
form of five basic recommendations:

1. Comprehensive medical service should be provided largely by organized groups of
practitioners, organized preferably around hospitals, encouraging high standards,
and preserving personal relations.

2. All basic public health services should be extended to the entire population, requir-
ing increased financial support, full-time trained health officers and staffs, with se-
curity of tenure.

3. Medical costs should be placed on a group payment basis through insurance, taxation,
or both; individual fee-for-service should be available for those who prefer it; and
cash benefits for wage loss should be kept separate.

4. State and local agencies should be formed to study, evaluate, and coordinate services,
with special attention to urban-rural coordination.

5. Professional education should be improved for physicians, health officers, dentists,
pharmacists, registered nurses, nursing aids, midwives, and hospital and clinic
administrators.*

A minority report was submitted. It agreed with recommendations two, four,
and five above, but took strong exception to recommendation one on the organ-
ization of medical services and to recommendation three on group payment for
medical service. The degree of concern of some of the opposition is illustrated
by the tone of the editorial comment of the American Medical Association at that
time.

The alinement [sic] is clear—on the one side the forces representing the great
foundations, public health officialdom, social theory—even socialism and communism—in-
citing to revolution; on the other side, the organized medical profession of this country
urging an orderly evolution guided by controlled experimentation which will observe
the principles that have been found through the centuries to be necessary to the sound
practice of medicine.t

*Falk, I. S.: The Committee on the Costs of Medical Care—25 Years of Progress, Am. J.
Pub. Health, 48:979, Aug. 1958.
iEditorial: J.A.M.A. 99:1952, Dec. 3, 1932.
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 055

 

The third period beginning 1955 and continuing into the present represents
again an action period similar to the first. Replacing the initiative of an unofficial
labor legislation association, however, is action by officialdom in the form of the
Federal government, strongly supported by well-developed and organized labor
groups. Progress was served by the exigencies ol the economic depression. The
necessity to provide medical care, as well as the other basic needs ol food, clothing
and shelter, to the many individuals receiving unemployment relief was recog-
nized and accepted by the American Medical Association as well as other groups.
However, this did not lead to inclusion of medical care insurance in the subse-
quent Social Security Act. The A.M.A. fought and defeated this, but, as Falk!
points out, “at the price ol insuring the enactment in 1935 of Title VI of the
Social Security Act which inaugurated federal grants to states for public health
services and the federal funds for a research program out of which the National
Institutes of Health have burgeoned.”

The passage of the Social Security Act was followed promptly by the 1935-36
National Health Surveys of illness and underlying social and economic factors,
and by the Presidential appointment of the Interdepartmental Committee to Co-
ordinate Health and Welfare Activities. Its Technical Committee on Medical
Care recommended the need for a general program of medical care and insurance
against loss of wages due to sickness. A National Health Conference was called
in July, 1938, to consider the Technical Committee’s findings and recommenda-
tions with wide representation and discussion by all possibly interested parties.

Legislation for a national health program was introduced the following year
by Senator Wagner (5.1620) and extensive hearings were held. The bill died
but was followed in subsequent years by numerous others. In 1948 another Na-
tional Health Assembly was held out of which came a statement of the principle
that contributory insurance should be the basic method of financing medical care
for most of the American public. Agreement was not reached as to implementa-
tion. The period since then has seen (1) the continuation of the introduction of
various types ol medical care and compromise bills, (2) the acceptance and imple-
mentation of all of the recommendations of the Technical Committee on Medical
Care of the President’s Interdepartmental Committee with the exception of the
general medical proposal, (3) a growing and marked concern and awareness by
the general public regarding problems of medical care, its distribution, and costs,
(4) a considerable extension of group medical practice, (5) a significant develop-
ment of labor and union medical care programs, and (6) a remarkable growth
of voluntary medical and hospital insurance.

Voluntary Medical Care Insurance. With regard to the latter, by mid-1958,
about 123 million people in the United States were covered by hospitalization in-
surance and 111 million had insurance for surgical expenses under various volun-
tary health insurance plans. Unquestionably, the interest and activity of govern-
ment in the problems of medical care since the 1930's served as the major stimu-
lus to the development and extension of voluntary prepaid medical care in-
surance plans and their acceptance and endorsement by organized medicine.

Experience has indicated that voluntary plans are not without their prob-
lems, and at the time of this writing a number of them are faced with serious
050 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

fiscal difficulties. Furthermore, they have a number of significant limitations.
They are rarely comprehensive, being limited essentially to hospitalization and
medical services while in the hospital. Only a few provide preventive and diag-
nostic services, and certain illnesses such as tuberculosis and mental disease are
generally excluded from coverage. Frequently, hospitalization for long-term
catastrophic illness is not adequately provided. Much of the population, includ-
ing a large part of the low-income group and the aged, those with greatest need,
are not covered. It is interesting that although about 70 per cent of the popula-
tion is covered by some form of medical and hospital insurance, only about 25
per cent of the total expenditures for medical care are in the form of insurance
payments. Furthermore, as Reed?2¢ points out, a significant amount of health in-
surance is written by insurance companies on an individual basis, a form of in-
surance which results in about one half of the premiums going to selling costs
and overhead and not for medical service. Similarly, coverage by voluntary in-
surance has done nothing to prevent occasional excessively high medical fees or
to effect economical hospital practice or to encourage sound hospital fiscal
procedures.

The Future. Anderson has made the significant point that the controversy
over compulsion has tended to obscure the significant points of agreement among
all those concerned. All agree that everyone should have access to medical care re-
gardless of income. All agree that the generally most satisfactory means is by in-
surance. Disagreement appears to be limited to the question of sponsorship and
control. Finally, he emphasizes that both sides share a basic faith in the present
political and economic institutions. As he concludes, the proponents of com-
pulsory medical care insurance are not necessarily revolutionaries, and the op-
ponents are not necessarily reactionaries.

It must be recognized that a tax-supported plan for medical care is certain
to have both advantages and disadvantages, potential dangers as well as benefits.
Undoubtedly the outstanding advantages of such a plan would be the equaliza-
tion of geographic and economic differences among states and regions, and among
the citizens of a community and the nation. This equalization would manifest
itself, among other ways, in a more equitable distribution of medical personnel
and facilities. Furthermore and perhaps of greatest importance would be the
equalization through time of the costs to an individual of medical diagnosis and
care. Against these advantages are the potential dangers of political influence
on the selection of patients, the appointment of administrative and professional
personnel, and the methods of institutional management. Physicians and others
might in some instances be poorly selected or poorly trained and practice under
inadequate or no supervision. It may be pointed out, however, that in the com-
plete absence of a plan, these same poorly selected or trained persons would be
engaged as they now may be in private practice with no supervision. Similarly
the cry is often heard that a publicly or governmentally sponsored medical
care program will cause the quality of care to suffer. Objections on these grounds
imply that all present physicians would be disenfranchised and an altogether
new group would move in. It should be realized that the aim of all proposals
up to the present has been control of the economic risks of illness and not of
PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 057

 

the manner in which those illnesses are treated. If under any plan, private or
public, the quality of the care rendered decreased, the fault could be attributed
only to those who render the service, and not to the manner in which they re-
ceived payment. Much depends, of course, on the structure of a plan and the
manner in which it is administered. A tax-supported medical care program must
involve some degree of governmental administration and supervision, but this
does not necessarily imply governmental control over technical and professional
procedures and personal relationships.

That some form of nationwide, tax-supported, medical and surgical care plan
will be eventually developed and put into effect in the United States is almost
certain. The wheels of social progress grind slowly but inexorably. The increasing
agitation and the concurrent stresses to which we are witness at present in this
country, the plethora of legislative bills introduced, discussed, and discarded dur-
ing recent years, and the increasing din of propaganda pro and con are but signs
and symptoms of a social change already well under way and long since ex-
perienced elsewhere. A recent forum ol current thought on the subject?” has
presented an admirable brief summary analysis of this momentous social move-
ment which gives the clue to the events which are almost certain to transpire
in the United States in the near future. The statement is included here at length
because of its pertinency.

When we study the history of social sccurity legislation, we soon find that it
follows a certain pattern, one that first became very clear in Germany. Increased indus-
trialization creates the need, because it increases the social insecurity of growing numbers
of the population. A second factor is found in the phenomenon that under the pressure
of industrialization the working class organized into militant political parties that
present a threat to the existing order. This was the case in Germany when the Social
Democratic Party was founded in 1869 by Bebel and Liebknecht; in 1875 it absorbed
the conservative Lasalle group. The Paris Commune of 1871 created a great scare in
all conservative circles of Europe because it showed that socialism was not a parlor phi-
losophy but might well become a tangible reality. A conservative statesman, Bismarck
stepped in and with social insurance created a corrective mechanism to the system that
he wished to perpetuate.

The very same pattern can be traced in England, the next large country that
enacted national social insurance in the beginning of our century. At that time the
impact of the second industrial revolution was being felt. The number of wage earners
increased as a result of it and so did their insecurity. In 1900 the Independent Labor
Party, the Fabian Society, and the Trade Unions joined to organize the Labor Party,
which was in no way revolutionary but nevertheless had great potentialities in a highly
industrialized country. In the election of 1906 the Labor Party won 29 seats and England
changed from a two-party country to a three-party country. The Russian Revolution of
1905 broke down as the Paris Commune had done thirty-five years before, but it again
reminded conservative groups that socialism was not dead. Lloyd George and Winston
Churchill began to promote social legislation, culminating in the National Insurance Act
of 1911, which included sickness and unemployment benefits. Like the German system, it
had all the weaknesses of a compromise, was not comprehensive enough, and suffered
from a considerable lack of uniformity, as it had to take into account the vested interests
of a great number of private benefit societies and insurance companies.

World War I created a new and very strong stimulus to the enactment of social
legislation. It was the first war in which the industrial potential of a group of countries
proved to be the decisive factor. Industrialization was intensified in every warring
country and the Russian Revolution of 1917 created a totally new situation. Not only
058 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
France, but a number of other countries adopted systems of health insurance, and it was
recognized that no nation could enjoy the benefits of industrialization without provid-
ing a corrective mechanism for the hardships and insecurity it created. This became
particularly apparent during the protracted economic depression that followed the crisis
of 1929 when all over the Western world millions of people were unemployed. At
that time social insurance bills were introduced increasingly in the American republics.
Chile introduced health insurance as early as 1924, and by 1942 nine Central and South
American countries had some form of health insurance. In the United States, following
the National Health Conference of 1938, various bills were introduced into Congress
that had the purpose of completing the social security legislation of the Roosevelt era
by developing a national health program that would include health insurance. So far
no bill has been passed, but the need remains and some solution will have to be found
because the attitude of medicine to society has changed and the view is generally ac-
cepted that in a civilized commonwealth the benefits of medical science should be avail-
able to all people.*

REFERENCES

I. Shryock, R. H.: In Galdston, Tago (editor): Social Medicine, New York, 1949, Common-
wealth Fund.

2. Sand, Rene: Health and Human Progress, New York, 1936, The Macmillan Co.

3. Buhrman, H. M. F.: Leaves from a Doctor's Notebook of Seventy Years Ago, Mil. Surgeon
86:547, June 1940.

4. Robinson, G. C.: The Patient as a Person, New York, 1939, Commonwealth Fund.

5. Current Population Reports, Series P-60, No. 29, June 1958, Consumer Income, Bureau of
the Census, U. S. Department of Commerce.

6. Perrott, G. St. J., and Pennel, M. Y.: Health Manpower Chart Book, Washington, 1957,
Public Health Service Publ. No. 511.

7. Distribution of Dentists in U. S., Chicago, 1958. American Dental Association.

8. Abbe, L. M.: Hospital Beds in the United States, 1955, Pub. Health Rep. 70:484, May 1955.

9. Abbe, L. M., and Baney, A. M.: The Nation's Health Facilities, Washington, 1958, Public
Health Service Publ. No. 616.

10. Collins, S. D., Lehmann, J. L., and Trantham, K. S.: Major Causes of Illness of Various
Severities and Major Causes of Death in Six Age Periods of Life, Washington, 1955,
Public Health Service Publ. No. 440.

11. Collins, S. D., Lehmann, J. L., and Trantham, K. S.: Surgical Experience in Selected Areas
of United States, Washington, 1956, Public Health Service Publ. No. 473.

12. Falk, I. S., Klem, Margaret C., and Sinai, Nathan: The Incidence of Illness and the
Receipt and Costs of Medical Care Among Representative Families, Chicago, 1933,
CCMC Publ. No. 26, University of Chicago Press.

13. National Resources Planning Board, Family Expenditures in the U. S., Washington, 1941.

14. Statistical Abstract of the United States, Washington, 1958, U. S. Department of Commerce,
Bureau of the Census.

15. A.M.A. News, Jan. 12, 1959.

16. Kramer, L. M.: Drugs and Medicine, Pub. Health Rep. 73:934, Oct. 1958.

17. Rosen, George: Provision of Medical Care—History, Sociology, Innovation, Pub. Health
Rep. 74:199, March 1959.

18. Rosen, George: In Galdston, Tago (editor): Social Medicine, New York, 1949, Common-
wealth Fund.

19. Editorial: J.A.M.A. 139:529, 1949.

20. Evang, K.: Medical Care in Europe, Am. J. Pub. Health 48:427, April 1958.

21. Davis, M. M.: Public Medical Services, Chicago, 1937, University of Chicago Press, pp- 117-
118.

 

*Galdston, Tago (editor): Social Medicine, New York, 1949, Commonwealth Fund, pp. 48-50.
29
a4.

23.

PUBLIC HEALTH, THE PRIVATE PHYSICIAN, AND MEDICAL CARE 059

 

Editorial: Tax-Supported Medical Care of the Needy, Am. J. Pub. Health 42:1314, Oct. 1952.

Anderson, O. W.: Compulsory Medical Care Insurance, 1910-1950, Ann. Am. Acad. Polit.
and Social Sc. 273:106, Jan. 1951; Also in Committee on Medical Care Teaching of the
Association of Teachers of Preventive Medicine: Readings in Medical Care, Chapel Hill,
1958, University of North Carolina Press.

Falk, I. S.: The Committee on the Costs of Medical Care—25 Years of Progress, Am. J.
Pub. Health 48:979, Aug. 1958.

Editorial: J.LA.M.A. 99:1952, Dec. 3, 1932.

Reed, L. S.: Group Payment Since the Committee on the Costs of Medical Care, Am. J.
Pub. Health 48:992, Aug. 1958.

Galdston, Tago (editor): Social Medicine, New York, 1949, Commonwealth Fund.
chapter 3 1

The voluntary health agencies

 

Introduction. Voluntary health agencies are organizations supported by
private or nontax funds, directed by privately employed individuals often with
no public health training and with no legal powers. While by no means unique
to the United States, they are especially common in this country. This may be re-
lated to certain characteristics which were important in our historical and
social development: good will, friendliness, sympathy for the fellow who is down,
a desire to improve the human race, a penchant for carrying out studies and
reforms, and a tendency to form and join organizations of all sorts for many
purposes. It might be said that one aspect ol the democratic philosophy as de-
veloped in America was a widespread concern for the wellare of one’s neighbor
or fellowman.

The movement for voluntary health agencies began with the Anti-Tubercu-
losis Society of Philadelphia in 1892, and within a half-century over 20,000 vol-
untary health agencies which draw their support from literally millions of per-
sons and which serve in various ways millions of others have been organized.
Variously they have been effective and ineffective, efficient and inefficient, blessed
and scowled at, intelligent and unreasonable, cooperative and uncooperative.
These are just a few of the possible and inevitable outcomes ol rapid develop-
ment of a large number of independent undertakings. They have, however, one
characteristic in common—they seldom die.

The development of the National Tuberculosis Association epitomizes the
voluntary health movement as a whole. Encouraged by the formation of the
earlier Philadelphia society, a group of unusually intelligent and enthusiastic
private citizens banded together in 1904 to organize the National Association for
the Study and Prevention of Tuberculosis. The membership of the group is
worthy of special mention. It included Trudeau as president, William Osler,
Bowditch, Bates, Janeway, Welch, Billings, Victor Vaughan, and others of like
quality. Among the six lay members of the board were Homer Folks, Samuel
Gompers, and Edward T. Devine, who were most prominent in the development
of social welfare in the United States. At the time, tuberculosis caused one tenth
of all deaths and was the leading cause of destitution and orphanhood. From the

600
VOLUNTARY HEALTH AGENCIES 001

 

start, it was decided that eventually the job was one for government since volun-
tary funds could never hope to meet the total bill. It was recognized, however,
that government action in a democracy does not precede public opinion and that
the public and government had to be educated. This, the National Association
believed it could do, and it proceeded with the organization ol eventually filty
state associations and approximately 3,000 local affiliates.

At first the financing of the National Association posed a difficult problem,
temporarily solved during a transition period by the Russell Sage Foundation
which assumed the responsibility for the ten years 1907 to 1917. Meanwhile the
tuberculosis Christmas-seal idea was adopted [rom Denmark. This was consid-
cred a desirable fund-raising technique since it gave cach individual citizen a per-
sonal interest in the fight against tuberculosis. The idea was quickly adopted and
by 1914 provided the bulk of the funds not only of the national but also of the
state and local associations. As an indication of its wide appeal about 26 million
dollars were raised in 1956 by the sale of penny Christmas seals. The pattern ol
distribution ol proceeds [or most publicly supported voluntary health agencies
was set from the beginning by the National Tuberculosis Association which de-
cided to leave the bulk of funds raised, 95 per cent, in the state and local associ-
ations, only 5 per cent being retained by the national agency.

Number and Type. Voluntary health agencies involve the time and often the
money of at least 500,000 rather exceptional men and women who serve on boards
or committees, the time and effort ol over a million other voluntary workers, and
an annual expenditure of about 800 million dollars. These figures exclude not
only the American Red Cross but also the large philanthropic foundations, in-
dustrial health services, and a large number of agencies which only incidentally
furnish health services. The American Red Cross is in a class by itsell. It had a
peace-time membership of about 5 million, which increased during the war years
to 36 million people. There are 3,757 chapters and 5,785 branches. During the
three and one-half years from the Pearl Harbor bombing to May, 1945, contribu-
tions amounting to 654 million dollars were raised. The American Red Cross is
the only voluntary agency with quasi-official status; the President of the United
States serves as its president and the organization is considered the official disaster
relief agency of the nation.

Voluntary agencies concerned with health may be considered to lall into
several categories. First and most important is a large group of agencies sup-
ported by citizen contributions and donations. These are subdivisible into the
following [our types, which demonstrate a remarkable degree of specialization:

1. Agencies which are concerned with specific diseases, such as the American
Cancer Society, the National Tuberculosis Association, the former Na-
tional Foundation for Infantile Paralysis, The National Social Hygiene
Association, and the American Diabetic Society.

2. Agencies which are concerned with certain organs or structures of the
body, such as the National Society for the Prevention of Blindness, the
American Society for the Hard of Hearing, the National Society for
Crippled Children, and the American Heart Association.
002 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

 

3. Agencies which are concerned with the health and welfare of special
groups in society such as the American Child Health Association (now
extinct), the Maternity Center Association, and the American Negro
Health Association.

4. Agencies which are concerned with particular phases of health and wel-
fare such as the National Safety Council, the Planned Parenthood Fed-
eration of America, and the National Sanitation Foundation.

The second large group of voluntary agencies engaged in health work is
composed ol foundations established and financed by private philanthropy.
Prominent among the many of these that might be mentioned are the Rocke-
feller Foundation, the W. K. Kellogg Foundation, the Commonwealth Fund, the
Millbank Memorial Fund, the Children’s Fund of Michigan, the Rosenwald
Fund, and the Markle Foundation. Organizations ol this type function in a
variety ol ways, particularly by promotion and subsidy of local health depart-
ments especially in rural areas, basic research, and public and professional
education.

The third main group of voluntary health agencies is made up of the pro-
fessional associations such as the American Public Health Association, the Ameri-
can Medical Association, the National League [or Nursing, and their state and
local affiiliates. In addition to providing a meeting ground for professional work-
ers in their respective fields, these associations do much to improve standards, en-
courage research, further health education, and promote programs.

Integrating agencies such as health councils and community chests and coun-
cils constitute what may be considered a fourth group. There are now more than
a thousand ol these multiple interest organizations. They are found on local,
state, and national levels, their intent being the coordination of the activities of
the many specialized voluntary agencies.

A fifth group of nonofhcial agencies that may be considered to have some
interest in the public health consists of an increasing number of commercial
organizations which have found it worth while, for one reason or another, to par-
ticipate in the promotion of sanitary and hygienic habits and programs. Pre-
dominant among these are several of the large insurance companies which have
carried out very extensive and valuable educational programs and demonstrations.
Some activities have also been engaged in by industries concerned with the manu-
facture and sale of soap, sugar, milk, meat, eating and drinking utensils, and
other products. Generally speaking, this latter group must be dealt with cautiously
since their programs are based primarily upon a desire for increased profits and
improved public relations.

Functions and Activities. The Gunn-Platt study and analysis' of voluntary
health agencies has listed eight basic functions of voluntary health agencies which
are described briefly in the following paragraphs.

Pioneering. This involves exploring or surveying for needs not being served
and for new methods of dealing with needs already recognized.

Demonstration. Voluntary health agencies have rendered particularly sig-
nificant service by carrying out or subsidizing experimental projects designed to
VOLUNTARY HEALTH AGENCIES 003

 

demonstrate practical methods for improvement of public health and for the
wider application of proved methods by official and other agencies. Projects have
ranged all the way from the demonstration of the value of full-time local health
departments, to home delivery service, visiting nursing service, nutrition pro-
grams, and business and record procedures.

Education. This is probably the single most important function of volun-
tary health agencies. In fact, it might be said that all other functions have educa-
tion as their goal. While activities in this field have been designed primarily for
the public, many of the agencies have made provisions for or have engaged in all
types of professional training by means of fellowships, inservice training courses,
and the maintenance or subsidization of field training areas.

Supplementation of Official Activities. With no legislative restrictions to
encumber them, the voluntary health agencies have very [requently found them-
selves in a position to augment the activities of official health departments. All
too often, official health agencies have been unable to enter new fields of service
and action because of political restrictions or public reservation. In such in-
stances, the voluntary agencies have rendered yeoman service by stepping in to fill
the gap between currently accepted practice and more advanced scientific knowl-
edge. Usually, when this is done, the custom has been to provide the new service
for a limited period of time, at the end of which the official agency is expected to
carry on.

Guarding of Citizen Interest in Health. Voluntary health agencies, because of
their nature, representation, and support, have often found themselves in a posi-
tion to guard the public interest not only by promoting the official health pro-
gram but also by defending it against political and other interference. By like
token they have sometimes found it necessary to subject official health agencies,
programs, and officials to study and criticism. This has occasionally given rise to
ill-feeling, and some health officials have looked upon voluntary agencies as pre-
sumptuous and interfering. Health departments, however, being official tax-
supported agencies, should expect to be subject to scrutiny and, if necessary,
criticism by the citizenry and the various groups that represent them. It has been
exceedingly rare that such criticism has not been to the ultimate good not only
of the community but of the official health agency itself. More than one un-
qualified, politically sponsored individual has been barred from health officer-
ship and more than one qualified health officer has been supported in his pro-
gram and maintained in his position by vigorous and sometimes almost violent
support stemming from the voluntary health agencies.

Promotion of Health Legislation. In every state and community there is a
constant stream of proposed legislation of concern to the public health. It is, of
course, a responsibility of the health officer to provide leadership in the support
or condemnation of each one. In most instances, his voice alone is of little
avail and attracts scant attention from the legislative body. His chief and, in
fact, his only great source of strength in this regard is the group of cooperative
voluntary health agencies that are active and influential in his community. Hav-
ing a prime interest in health matters and representing large numbers of voting
citizens, their opinions carry much weight. In addition, these agencies have played
004 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES
an active part in the initial formulation and promotion of desirable health
legislation.

Group Planning and Coordination. These [unctions have been particular
concerns of health federations and councils and of health divisions of councils of
social agencies. With the development of many voluntary agencies in a com-
munity and their potential or actual overlapping and conflict, there has resulted
a great need for action in this field. Related to it is the need for increased coordi-
nation between the programs ofl the voluntary agencies and those of the official
agencies in the community.

Development of Well-Rounded Community Health Programs. This is really
not a function in itself but rather the total cumulative result of the successful
accomplishment ol the several foregoing purposes and functions. By protecting
and promoting the official health department, by increasing the hygienic con-
sciousness of the community, and by stepping in with funds and [facilities where
gaps exist, the voluntary health agency may make the difference between a medi-
ocre community health program and one that is truly effective.

Financing. Important to the understanding and evaluation of voluntary
health agencies is the manner in which they are financed. The professional as-
sociations are supported by membership dues whereas the health activities of com-
mercial agencies are usually financed by budgetary items designated for education
or public relations. The philanthropic foundations, of course, owe their existence
to large bequests [rom wealthy individuals. This source of funds, however, is sig-
nificantly decreasing in importance with the breaking up of large personal
fortunes. The most important group to be discussed is that made up of agencies
supported by the individually small contributions or donations of large numbers
of private citizens. A number of techniques have been developed by these organ-
izations, each tending to be jealously guarded by whatever agency first devised
and used them. Some of these techniques have been spectacularly successful, de-
pending in many instances upon emotional rather than intellectual appeal, care-
fully developed and conducted by agencies which specialize in the business ol
fund raising.

The first and still one of the most successful methods has been the Tuber-
culosis Christmas Seal previously referred to. Their cost of only a penny each has
appeared to be insignificant to the members of all economic or social groups,
and while most sales are in the form of several sheets of one hundred each, it is
by no means unusual to find children in the poorest districts purchasing at least
one or a few separate stamps. While to some this may be a point of criticism, the
fact that it is done represents at least a certain amount of educational impact
upon all classes of society, thereby making the fight against tuberculosis truly a
people’s fight. It has been so successful that several other agencies have adopted
the technique. An example is the Easter Seal, inaugurated in 1934 by the Na-
tional Society for Crippled Children.

Another effective technique is that developed by the National Foundation for
Infantile Paralysis. Associated with the name of a great national leader, Franklin
Delano Roosevelt, who was himself stricken with that disease, there developed a
custom of annual drives involving very careful planning and organization. A
gala ball is held in the national capital attended by many dignitaries. Similar
VOLUNTARY HEALTH AGENCIES 005

 

events are held in cities, towns, and even small villages throughout the nation,
Concurrently, the public is deluged on the streets, in their homes, and in places
ol amusement, such as theaters, with requests for contributions to the March of
Dimes. These techniques have been amazingly fruitful and have brought in large
sums ol money. This organization in 1958 changed its name to The National
Foundation and expanded its scope of interest to include arthritis, birth defects,
and disorders of the central nervous system.

Other methods used to raise money are dues for nominal membership, the
sale of educational literature, lees for services, personal solicitations, and direct
mail appeal. Another innovation has been the radio or television quiz program
which has benefited several voluntary health agencies very considerably. Certain
of the techniques have caused not a little public resentment, particularly when
pressure or embarrassment potentially enter into the appeal. Examples of this
nature are the passage ol contribution boxes in a lighted theater and the use of
neighbors for personal door-to-door solicitation. One good feature of recent fund-
raising programs has been the increasingly followed policy of distributing the
proceeds in accordance with a formula among the national, state, and local offices
of the agency. In this way, local interest and support are maintained, still allow-
ing for state and national funds for research and emergencies.

An important consideration in connection with the fund-raising activities
ol voluntary health agencies is the cost ol the [fund-raising campaign itself.
An analysis of seven national organizations showed a variation ol from six cents
to about thirty-eight cents per dollar collected.! I recall analyzing the annual re-
port of one agency with the conclusion that 68 per cent ol the income was spent
for agency office maintenance and fund raising. This, however is somewhat ex-
treme. The average cost of raising a “voluntary” dollar has been reported as $.059
by Community Chests and Councils, Incorporated. Voluntary agencies them-
selves are becoming increasingly concerned with the multiplicity of requests and
demands made upon the public. By now, so many days, weeks, and months have
been designated for this or that purpose with accompanying appeals for contri-
butions that the public is becoming confused and not a little resistant to the
whole idea. An attempt has been made to remedy this situation by the formation
ol community chests and united funds. These are federations of agencies which
consolidate in one office certain of the interests of a number of the voluntary
agencies existing in a community. The intent is a single consolidated drive or ap-
peal for funds which are subsequently distributed in an equitable fashion among
the individual agencies involved. By and large, community chests and united
funds have been successful. An unfortunate fact, however, is that, not only do
some agencies stay apart, but also that in a short time a number of new volun-
tary agencies appear which add their separate appeals to that of the community
chest or united fund and thereby again create conlusion. Recognition must also
be given to the very natural wish of many people to contribute to one or a few
causes in which they are personally interested, rather than to what may appear as
a large, vague and indefinite fund.

Desirable and Undesirable Characteristics. From the foregoing, it is apparent
that voluntary health agencies have both desirable and undesirable features. On
the favorable side is the fact that these agencies have developed as a result of
000 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

spontaneous reaction on the part ol groups of citizens. Their leadership usually
consists of devoted, personally disinterested, intelligent, nonpartisan individuals.
Usually, the agencies have been established to meet a real and commonly felt
need. Without question, public health in America could never have reached its
present high level in the absence of the voluntary health agencies. They are un-
restricted by statutory or program limitations or by partisan politics. Because they
are so relatively unhampered, they can adapt their programs rather readily to
changing needs and conditions, thereby often shortening the lag between the ac-
quisition of new scientific knowledge and its application. Much that has been
accomplished in improved professional education, standardization of techniques
and procedures, and research can be placed to their credit.

On the other hand, voluntary health agencies have certain undesirable fea-
tures or disadvantages. Not a few official health departments have been placed in
the position of having to conduct poorly balanced programs because of pres-
sure {rom voluntary agencies. This may come about in two ways: a voluntary
agency may exert pressure upon the health department to overemphasize its par-
ticular pet interest; contraiwise, some voluntary agencies have caused health
departments to underemphasize certain programs because the voluntary agencies
have wanted to monopolize activities in those fields. Such tactics may serve to
jeopardize appropriations for official health agencies. Similarly, despite the
avowed purpose ol leading the way until an activity is officially adopted,
many voluntary agencies are loathe to surrender any parts of their programs. In
fact, it is rare to find a voluntary agency closing up shop as did the American
Child Health Association. With the multiplicity of existing organizations, over-
lapping of function and high administrative costs are certain to result. Reference
has been made to the growing confusion of the public. This results from over-
lapping functions as well as [rom multiplicity of appeals. Thus one may still find
communities in which several groups of nurses operate out of an equal number
ol agencies, visiting homes and working in clinics. Certain of the voluntary
agencies do not accede to the policy of affiliating or even coordinating their ac-
tivities with those ol local official health organizations. Finally, and one of the
most serious objections, the public tends to contribute on an emotional basis
and to the organization which makes the loudest and most prolonged appeal and
then feels that it has done its part toward the support of the entire public health
program. An interesting example is that in recent years the agencies concerned
with tuberculosis and with poliomyelitis have each raised about the same amount
annually despite the fact that there are many more cases and deaths from tuber-
culosis each year than there are cases and deaths from poliomyelitis.

Current Trends and the Future. In an article entitled Is the Private Health
Agency on the Way Out?? Marquette has called attention to three major develop-
ments of recent times which are certain to have an important effect on the future
of voluntary health agencies. First is the current trend toward the allotment of
Federal social security funds to the United States Public Health Service and other
agencies for the categorical approach to important health problems such as
venereal disease, tuberculosis, cancer, mental health, heart disease, and dental
health. These allotments of Federal funds intended for state and local as well as
VOLUNTARY HEALTH AGENCIES 007
for national use are already making it possible for official health agencies to enter
into territory previously occupied almost exclusively by the private health agency.
The second development, which grew largely out of the National Health Con-
ferences, is the increased appropriation of tax monies for hospital and medical
services. Related to this is the support by the American Medical Association of
moves for more government participation in public health, mental hygiene, health
education, the care of mental patients, the support of tuberculosis hospitals, fa-
cilities for convalescent care and rehabilitation, group hospitalization, and cash
indemnity against sickness. A third development of great impact was the eco-
nomic depression of the 1930s followed by the trend toward higher taxes during
and since World War II. Working together, these two factors have served to
eliminate some large fortunes and to reduce somewhat the inclination of many
people to contribute to what they consider as governmental responsibilities.

The voluntary health agencies are now faced with the problem of what to
do about these trends. Some have already accepted the policy that when a tax-
supported agency develops to the point where it can take over the work, the
private agency should either leave that field or cease its operation entirely. In
order to decide logically upon a sound future course, it has been recognized as
desirable that these agencies subject themselves and their communities to careful
scrutiny in order to re-evaluate problems that do or may exist and their relation-
ship to them. Re-evaluation is further indicated for bringing up to date the
position occupied by the voluntary agency in the community and its relation to
all other official and nonofficial organization. Accordingly, recent years have seen
the establishment of appraisal committees in an increasing number of voluntary
health agencies. The Community Chests and Councils, Incorporated, have played
an important role in the encouragement of this procedure. Further impetus has
been given to it by the Gunn-Platt Report on Voluntary Health Agencies which
itself is an outstanding example of evaluation ol the entire field. This study,
sponsored and financed by the Nation Health Council, provides one of the most
comprehensive analyses and sources of information concerning this subject. The
authors of the report, in speaking ol agency appraisal, suggest that the following
be set up by the board of each voluntary health agency.

. machinery for the periodical appraisal of the agency, at intervals of perhaps
five years, by qualified experts with wide knowledge of the field of activity as well as of
agency and community organization. This is particularly needed in the swiftly changing
trends that are ahead. Valuable as is self-analysis, the outside and objective approach
reduces the likelihood that smugness or self-satisfaction will establish itself. Such an
appraisal should consider (a) adequacy and effectiveness of program; (b) financial status
and future; (c) cooperative relationships; (d) adequacy of staff and executive direction;
and (e) future opportunities and functions. Properly planned and carried out with the
full cooperation of board and staff, such an appraisal will be worth more than it costs.
Funds should be set aside and gradually accumulated for such an accounting and future
planning. No agency would think of omitting its yearly financial audit merely to save
the cost. It is even more important to have an audit of the organization itself made at
intervals in order to determine how wisely it expends its money. *

*Gunn, S. M., and Platt, P. S.: Voluntary Health Agencies: An Interpretative Study, New
York, 1945, The Ronald Press Co., p. 105.
 

068 PATTERN OF PUBLIC HEALTH ACTIVITIES IN THE UNITED STATES

In addition to the evaluations sponsored by voluntary agencies themselves,
the past decade has seen the development of community-wide surveys performed
by outside experts. Many of these have been sponsored by Community Chests
and Councils, Incorporated, financial support coming [rom any one of a number
of sources: the local community fund, the council of social agencies, private
subsidies, or the local government itself.

Reference has been made to the National Health Council. In a sense its or-
ganization represents an attempt to adapt voluntary health agencies to the chang-
ing times. At the time of its organization in 1920, it was hailed as one of the most
important steps taken in the field of public health up to that time. Its avowed
goals included consolidation of funds and facilities, increased efficiency ol ac-
tion through joint planning, housing, and programming, and the provision of
services and conlerences conducive to evaluation. Its program has not been as
successful as had been originally hoped, due among other reasons to resistance
on the part of many agencies to the idea of unification for fear of loss ol agency
integrity.

A number ol other steps worthy of mention have been taken to keep volun-
tary health agencies up to date and to increase their community value. Until
relatively recently, many agencies have been directed by interested lay per-
sons. At first they served without pay, but that policy was soon recognized as
being administratively unsound. Accompanying the increased employment of
full-time agency directors has been a recognition of the need for some type of
training. As a result, inservice training courses and other types of programs de-
signed to fill the need have been established and conducted. Recognition of the
need for training has grown to the point where at the present time not only are
curricula presented, usually during the summer months, for executives of volun-
tary health agencies but also educational qualification lor this type of personnel
have been developed by the Committee on Professional Education of the Ameri-
can Public Health Association.

A notable trend in voluntary health agencies has been to broaden their
programs rather than to concentrate on only one specialized problem. Some ol
the tuberculosis associations have become tuberculosis and health associations.
The National Foundation (formerly The National Foundation for Infantile Pa-
ralysis) has added several other disease conditions to its interests. To an interest
ing and potentially significant degree, some agencies, again particularly the
tuberculosis associations, are becoming active in the field ol chronic noncom-
municable diseases. More than ever before the programs of voluntary health
agencies are being brought into closer proximity and integration with those ol
the official agencies, a movement which is essentially an emphasis of one of the
original and primary functions of voluntary health agencies, i.e., the support and
augmenting ol the community's official program.

That the voluntary health agencies should find themselves in the position
of having to give way here and tighten up there is neither surprising nor unde-
sirable. Nor do these trends necessarily indicate their approaching demise. As
aptly stated by Marquette:
VOLUNTARY HEALTH AGENCIES 009

 

There is really no occasion for leaders outside the tax supported health field to
have any concern as to the continued importance of their work. It is rather a matter of
elasticity and adjustment. Everybody in the public health field knows that so much
remains to be done that we fall so far short of using effectively the instruments that
medical science has placed at our disposal for combating disease, that the combined
public and volunteer health forces will be needed for years to come. It must all be
properly integrated and the private agency must see the changing picture and be ready
to modify its role.*

REFERENCES

I. Gunn, S. M., and Platt, P. S.: Voluntary Health Agencies: An Interpretative Study, New
York, 1945, The Ronald Press Co.

2. Marquette, Bleeker: Is the Private Health Agency On the Way Out? Am. J. Pub. Health
29:46, Jan. 1939.

*Marquette, Bleeker: Is the Private Health Agency on the Way Out? Am. J. Pub. Health
29:46, Jan. 1939.
part 4. the future

The role of the progosticator, at any time and under any
circumstance, is fraught with difficulties and dangers. Change is
known to be inevitable in a biological complex such as that in
which we humans play a dominant role. The nature and extent
of the change, however, present quite different questions. It is
here that one challenges credulity, stubs one’s intellectual toe,
and risks one’s reputation. Prognostication nevertheless is justi-
fied and serves a useful purpose. When based upon considered
analysis and judgment of things past and present, it forms the
best possible, in fact, the only reasonable basis for determining
sound planning and action for the future.
chapter 3 2

The past as prologue

 

 

Introduction. During recent years, public health workers in the United
States have experienced increasing introspection and have asked themselves and
each other a number of provocative questions: What is the future of our pro-
fession? Have we served our essential purpose and should we begin to phase out?
Is public health at crossroads? Have our training and our programs kept up with
the times, or have we become passé? Are we sufficiently dynamic or have we be-
come static? What are the next steps in public health? Indeed, questions such as
these increasingly form the keynote or theme of local, state, and national pro-
fessional meetings and discussions.

What is the background against which we should judge ourselves and de-
termine our future course in public health? I believe that at this point in time it
is insufficient merely to look over one’s shoulder at the events of the past five, ten,
or twenty-five years. Rather, it may be worth while and necessary to turn full face
about and view our entire past as a species.

A Look at the Past. Our planet was formed about 3 billion years ago. It was
only a mere half million years ago that the first creatures which might be called
men appeared. They were distinguished by their ability to grasp with an opposing
thumb and their development of the power of conceptual thought and means of
transmitting the results of their thinking, information and knowledge to others.
Although he possessed these remarkable innovations, man nevertheless progressed
very slowly and tortuously. For most of his million years, the conditions of his
existence have been decidedly primitive—indeed, in major parts of the world
today they remain so. This primitive existence consisted of obtaining food, avoid-
ing death from the elements, wild beasts, and other men, reproducing, and
attempting to establish an understanding of and relationship with some super-
human force or being. For most of the period, men obtained food merely as
predators living off the fruits of the land as they occurred naturally. This, of
course, had its limitations.

Eventually, after some hundreds of thousands of years, man made and applied
a number of truly fundamental discoveries, i.e., the control of fire, the domestica-
tion of animals, and the development of planned agriculture. These three great
advances led to further discoveries and made possible all subsequent development

073
674 THE FUTURE

of the species. However, they all took time. Thus, countless generations were
to pass before man got beyond the digging stick, before he smelted metal and
made useful tools therefrom, and before he developed even simple methods
of food preservation. Only recently and only in certain areas did men reach the
point at which they could produce not only enough food for themselves and their
families, but also a surplus with which to support the now specialized fabricators
of their tools and clothing. The latter began to concentrate in convenient places,
usually determined by proximity to natural means of transport or to natural
strongholds. Thus, the first urban centers came into being, and with them came
new problems including many of a public health nature. These urban centers
with their attendant developing cultures probably first appeared about 3500 B.C.
in the Tigris and Euphrates valleys of Mesopotamia and in the Nile valley. Simi-
lar unique centers developed subsequently in Crete, in the Indus valley, along the
lower Yellow River of China, in Central America, and on the coast and Andean
highlands of what are now Peru and Bolivia.

The urban centers became increasingly important for a number of reasons,
i.e., as trading places, as headquarters for those who governed and the military
who supported them, as convenient and desirable living locations for those who in
one way or another had gained control over large areas of land and all they con-
tained, as the focal points for the religions which developed, as repositories of ac-
quired knowledge, and eventually as centers of learning and research. Gradually,
some of these urban civilizations grew, reached their zeniths, then faded due to
conquest, plague, or famine. Others grew, spread, and continued their influence in
adapted forms in other parts of the world. Remarkable throughout most of this
period, however, was the slowness of improvement and the small number of
people involved.

At the time the Roman Empire reached its peak, in the second century A.n.,
Italy had a population of only about 14 million, almost 10 per cent of whom re-
sided in Rome. By the time of the Norman Conquest in 1066 A.p., there were
only about one million people in the British Isles. As recent as the beginning of
the eighteenth century, the population of the British Isles had grown only to
about 7 million persons, almost 10 per cent of whom inhabited the city of Lon-
don. From about this point in history on, however, great discoveries and events
began to occur at an accelerating rate: the discovery, exploration and colonization
of new lands; the use of coal; the discovery of steam power and its application to
transportation and industry; advances in medical and related sciences; the be-
lated planting and nurturing of the seeds ol social consiousness and democratic
self-government. These and other types of revolutions led to a sudden spurt in
the size and distribution of the human race, in effect, to a human explosion. As
previously pointed out, to appreciate the recency and magnitude of this human
explosion, it should be realized that whereas during the tremendous period before
1650 A.p. the world population grew to only 250 millions, in the mere 300 years
since there has been a fivefold increase to over 214 billions.

Even from this very sketchy résumé of man’s experience, it is clear that pub-
lic health as we have known it is still an extremely recent concept, that man has
been exposed to its potential benefits through only a tiny fraction of his total
THE PAST AS PROLOGUE 07)

 

time span, and that of necessity up to the present, the quite new public health
profession has been addressing itself essentially to a vast accumulated backlog of
problems and needs and, incidentally, with signal success.

If our eventual goal is the ultimate possible length and quality of human life,
considering all of man’s past, present and future, it may be contended that public
health through time must consist of three phases, i.e., cleanup, repair, and build-
ing. Timewise, it must be clear that we have been devoting our attention so [ar
to the first and to some extent the second of these, and it is hoped that this period
will be of limited duration. It is the construction phase, the positive building of
good health, which must endure through the long period of man’s future as
our goal, and this is the goal which henceforth should occupy a major share of the
attention and effort of society in general, and of public health workers in particu-
lar. In other words, we have merely begun, and the best is yet to come.

Our Exploding Era. In order to determine our proper place and role in the
present and [uture world scene, and in order to understand the environment in
which we must work, let us again examine closely the world at large. We must
recognize that we are living in the midst of what is undoubtedly the most active
revolutionary period of man’s history. Historically of course, it had its origin in
the earlier remarkable period of the eighteenth century which saw, among other
things, the birth of the French and American Revolutions, and the Industrial
Revolution. In some ways, this earlier period might be considered to represent
the lighting of the fuse, and the present full force of its consequences to repre-
sent a series of intimately interrelated explosions, i.e., demographic, economic,
social and political, cultural and scientific and technological. All of these revolu-
tions or explosions bear great significance to the direction which public health
activities of the future must take.

The Demographic Revolution. Because ol its complexity and the number of
variables involved, an adequate explanation and understanding of the current
demographic revolution is not easy to come by. Some of the many factors were
discussed briefly in the first chapter of this book. With particular reference to the
United States, several readily apparent recent phenomena of consequence may be
noted. It is a lact that we have never experienced such an increase in marriages,
such a reduction in the average age ol marriage and parenthood, and such an ab-
solute relative increase in births as has occurred since 1940. All of these have had
a positive effect upon the population. Even if the marked reversal of the average
size of the family were not increased, the mere lowering of the average age of
marriage and parenthood, with a shorter interval between generations would
result in a larger number of people living at any given moment.

Barring unforseen adverse economic or other events, the number of births
may be expected to continue to increase. The millions of babies born during the
last decade will become marriagable during the 1960's, producing an additional
spurt in the number of births. Expectations are, therefore, for about 4.5 million
annual births by 1965, over 5 million by 1970, and almost 6 million by 1975.
Added to this, of course, is the similar effect of greater longevity due to the
markedly successful application of public health measures, improved nutrition,
and similar beneficial factors. Thus, life expectancy at birth has increased from
076 THE FUTURE

47.3 years in 1900 to 69 years at the present time, with a high of 73 years for
white females. At the turn of the century, of every thousand infants who sur-
vived, 162 died within their first year, whereas now fewer than 26 succumb.
Notestein! has emphasized this by pointing out that a white female born in the
United States today has a better chance of living to the age of 60 years than she
had of surviving to her fifth birthday in 1900. Nor have the benefits been re-
stricted to children. In 1900 more than 25 per cent of children born in the United
States faced the prospect of becoming orphans by the time they reached 18 years
ol age. This grim figure, fraught with so many social implications, has now been
reduced to 7 per cent.

The unforeseen dramatic extension of the length of life is well illustrated by
reference to the innumerable correct predictions of the imaginative Jules Verne.
In most things, time proved him to be amazingly accurate. However in 1890,
when the average length of life was 37 years, he optimistically predicted that 1000
years later, in the year 2890, the average life span would reach 58 years! Un-
doubtedly this trend will continue for some time, and it is entirely conceivable
that by 1975 the average age expectancy ol life at birth might be at least 80 years.
As a result, it is reasonably certain that our population will increase 10 to 12 per
cent per decade during the next two to three decades. This will bring about a
total population in 1975 of from 210 to 230 million people.

One result of the foregoing is that while in 1900 only 13 million persons or 18
per cent of the total population were in the age group over 45 years of age, now
the corresponding figures are about 45 million and about 30 per cent. Further-
more, it is estimated that by 1975 almost 50 per cent of the labor force in the
United States will be over 40 years of age. In briel, then, the current population
boom is characterized by marked increases at both ends ol the life span—inci-
dentally, the periods of life which ordinarily demand the greatest amount of
medical and public health attention.

The Economic Revolution. There are many characteristics ol the current eco-
nomic revolution which do and will affect the nature of public health problems
and programs. There is a distinct and rapid trend toward economic equality
among people. In the United States, for example, this is evidenced by continued
broadening of the social security coverage, the development ol the concept of the
guaranteed annual wage for industrial workers, the increased purchase of insur-
ance and retirement policies, and the ever-widening ownership of corporate
stock. A recent survey ol college students emphasized this trend. It showed
a decided perference for a moderate salary with reasonably adequate social
security provisions to a much larger salary with no such security benefits. The
significance of this had best be left to the sociologist, the psychiatrist, and the
theologian. As a result of this trend, the standard of living among all groups
and classes of the population has been equalizing and going up steadily and
markedly at the rate of about 1 per cent per year. Already it has reached a level
quite unexpected only a few years ago. Where only a short time ago politicians
promised two chickens in every pot, one now hears about two cars in every
garage.

Social and Political Revolution. The effects of the rapidly expanding econ-
omy are closely linked with the recent striking social and political changes. In-
THE PAST AS PROLOGUE 077

 

creased labor has not been the price of the rapid improvements in the standard
of living. Quite the contrary, the annual days of work required, if anything, are
getting fewer and work itself is becoming physically easier. With the increasing
use of electronics and automation and the beginning availability of atomic power,
even more marked changes may be expected. In fact, a work week of as few as
three or four days is not impossible to anticipate. The implications of more
time for cultural and recreational pursuits on the one hand, and to additional be-
havioral and mental health problems on the other hand, should not be over-
looked. In addition, expanded use of automation will mean less tedium, less
job fatigue, and fewer opportunities for industrial accidents and illness. It should
be noted that the number of women in the labor force has increased to about 30
per cent of the total. Significant also is the change in the types of women’s oc-
cupations from domestic, farm, and semiskilled labor to clerical, semiskilled,
skilled, and professional activities. Possible results may be an increase in the
number of women involved in industrial and vehicular accidents, and in the num-
ber who have physical and mental disabilities attributable to chronic tensions.

Of great social significance is the strong trend toward urbanization and
metropolitanization. In the past fifty years, the urban population has increased
[rom one half to over two thirds of the total population of the United States,
with only 15 per cent now left on farms. Even so, the 15 per cent on farms are
producing surpluses of many food products. The last decade has witnessed the
appearance around every city ol large numbers ol relatively self-sufficient subur-
ban developments of moderate-priced homes or apartment dwellings, usually cen-
tered around self-contained decentralized shopping and recreational centers. It
would appear that these are destined to become the social, economic, and political
units of the future and should represent important points of impact for public
health education and the programs it promotes.

The combination of expressways, industrial decentralization, suburbaniza-
tion, and metropolitanization has led to the appearance of two new phenomena:
the town which appears almost overnight around a single decentralized industrial
plant, and the so-called “strip city” which consists of a number of cities or metro-
polises and their merged suburbia. An excellent example is the continuous
strip which extends from New York City to Washington D. C. These phenomena
bring with them many new and challenging problems in public health, sanitary
engineering, and the provision of medical and hospital care. Among them are
the “central rot” of the older cities, the needs for urban redevelopment, prob-
lems of stream and air pollution, the development of suburban slums, and
the search for a tax base lor the financing of services.

One other characteristic of the present social change is the remarkable
mobility of the average American. What with work car pools, changed employ-
ment, business trips and vacations, a viewer from the higher atmosphere must
obtain an impression of Brownian movement. An idea of the extent of the
movement may be realized by the fact that one fifth of the population now
changes residence each year. The shallow social roots which result have far-
reaching implications with regard to family stability and cohesiveness, the patient-
physician relationship, and the epidemiological factors of susceptible-immune
ratios and exposure. In addition to the millions of travelers within the country,
678 THE FUTURE
more than a million United States citizens travel abroad each year, and millions
more will cross the borders into Mexico and Canada. In the process of visiting
all parts of the world, United States tourists spend approximately 1.5 billion
dollars each year. The injection of this amount into other national economies
must have some ultimate beneficial effect upon their standards of living, in-
cluding health services for themselves and for tourists. The public health im-
plications of this amount of travel are obvious, and it is of passing interest that
a new specialty known as emporiatrics (the science or the study of the health
ol the traveler) was recently born.

The Cultural Revolution. Hints of the significant cultural changes to come
are many. Already there is ever-increasing attention given to education both
quantitatively and qualitatively. This is as true for adults as it is for children.
There is more time for leisure, social interests, [amily activities, and intelligent
consideration of current social and political issues, including those related to
personal and community health, and the needs for and possible methods of
providing adequate medical and hospital care for all. The combination of rising
labor costs and of more free time has brought about a considerable interest in
hobbies and “do it yoursell” activities; these activities are good for mental health
on the one hand, but risky in terms of increased chances for home accidents on
the other hand. With the lowered age at marriage, parents may really be young
with their children, and the trend toward disintegration of family ties appears
to have been stopped and reversed. These factors cannot help but contribute
to improved family relationships and better mental health. Furthermore, younger
mothers, with a better education, more leisure, and a somewhat more sophisticated
outlook, will of course have an effect on the birth rate, family size, child health,
maternal health, and insistence upon adequate medical and institutional care.
This is part of the phenomenon to which several have called attention: the
shift from the era of the dominant father to the era ol the dominant mother,
and especially of the dominant child.

The Scientific and Technological Revolution. In the crucible in which the
scientific and technical revolution is occurring, many wonders which bid well
for the future may be found. The amazing advances in the medical and surgical
fields are common popular knowledge and undoubtedly will become increasingly
popular news items. One thing is clear—people want to know about anything
that will make them well and keep them that way.

New techniques, instruments, drugs, and antibiotics are appearing with a
dizzy rapidity which makes it literally impossible to remain adequately informed.
There would appear to be no limit in this field, and the future is certain to
bring forth products more remarkable than those already developed. The rate
of major medical developments has been about one per century before 1900,
about one per decade between 1900 and 1940, and one or more per year since
1940. New pharmaceuticals are being developed, tested, and mass produced on a
calculated investigative production-line basis. This was reflected in a recent
survey which disclosed that 90 per cent of the prescriptions now written in the
United States are for medications and prophylactic products which did not
even exist ten years ago.? Oral agents for immunization against several infec-
THE PAST AS PROLOGUE 079
tions are now being tried with apparent good results. Already significant phar-
maceutical cracks have been made in the walls ol certain cardiovascular diseases,
a number of metabolic diseases and even certain mental illnesses. It would appear
to be just a question ol time before an effective oral contraceptive appears on
the market. As an additional example, it is probable that eventually a chemical
or hormonal means of significant delay of the menopause will appear. The
social, moral, medical, economic, and demographic effects of such discoveries will
be far-reaching.

An area of important technical advance is to be found in the construction
industry. New materials and methods ol construction ol dwellings are being
tried on large scales. It may be expected that out of these efforts will come more
satisfactory and more sanitary low-cost and medium-cost housing, which will
help to eradicate one ol the contributing causes of physical and mental ill health
and juvenile and adult delinquency. At the same time it may be anticipated
that increased activities in the fields of community planning and traffic engineer-
ing will result in fewer vehicular accidents.

Ol all technical advances, those relating to the use of nuclear energy of
course overwhelm everything else. We are all increasingly aware ol and con-
cerned about the problems it will bring as well as its blessings. On the one hand,
public health workers view hopelully its application to the treatment of malignan-
cies, to portable x-ray equipment, to food preservation, to sewage treatment, and
many other things. On the other hand, we must view with concern the problems ol
civil defense, disposal ol radioactive industrial wastes, and the like. The poten-
tialities of the peaceful application ol nuclear energy are so great however as
to contraindicate anything but a hopelul, optimistic viewpoint of the future.

Course of Action. In the light of man’s past history and ol all of these
momentous current events, what must be our course ol action in the field of
public health? Relerence was made previously to the three phases—clean-up, re-
pair, and building—that public health must consist of through time. It would
seem logical that their counterparts during this present period of public health
history should be (1) consolidation ol past successes, (2) remediation of the
backlog ol disabilities, and (8) a truly vigorous, carefully planned attack upon
both new problems and unsolved old problems.

Consolidation of Past Successes. Consolidation of past successes, really con-
sists of unfinished business. There is a tremendous amount yet to be accomplished
in the areas lor which we now have quite adequate tools and knowledge for
rather complete success. Consider the area of health statistics. The gathering
and processing of relevant data form an essential part ol the approach whereby
the problems which confront us are studied, understood, and attacked. Excellent
and current data are available on the circumstances surrounding births and
deaths in the United States. But we still fall far short of the more important
goal of satisfactory morbidity data, i.e., the incidence and distribution through
time and space ol illness, the types of illnesses, proneness to illness, and many
other analyses. There is a serious need, particularly at this time, to extend the
use of proved procedures such as sampling techniques and the full collation
of available data. The recently established continuous national health survey
680 THE FUTURE

will be of assistance. Beyond this, public health agencies, the medical profession,
hospitals and clinics, insurance companies, business and industry, and various
social agencies must soon work out a much more adequate means of standardizing
and pooling their respective data concerning illness. Similarly, more extensive
use must be made of longitudinal studies of health and disease. In addition,
there are certain customary categories such as cardiovascular disease and cancer
which should be broken down in order to pinpoint and expedite our future
attack upon their components.

There is still a vast amount ol unfinished business in the control of diseases
against which we already have quite effective tools. It is entirely reasonable to
visualize that during the next twenty to twenty-five years tuberculosis, the venereal
diseases, poliomyelitis, undulant fever, meningococcic meningitis, tetanus, rabies,
trichinosis, and a number ol other diseases might for all practical purposes be
eradicated in this country, and even in the world. Tuberculosis and syphilis still
account for about 25,000 deaths per year in the United States. Certainly these
deaths are needless in view of our expanding economy, our existing knowledge,
the increased availability of hospital beds, isoniazids, PAS, and the ever-broaden-
ing spectrum of antibiotics.

Eradication is admittedly a strong word, but twenty-five years ago how
many people would have believed that by now deaths from typhoid fever, small-
pox, malaria, typhus fever, diphtheria, scarlet fever, pertussis, measles, and a
number of other previously important diseases would no longer occur to any
practical extent in the United States? Yet, today these triumphs are realities.
On the international level, a number of countries are already working with the
World Health Organization toward the goal ol world-wide eradication of malaria.

There are still many other discases which, although not yet eradicable, can
be depressed to a [raction ol their present level. Among these are pneumonia,
influenza, dysenteries, diabetes, appendicitis, and many maternal and infant
deaths. Not including the approximately 110,000 infant deaths, these conditions
result in the loss of almost 100,000 lives each year. A nonfatal but very important
pathological condition that can be expected to decrease substantially is dental
caries.

In the area of environmental health an enormous amount of consolidation
awaits fulfillment. As pointed out elsewhere, there are still about 5,500 com-
munities, containing [rom 2 to 3 million people, that have no public water
systems; and almost 15,000 communities, containing about 80 million people,
that have waterworks in need of improvement or extension. Over 9,000 towns,
containing about 614 million people, need sewerage systems, and about 10,000
other communities, containing about 80 million people, have sewerage systems
which need improvement or extension. In rural areas, more than 33 million
people still lack satisfactory excreta disposal facilities ol even the simplest type.
Many ol the sanitary shortcomings mentioned relate to the expanding suburban
areas. There is a great need to discover and develop more adequate solutions
to the environmental health problems of these areas. The political scientist will
probably contribute to this as significantly as the sanitation scientist.
THE PAST AS PROLOGUE 081

 

Disease outbreaks traceable to food, milk, or water, while fewer each year,
still occur to a significant extent. Workers in the field of environmental health
still have before them the application or provision of customary sanitary services
and safeguards to the great number of new suburban communities, the exten-
sion of industrial safety and hygiene to the large number of smaller plants,
and the challenge of the rapid economic and industrial development of the
South and West.

A great social challenge still facing public health workers and others is
the complete equalization of opportunities for health among the races. The
relationship of poverty to illness, disability, and malnutrition is now accepted.
With greater equalization of educational and employment opportunities, wealth,
foods, and goods, and the ever-rising standard of living, the differences in health
potential should become much less. In order to accomplish this, the development
of a more effective working interrelationship among agencies in related fields
will be necessary.

For quite a few years, we have discussed and promoted the concept of com-
plete coverage of the nation with adequate local health services. Yet, many
significant areas remain unserved or, if served, served by too few professional
workers. Also, it must be realized that more is involved than the mere quantita-
tive filling-in of a geographic jigsaw puzzle. Quality of personnel and program
is involved too. In addition, we are now confronted with the problem of further
practical administrative decentralization of local health services to serve more
adequately the multiplying and growing neighborhood and suburban housing
developments, possibly through their trading centers.

Perhaps the most important point for consolidation, and one which affects
most of the others, is assurance of the availability of adequate medical and hos-
pital services for all of our population. Provision of this is most difficult because
many complex economic problems are involved and traditional political and
professional philosophies must be considered. Actually, much progress has been
made in recent years, especially by means of voluntary group medical and hos-
pital insurance. With regard to future developments, it may be anticipated
that the public health profession will play a significant role as a catalyzer, a
meeting ground, and possibly as an administrative agent, for all interested parties.
While the basic problem at the moment is to provide a way to lighten the burden
caused by catastrophic illness or injury, we must also consider it in the light
of the eventual development of an all-inclusive medical, hospital, nursing, and
social service with strong if not major emphasis upon positive health promotion,
early diagnosis, and prevention of disease. An increasing number of institutions
are already experimenting along these lines.

In order to meet the foregoing needs, certain personnel problems must be
solved. We must develop more successful methods of recruitment into all of
the health fields. A more aggressive and carefully planned approach to high
school and college students must be pursued. But before we attempt to interest
students in our field we must define our future goals and must ouselves be sure
of what we are trying to accomplish and in what we are trying to interest them.
Needless to emphasize, more reasonable salaries and benefits must be secured
682 THE FUTURE

 

for public health workers. Beyond this, however, is the necessity to work out
some equitable means of transfer of accumulated benefits such as retirement
and pension rights from one location to another.

Over a relatively short interval of history we have witnessed the development
ol numerous splendid training centers related to the health sciences: schools and
institutions of medicine, nursing, engineering, and public health. They have
developed high standards and practical methods of teaching and have contributed
greatly to the world’s knowledge through their research. Nevertheless, it would
seem imperative that their goals, curricula, and facilities be reviewed particularly
carefully and continuously at this time, in relation to the revolutionary changes
which are occurring with such rapidity and which are shaping the future. It
is quite probable that a rather considerable retooling job is needed in all quarters.
Certainly the time has come for health workers in all fields to have a much
better background than heretofore in sociology, social pathology, behavioral
science, community analysis and dynamics, and political science. Medical schools
as well as schools of public health must place more stress upon subjects such
as the medical and health problems which arise {rom exposure to fissionable
material, accident prevention, mental health, chronic disease control, physical
medicine and rehabilitation, and especially geriatrics and preventive and promo-
tive medicine. The health department of the near future will probably include
geriatricians, as yesterday they added pediatricians.

A final personnel problem is the inability to supply and pay for a qualified
staff of sufficient size to meet the needs and demands of the citizenry. As a result,
we must be willing to explore possible satisfactory compromises which will pro-
vide more efficient service to more people. The potentialities of joint employ-
ment with other health agencies and with agencies in related fields should be
explored further. We must experiment much further with the use of auxiliary
personnel such as nonmedical administrators and epidemiological field invest-
igators, and nurses’ aides. Proper relationships and division of responsibilities
must be worked out between sanitary engineers and sanitarians and between
public health nurses and medical social workers. It may be useful to consider
blends of public health nurses, social workers, health educators, and other per-
sonnel. Possibly we may find it worth while to develop some entirely new cate-
gories of personnel which will more adequately meet the new challenges which
are on the horizon.

Remediation of the Backlog of Disabilities. What sometimes has been referred
to as the fourth phase of medicine forms the second part of our present and future
concern—the remediation of the great backlog of disabilities to the point where
the certain amount of inevitable current disabilities may be handled with rela-
tive ease and economic efficiency. Two aspects of this are important for us to
realize at this time, i.e. the size ol the backlog and its economic significance.
With regard to extent, it has been estimated that there have accumulated in
the United States at the present about 21% million persons with orthopedic
impariments, about the same number with unremedied hearing defects, and about
a quarter of a million blind. Furthermore, about a quarter of a million disabilities
due to accidents, illness, or congenital defects are added each year.

Recent experience, particularly during World War II, has established the
THE PAST AS PROLOGUE 0683

 

fact that a very large number ol all types of handicapped persons are capable
of making real and significant social and economic contributions if given an
opportunity to readjust to the demands of working and living situations. In
every community there are disabled persons in need of assistance, but how
many public health agencies have really addressed themselves to this challenge?
The public health agency obviously cannot be expected to do the whole job,
but it can serve as the catalyzer in the first instance lor the establishment of a
sound program, as a rallying point [or all public and private agencies involved.
Beyond that, it may provide certain specific activities in the field of physical
and mental rehabilitation. It may also make known to the public and to special
groups the needs, methods, and opportunities for prevention and rehabilitation
ol disabilities. It is impossible, of course, to predict, but the incidence of dis-
abilities may not necessarily continue at its present level. Progress in control of
tuberculosis, immunization against poliomyelitis, prevention ol a few of the
congenital malformations, and potential advances in the prevention of accidents
or better management of their consequences, and prevention of cardiovascular
diseases and mental illness may result in a smaller annual addition to the number
of disabilities.

Attack on New and Unsolved Old Problems. There are so many new areas
left for aggressive pioneering attack that it is dificult to know where to begin.
All of these are problems to which various persons, groups, or agencies have
addressed themselves to some extent. For the most part, however, as a professional
group we must admit that we have been merely dabbling around the fringes.
Of one thing we can be sure—the abatement and if possible the control of the
so-called chronic noncommunicable diseases will be our major concern for quite
some time into the future. With regard to these conditions, the importance of
early diagnosis of predisposition or actual illness has logically been stressed.
In this connection, periodic physical or so-called health examinations have been
discussed and promoted for many years. Yet it must be admitted that the recep-
tion of the idea both by the public and unfortunately by many of the medical
profession has been disappointingly poor. There are a number of reasons for
this, each representing a challenge. There is the matter of economics. The phy-
sician is entitled to a fee for his professional service. But many people are either
not sufficiently sophisticated to seek out or not economically able to afford
medical attention in the absence of a frank illness or disability. A serious deter-
rent is general medical disinterest in the periodic physical examination. One
has only to canvass a number of conscientious enlightened citizens who have
sought to obtain this sort of medical service to learn of their all too common
disillusionment. Too often the physician is so preoccupied and overloaded with
patients who have frank ills and injuries that he essentially pats the apparently
well patient on the back, tells him he appears healthy, and sends him on his
way. Then there is the deterring factor ol misguided modesty which delays
many people from seeking out periodic physical examinations until the develop-
ment of definite signs or symptoms drives them to it. All of these deterrents
represent real challenges for the medical profession, medical educators, medical
economists, public health administrators, public health educators, and behavioral
scientists.
084 THE FUTURE

 

Let us pass on to some of the chronic noncommunicable diseases which are
now of such high incidence and consider briefly some of the prospects for the
future. The total picture, although at the moment somewhat overwhelming, is
not necessarily entirely dark. Recognition must be given to the remarkable
advances which have been made in only very recent years in the better under-
standing of the physical chemistry and physico-pathology of many of these
diseases, and in the fields of biochemistry, pharmacology, and chemical and
industrial antibiotic production. Consider cardiovascular disease, the current
captain of the causes of death. It accounts [or 50 per cent of the total death
toll in the United States. Actually, it is a complex of different conditions, i.e.,
congenital heart disease, rheumatic heart disease, arteriosclerotic heart disease,
hypertensive heart disease, cardiac syphilis, thyroid heart disease, and various
other organic and [unctional cardiac conditions. Some of these are potentially
eradicable, while the incidence and seriousness of others may be reduced. Eradi-
cation of heart disease due to rheumatic fever, syphilis, and thyroid dysfunction
is well within the realm of possibility. Some reduction in congenital heart disease
may be expected from the assurance of rubella and other viral infections in
woman before marriage and pregnancy. Discovery of the significance of familial
tendency, obesity, and personality also have done much to point to ways of
prevention or abatement of hypertension. More recently, the discovery of the
dramatic efforts of rauwolfia and other tranquilizers on hypertension, with few
adverse effects, opens a whole new vista for speculation.

Recent developments provided a possible means of prevention of athero-
sclerosis. There are indications that this condition may be delayed or its effects
kept to a minimum by lipotropic factors such as choline and inositol which
reduce high blood cholesterol levels. It may be possible to prevent or control
the disease by a diet low in cholesterol.

In all of these and related situations there are many possible points of
action for public health agencies: the administrative organization, promotion
and possibly management of positive health maintenance by means of periodic
health examinations; the use of chest x-rays for screening of certain cardiac de-
fects in addition to tuberculosis; generalized and individualized nutrition educa-
tion, especially with regard to obesity; the adequate provision of protective fac-
tors, and in some instances low cholesterol diets; activities in the field of mental
health, especially as it relates to personality factors; and general health education.
Two important and encouraging points should be borne in mind with regard
to cardiovascular diseases: (1) the inevitable beneficial effect of the recent con-
siderable and widespread improvement in the standard of living, including
nutrition; and (2) the fact that sulfonamides, penicillin, and the host of other
antibiotics have been used for only about fifteen years. There is reason to expect
that we have not yet even begun to reap some of the long-term delayed-action
benefits of these two factors and that their effects will show up in part in a future
lowered incidence of some of the cardiovascular diseases.

Cancer represents perhaps the most difficult disease problem for now and
for the future. There seems to be no question of a real increase. Some reasons
for encouragement do exist, however. Detection at earlier stages of cancerous
lesions not readily accessible is becoming more common, through the wider use
i THE PAST AS PROLOGUE 08)
of radioactive tracers and the Papanicolaou technique of cytologic examination.
The health officer might well devote attention to the physical and economic
availability of these procedures to all who might benefit from them. Considerable
progress is being made also in treatment with radioactive isotopes, improved
deep x-ray equipment, and improved surgical techniques. The large sums of
money now going into research on the causes, prevention, and treatment of
cancer also give reason for a substantial degree of optimism. Meanwhile, public
health personnel may participate further not only through increased general
public education, but also by extending control over certain environmental
factors, urging and arranging for periodic physical and laboratory examina-
tions, and encouraging continued and extended good obstetric and gynecologic
practice.

About a half million people suffering from mental disorders now occupy
about one half of the hospital beds in this country, and the demand is increasing.
There is some question, however, whether the increase in mental disorders is
real or apparent. The public is much more aware of the problem than ever
and now is willing to discuss it in other than hushed terms. As a result, many
more people are seeking treatment than previously. Also, more conditions are
being recognized as mental aberrations. The shortages of hospital beds, psychia-
trists, psychiatric social workers and inadequate psychiatric training among public
health personnel are serious problems. On the other hand, in addition to im-
proved fever and shock therapy, the door to a new approach has been opened
by the discovery of some remarkably effective drugs such as reserpine and other
tranquilizers and chlorpromazine. If, as previously predicted, a means of putting
off menopausal changes is developed, a significant result should be a decrease
in involutional melancholia and senile psychosis. About 16,000 deaths each year
are attributable to suicide. Here is a significant field related to sociology, psy-
chiatry, mental health, and community education that public health workers
with very few exceptions have completely ignored. It is not inconceivable that
local health departments, in addition to public education, might provide or ar-
range for around-the-clock guidance services for the despondent, somewhat simi-
lar to the activities of Alcoholics Anonymous. Such a program should use the
collaborative help of religious, medical and other groups in the community.
Related to this is the potential contribution that public health workers might
make to the solution of the problem of juvenile delinquency and other manifesta-
tions of the “maladjustment—ill health—dependency syndrome” discussed at
length in Chapter 6.

Finally, to touch briefly on a completely different area for pioneering, that
of environmental health, consider the relatively meager and ineffective manner
in which we individually and collectively have addressed ourselves to the public
health aspects of stream pollution, atmospheric pollution and control, the
disposal of radioactive wastes, the prevention of home accidents, and inadequate
housing. These are “musts” and will continue to be so into the future.

Conclusion. Challenges>—No end of them. Shortly before his recent death,
the great inventor and industrialist Charles F. Kettering said: “The achievements
of the past 50 years will be dwarfed by the things to come if we just keep our
minds open and willingly contribute each day an honest day’s work.”
086 THE FUTURE i

As participants in one of the most successful and significant endeavors in
history, we must each keep our minds open and contribute a share of thoughtful
imagination to the solution of the fascinating challenges of the future and, in
so doing, remember that intelligent mankind is still very young and that the
future will last a long, long time.

REFERENCES

1. Notestein, F. W.: As the Nation Grows Younger, Atlantic, 200:131, Oct. 1957.
2. News Item, A.M.A. News, Dec. 29, 1958.
Author index

 

Abbe, L. M., 642

Aberle, S., 522

Abrams, H. K., 612
Ackerman, N. W., 141
Adams, James Truslow, 125
Allan, W. S., 631

Allen, F. E., 276

Allen, F. P., 136
Altenderfer, N. E., 136, 375
Anderson, Gaylord W., 219, 434, 442
Anderson, Odin W., 63, 653
Anderson, William, 191, 239
Andrews, J. M., 440
Armstrong, D., 617
Armstrong, W., 522

Arnim, S., 522

Arnold, F., 523

Artis, R. N., 587

Ascher, Charles S., 205, 438
Ast, D., 523

Aston, E. R., 517

Atkins, C. H., 414

B

Bacon, S. D., 573, 580
Badger, George F., 549
Bahn, A. K., 625
Bailey, A. E., 372
Baird, D., 136

Baker, M. C., 52
Baney, A. M., 642
Bauer, C., 435

Bauer, W. W., 404
Baynton, H. W., 428, 430
Beadenkopf, W. G., 617
Beal, V., 500

Bearg, Philip A., 286
Beers, Clifford W., 621

Benedict, Ruth, 104, 106, 107
Bernard, Jessie, 109
Bessman, S. P., 618
Betters, Paul V., 191
Bibby, B. G., 523

Bird, F. L., 173

Black, G. V., 522
Blackstone, William, 194
Bloomfield, J. J., 604
Board, L., 414

Boek, J. K., 22, 617

Boek, W. E,, 22

Bogue, R., 110

Bolduan, Charles F., 91
Bolduan, N. W., 9]
Boudreau, F. G., 494, 495
Bourgeois-Pichat, J., 31
Bowditch, Henry 1, 46, 51
Bowes, G. K., 32

Boyd, Richard F., 219
Bradley, J. E., 618
Brakel, L. V., 467
Braunstein, P. W., 617
Brekhus, P., 522

Brewer, A. F., 554
Brightman, I. S,, 617
Briscoe, A. B., 181, 182
Britten, R. H., 592, 629
Brogan, Dwight W., 175, 177
Brossard, J. H. S., 142
Brumback, C., 526

Buell, B., 142, 148, 153
Buhrman, H. M., 640
Bull, F. A,, 523

Bullis, H. E., 623
Bunting, R. W., 520
Burke, B., 500

Burke, Edmund, 21

687
688 AUTHOR INDEX

 

Burney, Leroy E., 262
Buzzard, F., 131

Cady, F. C., 521

Calver, Homer N., 335
Cameron, D. C., 609
Cann, H. M,, 618
Cardoza, B. N., 194
Carothers, J. C., 105
Caudill, W., 144
Cavins, Harold M., 52
Chadwick, Edwin, 44, 45
Chadwick, Henry D., 47
Chapin, Charles V., 549
Chapman, A. L., 617
Chase, H., 523

Cheney, B. A., 262
Cheyne, V. D., 523
Christensen, A. W., 546
Ciocco, A., 375

Clark, G. A., 572
Clayton, G., 431, 432
Coffey, E. R., 407

Cole, W., 617

Collins, Selwyn D., 515, 521, 592, 629, 643
Condit, P. K., 554
Cook, R. C., 27

Cort, W., 544

Cox, G. J., 523
Crowther, B., 136

Daily, Edwin F., 479

Dappert, A. F,, 413

Darling, George B., 287, 386

Dauer, C. C., 424, 425

Davis, Michael M., 653

Davis, N. S., 596

Davis, W., 506

Dean, H. T., 521, 523

Deibert, A. V., 507

DePorte, J. V., 374

Derryberry, Mayhew, 404, 406

de Shelley-Hernandez, R., 387

Dewhurst, J. F., 171

Dietrich, H. F., 617

Dimock, Marshall E., 226, 227, 270, 273, 274,
282, 283

Dollar, M., 514

Douglas, Bruce H., 487

Druzina, G. B., 546

Dublin, Louis I., 82, 599

Dunn, Halbert 1.., 384

 

 

Dunsmore, H., 414
Dworsky, L. B., 420
Dyktor, H. G., 433

E

Eager, J., 522

Easlick, K., 518, 519, 520, 524
Ebbs, J., 500

Ehlers, V. M., 421

Eliassen, R., 421

Eliot, Martha, 64

Elkins, A., 119

Eller, C. H., 153

Emerson, Haven, 226, 262, 546
Erasmus, C. J, 116

Erwin, W., 519

Evang, K., 652

Falk, I. S., 643, 654

Falk, L., 422

Feiner, Herman, 180

Felix, R. H., 624

Fiore, A., 617

Firket, J., 431

Fitzgerald, J. S., 592, 629

Flook, Evelyn, 262, 339, 340, 342, 345, 351,
354, 374, 396, 446, 546, 551, 624

Florio, L.., 518

Fosdick, L., 522

Foster, G. M., 113, 117, 118, 119, 120, 127

Foster, R. G., 149

Fowler, William, 375, 552

Fox, Leon, 287

Fox, R., 142

Frederick, W., 432

Freeman, Allen W, 211

French, W. J., 467

Freund, E., 207

Frisch, J. G., 523

Frost, Wade H., 562

Fuchs, A. W., 427

G

Gafafer, W. M,, 521

Galdston, Tago, 132, 657

Galpin, Charles J., 166

Gaus, J. M., 226

Geiger, Jacob, 295

Gellhorn, W., 209, 215

George, M. Dorothy, 42, 43, 44, 46
Gibson, W. B., 430

Gilbertson, H. S., 164

Gillette, J. M., 32
AUTHOR INDEX 089

 

Gittler, J. B., 105
Godfrey, Edward S., 561
Gooch, M., 260

Gordon, John E., 549, 617
Gotaas, H. B., 422

Gould, John, 169

Grace, L., 515

Grant, M., 467

Gray, A. S., 607

Gray, J. C,, 119

Green, Howard W., 383%
Greenberg, A. E., 422
Grigg, W. K., 584
Grotjahn, A, 133
Gruebbel, A. O., 527, 530
Guernsey, Paul D., 335
Gulick, Luther, 225
Gunn, Selskar M., 662, 665, 667
Gurvitch, G., 195

Guthe, T., 76

Habashy, Azia, 110
Hagan, T. L., 523
Hailman, D. E., 593
Haldeman, J., 340

Halse, L. M., 555
Halverson, W. L., 191
Hankla, E. K., 262
Hanlon, John J., 207
Hansen, H., 522
Hardgrove, T. A., 523
Harmon, Gaius E., 405
Harral, Steward, 311
Hatcher, G. H., 153
Hazelrigg, H., 328
Hazlett, T. L., 607
Hecker, I. F., 41
Hedrich, A. W., 554
Hemeon, W. C., 605
Hemphill, Fay M., 262
Heyroth, F., 523

Hinkle, L. E., 142
Hinman, E. H., 441
Hirsh, S., 575

Hodge, H. C., 523
Holland, Dorothy F., 476
Hollis, Mark, 411, 414, 415
Holmes, Oliver Wendell, 49, 197
Holmquist, C. A, 413
Holst, Peter M., 549
Hoppert, C., 519
Horning, Benjamin G., 261, 407
Horwood, M. P., 423

 

Hoyt, E. E., 108
Hughes, M. C., 174
Hume, J., 76

Hunt, E. P., 629
Hunt, H. R,, 519
Hussey, Raymond, 605
Hutton, W., 523
Huxley, Aldous, 32
Hyde, D. C., 181-182
Hyde, H. V,, 75, 112

Isaac, P. C., 428
Iskrant, A. P., 617

J
Jacobziner, H., 584, 585, 617, 618
Jameson, W., 496
Jay, Philip, 506, 520
Jensen, H. E., 622
Joffey, L. A., 215
Johnson, A. S., 32
Johnson, M. L., 460
Johnson, R. J., 437, 439
Johnston, M., 578

Kandle, R. P., 152

Katz, M., 432

Keller, M., 572

Kelly, R. E., 431

Kent, F. S., 617

Ketcham, F. S., 578

Key, V. O,, 63

Keys, Ancel, 505

King, C. G., 495

King, M., 556

Kirkwood, S., 500

Klassen, C. W., 421

Klein, H., 513, 514, 516, 519, 521, 522

Klem, Margaret C., 607, 610, 643

Kluckhohn, Clyde, 104, 125

Knutson, J. W., 417, 513, 517, 521, 523, 524,
526

Kolb, L., 585, 586

Koos, E. L., 102, 103, 104, 154

Kramer, H. D., 49

Kramer, L. M., 648

Kramer, M., 624

Kroeger, G., 132

Kroeze, H. A., 443

Kupka, E., 556
090 AUTHOR INDEX

L

Lade, James H., 220
Langmuir, A. D., 377
Lantz, E., 522
Larson, C. P., 429
Lathrop, Julia C., 61
Lawrence, P. S., 436, 595
Lear, W., 607, 610
Leavell, Hugh R., 99
Lee, K. F., 578
Legge, R. T., 606
Lehmann, S. L., 643
Lemkau, P. V., 623
Lennie, O., 260
Lesser, A. J., 629
Lewis, S., 514

Lewis, S. A., 578, 579
Liberti, D. V., 555
Lidz, T., 142
Linscott, B., 523
Logan, W., 432
Loomis, T. A., 573
Lotka, A. J., 82
Lowell, A. Lawrence, 34
Lowenberg, J., 50

McCabe, L., 431

McCall, J. O., 517
McCarthy, R. G., 578
McCay, C., 504

McFarland, R. A., 573, 617
McKay, F. S., 522
McKiever, M., 610

McNeel, J. O., 529

Magee, H. E., 495

Magill, P. L., 429

Magoun, Frederick A., 276, 277
Maier, F. J., 419, 523, 526
Marquette, Bleecker, 666, 668
Massler, M., 506

Maurer, Wesley H., 326
Maxwell, James A., 183, 186
Mayo, L. W., 592

Mead, M., 497

Mellins, R. B,, 618

Meltzer, Nancy S., 126
Merriman, Charles E., 177
Messner, C. T., 521

Miller, W. S., 110

Molner, Joseph G., 405
Moore, P. A., 572

Moore, R. C., 617
Moorman, L. J., 33

 

Morgan, Lucy S., 407

Morton, Roy J., 442

Mountin, Joseph W., 24, 262, 265, 339, 340,
342, 348, 351, 354, 374, 396, 446, 546,
551, 624

Mullins, R. F., 396

Murdock, G. P., 117, 128

Murray, M. L., 330

Mustard, Harry S., 185, 213

Myrdal, G., 79

N

Neumann, Solomon, 22, 132
Newman, L. E., 612
Newsholme, Sir Arthur, 48
Norman, V. B,, 625
Notestein, F. W., 676
Notkin, H., 633

O

Odum, Howard W., 170
O’Harrow, D., 437

Orr, J. B., 497

Osborn, F., 27

Osler, William, 36

Otis, T. W., Jr., 335
Otto, G., 544

P

Palmer, C., 519, 521, 522
Palmer, George, 286

Palmerlee, F., 520

Pan, Chia-lin, 31

Parran, Thomas, 257

Parsons, T., 142

Pasternack, M., 523

Patterson, R. S., 52

Patty, F. A., 609

Paul, Benjamin D., 107, 111, 126
Pearl, R., 27

Pennel, M. Y., 642

Perrott, George St. J., 261, 622, 642
Pershing, M., 617

Petty, Sir William, 81

Pfiffner, John McD, 228, 235, 255, 321
Phair, W. P., 529

Phillips, E. C., 617

Phillips, J. C., 167

Piersol, G. M., 594

Pitney, E., 522

Platt, Phillip S., 662, 665, 667
Pond, Chester B., 186

Pond, M. A, 91, 136, 617
Prescott, S. C., 423
Prescott, W. H., 47
Press, E., 617, 618
Princi, F., 430
Prothro, W. B., 617

R

Ramsey, George H., 554

Reed, L. S., 656

Rich, W. H., 559

Richardson, B. W., 44
Richardson, H. B., 141
Roberts, H., 617

Robinson, G. C., 640
Robinson, T., 617

Rogotzkie, R., 422

Rolph, C. H,, 27

Rosen, George, 22, 36, 132, 649
Rosen, H., 142

Rosenau, Milton, J., 22, 57, 66, 259
Rosenfeld, L., 260

Ross, G., 459

Rudolfs, W., 422

Rusk, H. A., 628, 629, 632
Russell, P. F., 77

Ryle, J. A, 131, 132

Salthe, O., 495

Sand, René, 639

Sanders, B. S., 263, 340
Schachter, J., 372

Schneider, David M., 115
Scholz, G. C., 523
Schottstaedt, W. W., 132, 142
Schulzinger, M. S., 619
Schwob, C. E., 420

Scott, J., 432

Scott, W., 500

Seagle, William, 196
Sebelius, C. L., 530

Sebrell, W. H., 505

Senn, C. L., 425

Sensenich, H., 628

Shafer, J. K., 554

Shapiro, S., 372

Shattuck, Lemuel, 49
Shepard, W. P., 562
Shryock, Richard H., 26, 637
Silverman, C., 554

Simmons, L. W., 130, 139, 145, 149, 150
Simpson, D. F., 262

Sinai, Nathan, 63, 643
Skinner, B. F., 103

Slee, Virgil N., 93

 

AUTHOR INDEX 091
Smillie, Wilson G., 53, 490
Smith, H. B., 522
Smith, M. C., 522
Smith, Stephen, 53
Snavely, T. R., 182, 183
Southwood-Smith, 45, 131, 132, 134
Spielholz, 1. B., 467
Steel, E. W., 421
Steiger, W. A., 132
Stern, Bernard J., 130, 610
Stieglitz, E. J., 594, 595
Stoll, N. R., 74, 286
Stolnitz, J., 31
Stone, Donald C., 10
Stroud, H., 526
Strow, C. W., 170, 630
Stuart, H., 500
Swinney, D. D., 393
Sydenstricker, Edgar, 134

T
Tauber, I. B., 30

Taylor, E. J., 629, 632

Terris, M., 22

Terry, M. C., 559

Thompson, C., 504

Tisdale, E. S., 414

Tisdall, F., 500

Tobey, James A, 212, 213, 216, 217, 218
Todhunter, E. N., 503

Top, F., 36

Townsend, J. G., 431

Trantham, K. S., 643

Trice, H. M., 573

Turner, Clair E., 330

uU

Ule, O., 493
Underwood, Felix J., 286
Upson, Lent D., 274

Vv
Van Riper, H. E., 628
Vaughan, Henry F., 25, 306, 405
Vilter, R. W., 504
Vogel, S., 579
Vogt, W., 27

w
Wagner, P., 164
Waife, S., 505
Walls, R., 514
Warkany, J., 500
Waters, T. C., 606
Waters, Y., 450
092 AUTHOR INDEX

 

Webb, W. V,, 617

Weinerman, E. R., 617

Welch, William H., 395, 449

Wenkert, Walter, 633

Wertheimer, F., 527

West, M. D., 375, 377

West, T. C., 573

White, Leonard D., 177, 185, 186, 192, 226,
238, 265, 276, 291, 299

White, Leslie A., 29, 104

Whorf, B. L., 112

Widmer, Charles, 594

Wier, J. M.,, 110

Wilder, R. M., 495

Williams, D., 523

Williams, H. C. M., 148

Wilson, Woodrow, 194

Winslow, C.-E. A, 41, 434, 612

 

Wiser, G., 467

Wolf, S., 142

Wolff, George, 133

Wolff, H. G., 130, 139, 145, 149, 150
Wood, T. D., 402

Woodward, S. B., 407

Woolsey, T. D., 629

Woytinsky, E. S., 31

Woytinsky, W. S., 31

Wright, W. H., 74

Yost, O. R., 582, 583

Zappala, A., 578
Zindwer, R., 617
Subject index

 

 

A

Absenteeism, dental ailments, 517
industrial, 607
causes, 609
malaria, 77
Accidents, 27, 614-619
alcoholism, 573
home, 616, 678
numbers of, 615
occupational, 607, 616, 677
prevention of, 617-618
government programs for, 617-618
statistics on, 615-617
surveys for, 615-617
vehicular, 615, 618, 677
Accounting records, 299-302
system, 299
unit cost, 305-306
Addiction, alcohol (see Alcoholism)
drug (see Drug addiction)
narcotic (see Drug addiction)
national program for treatment, 58
types of, 570
Addictive diseases, 570-587
Administration, graphic aids, 381-391
public health, recent changes, 225-226
Administrative districts, 238
management, definition of, 269
manuals, 252-253
Administrators, types of, 271
Adolescent, value of, 84, 87
Adult health, 142-143, 150
nutrition and, 596
role of industry, 601-602
of private physician, 596
Advisory committees, types of, 232
Age distribution, United States, 589-590
specific rates, 593

 

Aged, and nutrition, 142-143, 504-509, 596
problems of the, 124
Agency, in law, 216-218
Aging population, and handicaps, 594, 627
problems of, 142-143, 150
Agricultural Adjustment Administration, 192
Agricultural Extension Services, 498, 506
Air pollution (see Atmospheric pollution)
Alcohol, effects of, 574
history and, 570
Alcoholics Anonymous, 577, 586
Alcoholics, types of, 575-576
wives of, 579
work behavior, 573
Alcoholism, 143, 146, 571-581
accidents and, 573
cost of, 572
definition, 571
mental health and, 575-576
National Council on, 578
nutrition and, 574
prevalence, 572
prevention, 580
programs, 578-580
reasons for, 575, 577-578
World Health Organization committee on,
574
Yale study committee, 572, 573, 578
Allergy and Infectious Disease Institute, 60
American Academy of Pediatrics, 483, 490
American Association for the Study and Pre-
vention of Infant Mortality, 471
American Association of Industrial Nurses,
455
American Association of Industrial Physicians
and Surgeons, 606
American Association of Public Health Den-
tists, 524

093
6094 SUBJECT INDEX

 

American Board of Preventive Medicine and
Public Health, 67, 261
American Child Health Association, 471
American College of Surgeons, Committee
on Industrial Medicine and Trau-
matic Surgery, 606
American Dental Association, 516, 517, 523,
529
prepayment plans, 529
American Medical Association, 24, 62, 67, 261,
523
Council on Industrial Hygiene, 607,
609
medical care plans, 654-655
American Nurses’ Association, 453, 455, 465
American Public Health Association, 52-53,
66, 126, 254, 255, 260, 261, 262
Committee on Medical Care, 653
Committee on Professional Education
66, 260-261
Committee on Qualifications of So-
cial Workers in Health Agencies,
467
Dental Health Section, 513, 523
development of, 52-53
Industrial Hygiene Section, 606
Laboratory Section, 398
American Public Welfare Association, Com-
mittee on Medical Care, 653
American Red Cross, 661
nursing program, 454
Town and Country Nursing Service,
453
Amputees, prevalence, 629
Anglo-American Caribbean Commission, 362
Annales d’ Hygiene Publique, 46
Annual reports, 331
Anthropology, contributions to public health,
125-128
Appeal, legal, 222
Appropriations, emergency, 298
Arthritis and Metabolic Diseases, National
Institute of, 60
Ascaris, incidence, 74
Association of Schools of Public Health, 67,
260
Association of State and Territorial Health
Officers, 523
Atmospheric pollution, 26, 412, 416, 428-433
results of, 430-432
sources of, 429-430
Attendance control, personnel, 275
Audiology, 64

Audiovisual methods, use of, 113, 329-330, 403

 

Auditing, 307
Aztec Empire, smallpox, 47

B
Bacteriology, effect on public health, 130-131
Bali, 108
Baruch Committee on Physical Medicine, 632
B.C.G. vaccination, and United Nations Chil-
dren’s Fund, 365
Behavior, undesirable, 111
Behavioral science, 99-129 (see also, Anthro-
pology; Cultural; Culture; Cus-
tom)
contributions to public health, 125-128
Bilharzia, incidence of, 74
“Bills of Mortality,” 370
Biological products, control of manufacture,

358
manufacture and distribution, 396-397,
400-401
Biology and Medicine Institute, Experimen-
tal, 60

Births, anticipated future, 675-676
cost of, 83, 86
illegitimate, reporting, 372
increase in, 675-676
international comparisons, 69, 70, 78
rate, changes in, 28
factors determining 69-70
ratio to deaths, 386
registration area, 371
reporting of, 371-374
Black Death, 32, 33, 39-40
Blindness, incidence, 74
National Institute of Neurological Diseases
and, 60
prevalence, 565
Board of Preventive Medicine and Public
Health, 67, 261
Boards of health, 229-231
advantages, 229-231
appointments, 46
constitution of, 229
disadvantages, 230
England, 45, 51
functions, 231
history, 46, 48, 51
national, 53-54
representation on, 229
responsibilities, 214
Bowditch, Henry 1., 46, 49, 52
Bread and flour enrichment program, 500,
510-511
Bronchitis, chronic, incidence and prevalence,
591, 593
Budget, 290, 292-309
construction, 294-299
management, 294, 307-309
Bureau, in administrative organization, 242,
244
Bureau of Mines (see United States)
Burke, Edmund, 21
Burma, sanitation problems, 114

C
Cabot expeditions, 47
Cabot, Richard, 466
California Department of Public Health, 566
California Public Health Assistance Law, 190-
191
Cancer, 27
control, 188
detection centers, 598
diagnosis, 685
health department role, 685
incidence and prevalence, 591, 593
National Advisory Council, 597
National Institute, 59
programs, 597-599
Cardiac ailments, prevalence, 629
Cardiovascular diseases, 27, 684
Caries control, 477, 519-528
definition, 518
etiology, 517-520
fluorides and, 477, 521-523, 526-528
lactobacilli and, 519-520
mottled enamel and, 522-523
oral hygiene and, 519
pregnancy and, 518
Carriers, disease, control of, 205
Case finding, antepartum, 480-481
infant and preschool children, 483
tuberculosis, 92
Census, Bureau of the, 64
development of, 370
problems of, 371
tracts, 384
Central purchasing, 246, 306-307
Centralization, 177-192, 249, 251
Cerebral palsy, 64
prevalence, 629
Chadwick, Edwin, 21, 43-45, 49, 131, 132, 134
Chamberlain-Kahn Act, 181
Chancery in law (see Equity in law)
Channels of organization, 236-237, 273
Charters, municipal, 162
Charts, organization, 237-251, 566
statistical, 381-391, 558
Child Health Association, American, 471

 

SUBJECT INDEX 095

Child health, expenditures for, 63-64
Federal contribution to, 61-64
hygiene, first bureau of, 471
labor, 148
England 42-43
Labor Law, Federal, 62
welfare, eighteenth and nineteenth centu-
ries, 42-43
United Nations Children’s Fund, 365-
366
Child Health Services, Committee for the
Study of, 483
Children, crippled, prevalence, 565
services, 361, 484
handicapped, health program for, 361, 484
in school health program, 490
indenture of, 34
infant and preschool program, function of
health department, 483-484
preschool age, mental health, 477
morbidity, 475-476, 644, 646
mortality, 475
school age, causes of death, 477
correction of defects, 486-487, 491
health examinations, 486-487
morbidity, 644, 646
mortality, 477
sources of care, 691
Children’s Bureau, 61-64, 186, 262, 265, 303,
352, 859-361, 507
E.M.L.C. program, 64
function of, 64, 359
origin and development of, 61-64, 184
transfer to Federal Security Agency, 64
Children’s Fund, United Nations, 365-366
and B.C.G. vaccination, 365
Chimney sweepers, 43
Cholera, 38-39
Chronic disease, 589-603
age distribution, 592
environment and, 142
extent of, 592, 628, 629
future, 683
incidence, 590-593, 645, 646
increase, 590-591
industrial workers, 601, 602
international comparison, 71
prevalence, 590-593, 645, 646
program, 598-601, 653
custodial care, 600
follow-up, 599
hospitalization and treatment, 599
limitations, 595
national, 601
096 SUBJECT INDEX

Chronic disease program—Cont’d
private physician, 596-597
rehabilitation, 600
role of industry, 601-602
voluntary agencies, 595
Cities (see also Government, municipal; Mu-
nicipalities)
strip, 677
City commission, 163-164
manager, 164
planning, 434-439
Civil service, 262, 264-267
Cleft lip, prevalence, 629
palate, prevalence, 629
Climate and disease, 72-73
Clinical Center, National, 60
Clinics, location, 384
Clothing and health, 111
Codes, building, for accident prevention, 618
Colonial American, hygiene, 46
Colored Graduate Nurses, National Associa-
tion of, 455
Columbia, yaws program, 116
Committee for the Study of Child Health
Services, 483
Committee on Professional Education, 66,
260-261
Committee on Southern Regional Studies and
Education, 170
Committee on the Costs of Medical Care,
643, 644, 654
Common law, 197
Communicability, primitive concepts of, 120
Communicable disease, 534-569
administrative aids, 545-556
biological factors, 537-540
codes, 546-547
consultation service, 557
effect of social and cultural factors, 536
gastrointestinal, 564
general principles, 540-545
graphic aids in, 557-559
laboratory services, 557
legislation, 545-549
faults of, 546-547
methods, 540-545
modes of spread, 537-540
organization for control, 566-568
program, 559-568
registers, 566
respiratory, 560, 565
responsibility, 545-546
schools, 487-488

 

Communicable disease—Cont’d
transmission factors in, 535
tuberculosis, 562-563
Communicable Disease Center, 61
Communication, barriers to, 112-114, 126
Community health and occupational health,
608-609
organization, 126, 154
for accident prevention, 614-619
for health, 102-104
meaning of, 407
planning, 151, 434-439
Compensation, basis for, 267-269
Complainant, definition, 220
Complaints, reception of, 319
Comprehensive medicine, 25, 132
Compulsory health insurance plans (see Med-
ical care, compulsory insurance

plans)

Conference of State and Territorial Health
Officers, 359

Consultation services, communicable diseases,
557

local technical, 247
public health laboratory, 396
Cooperation, business and industry, in sani-
tation, 427-428
Corn products enrichment, 510-511
Correction of defects in school children, 586-
587
Correspondence, in public relations, 323
Cortez, 47
Costs (see Births, cost of; Dental care, costs;
Environmental health, costs and
financing; Government, local, cost:
Infant deaths, cost of; Maternal
deaths, cost of; Medical care, costs;
Sanitation, costs; Syphilis, cost of;
Tuberculosis, cost of)
Council, Health and Welfare, 151
of Social Agencies, 151
Counties, functions of, 165, 167, 168
government, 166, 167
health services, 65, 340-341
liability of, 165-166
number of, 164
officials, 167, 168-169
problems of, 165-166
reasons for, 164-165, 166
sizes of, 164-165
subdivisions of, 168
types of government, 167
County health departments (see Health de-
partment, county)
Court procedure, 220-222
SUBJECT INDEX 097

 

Courts, 202-203
county, 203
equity, 198-201
Federal, 202-203
jurisdiction, 202-203, 220
special, 203
state, 202-203
types, 202-203
Criminal act, definition, 221-222
intent, definition, 221-222
Crippled children (see Children)
rehabilitation of the, 626-634
Cross-checks, 254
Crowding and disease, 134-136
Cultural (see also Behavioral science)
anthropologists, 125-128
barriers as result of taboos, 115
factors, and communicable disease control,
536
and diet, 498, 509
patterns, effect of public health activities
on, 122-125
on health, 109-112
on public health activities and pro-
grams, 112-122
problems, aging population, 150
migrants, 149
revolution, 678
Culture (see also Behavioral science)
meaning of, 104
purpose of, 106
Cumulative, causation, theory of, 78
degradation, 147
Curandero, 117-120
Custom, definition of, 197
Customs and culture, 107
dietary, 499, 509
disease and, 138-139

D
DDT, resistance to use, 100
Deafness, prevalence, 629
Death, accidental, 615-617
attitudes toward, 101
potential reductions in, 94-96
premature, 89
principal causes of, infants, 474
Philadelphia, 382
preschool age, 475
school age, 477
United States, 591
world picture, 71
rates (see also Vital statistics)
changes in, 132, 135-137

 

Death rates—Cont’d
crude, computation of, 386
limitations, 593
decrease in, 21
effect of change on, 123
international comparisons, 69, 71, 75,
78
registration area, 371
reporting of, 47, 371-374
Decentralization, 249, 251
Defecatory customs, 114
Defective persons, 90
Defendant, definition of, 220
Delegation of authority and responsibility,
271-274
Delinquency (see also Social pathology)
disease and dependency, 147, 221
family, 143-144, 147-149, 151-153
juvenile, 143-144, 146, 679
World Health Organization Committee, 152
Demographic revolution, 675-676
Demurrer, meaning of, 221
Dental assistants, 517, 531
Dental Association, American, 516, 517, 523,
529
Dental care (see also Fluoridation)
orthodontic services, 529
prenatal, 518
prepayment plans, 528, 529
programs, 520-521, 524-530
standards for adults, 528
caries (see Caries)
costs, 517
defects, 514-516
epidemiology and D.M.F., 521, 526
health education, 530
governmental responsibilities, 525, 526
Health Section, American Public Health
Association, 513, 523
hygienists, 517, 531
needs, evaluation studies, 521, 526
personnel, 510, 527, 531
practices, undesirable, 111
programs, 27, 126, 417
prophylaxis, value of, 519
Research, National Institute of, 60, 523
seminars, 531
students, employment, 527
supervision, periodic, 528
Dentistry and nutrition, 506
preventive, 417, 513-532
public health, 417, 513-532
Dentists, American Association of Public
Health, 524
distribution of, 516
098 SUBJECT INDEX

Dentists—Cont’d
needs for, 516
numbers of, 516
Department of Health, Education, and Wel-
fare (see United States)
Dependency, delinquency, disease syndrome,
147
Detroit, diphtheria prevention program, 379,
381
infant mortality in, 109
Deviants, social, 150
Diabetes, 142
prevalence, 629
screening, 597
Diagnosis, in chronic disease, 598
Diarrheas, incidence, 75
Diet and health, 596
influences on, 497-498
Dietary habits, changes in, 499-500
factors influencing, 499, 509
Digger Indians, 107-108
Diphtheria, compulsory immunization, 552,
554
immunization, 561
prevention program, use of vital statistics,
379, 381
Disabilities (see also Handicaps)
causes of, 629
economics of, 630-631, 632
extent of, 592, 628-630, 682
occupational, 607
rates by age and sex, 644, 645
sources of, 627-628
Disability, insurance, 614-615
military, 629-630
Disabled persons, rehabilitation of, 626-634
statistics on, 629-630
Discipline, 177-184, 274-281
Discratic index, 387
Disease (see also Addictive disease; Chronic
disease; Communicable disease;
Epidemics; Epidemiology; Metabo-
lic disease; names of specific
diseases)
cardiovascular, 684
carriers, control of, 205
changes in types, 590
climate and, 72-73
control, needs, 680
crowding and, 134-136
customs and, 138-139
dependency and delinquency syndrome,
147
economy and, 76-79
environment and, 132-140

 

Disease—Cont’d
eradication, 680
etiological concepts, 116-119, 121-122
industrialization and, 142, 146
noncommunicable, laboratory, 396-397
nonreportable, 548
reportable, 548
social class, incidence by, Aberdeen, 136-138
Cincinnati, 135
Cleveland, 135
England, 148
Liverpool, 135
St. Paul, 148
United States, 134, 136
social factors and, 132-140
society and, 76-79
Dix, Dorothea, 622
D.M.F. in dental epidemiology, 521, 526
Doctors (see Medical care; Physicians)
Donora, atmospheric pollution in, 431
Dracunculus medinensis, incidence, 76
Drug addiction, 581-587
causes of, 583
cost of, H82
cure, 585
definition, 587
effects of, 582-583
extent of, 582
hospitals for, 585
legislation concerning, 586-587
national program, 58
relapse, 585
World Health Organization, committee
on, 581, 585, 586
Drug Administration (see Food and Drug
Administration)
Drugs, and history, 570
rate of discovery, 678
Dysenteries, incidence, 75

E
Earning potential, 88, 89
Economic equality, 676
relationships, world health problems, 76-79
revolution, 676
Economics, culture and, 127
disease and, 76-79
of public health, 80-98
Ecuador, attitudes toward disease, 118
yaws program, 116
Education and culture, 127
Education, Committee on Professional, 260
Education, Committee on Southern Regional
Studies and, 170
Efficiency ratings, 268
Egypt, drinking water, 112
sanitation problems, 110
Eisenhower, Dwight D., 64, 107
Emergency Maternity and Infant Care Pro-
gram, 64, 180, 182, 185, 282, 303,
360, 472
Emerson Report on Local Health Units for
the Nation 226, 262
Eminent domain, 204-205
Employees, appearance, 315
behavior, 316-320
discipline, 274-281
evaluation of, 268
public relations, 315-326
training in public relations, 324
working conditions, 281-288
Emporiatrics, 678
Encumberance control, 302-305
Endemic index, 387, 557-559
Engineering, sanitary (see Environmental
health; Sanitary engineering)
Enrichment, bread and flour, 500, 510-511
Environment, health and, 25, 41, 132-140
social problems and, 134-140
work, 283
Environmental health, 343-344, 411-448 (see
also Atmospheric pollution; Food
and milk sanitation; Housing; Oc-
cupational health; Sanitation;
Sewage; Stream pollution; Taft
Sanitary Engineering Center; Vec-
tor control; Waste disposal; Water
supplies)
chronic disease and, 142
cooperation of business and industry in,
427-428
costs and financing, 416-417
development of, 411-413
and state and local agencies, 444-445
evaluations, 415
Federal-state relationship, 415
international, 364, 366
needs, 415-417, 680-681
organization of programs, 444-446
personnel, 441-444
program, 414
content of, 412-413
planning, 445-446
radioactivity and, 441, 679
regional differences, 413-415
sanitary engineers in, 441-442
state-local relationship, 415
Taft Sanitary Engineering Center, 61, 420
World Health Organization and, 364
Epidemic, definition of, 566-567

 

SUBJECT INDEX 099

Epidemics (see also Communicable disease)
closing of schools, 488
colonization and, 47
food-borne, 424-426
milk-borne, 424-426
pilgrimages and, 38-39
water-borne, 424-426
Epidemiologic intelligence, 61
master chart, 386, 388-391
Epidemiological studies of accidents, 617-618
Epidemiologists, collaborating, 61
Epidemiology, 566-568
dental, 514
history, 39
Epilepsy, 64
prevalence, 629
Equity in law, 198-201, 206
Eradication of disease, 680
Erasmus, C. J., 116, 117
Evaluation, employee, 268
housing, 436-437
nutritional, 508-509
program, use of statistics, 392
Evaluation Schedule for Local Health Work,
27, 254-255
Evil eye, 116-118
Examination, compulsory, 554-556, 563
Examinations, of school children, 486-487
periodic medical, 683
Excrement, as fertilizer, 110
as fuel, 110
disposal of, 412, 421-422
Expectancy of life (see Life expectancy)
Expenditure control (see Accounting; Budget;
Purchasing, central)
Expenditures, family, 644-645, 647
Experimental Biology and Medicine Institute,
60
Extension Services, Agricultural, 498-506

F

Faith healers, 117

Fallout, radioactive, 441

Families, hard-core, 147-149
multiproblem, 147-149, 153
types of, 147

Family, disintegration, 144-146, 149, 153
importance of, 140-142
in public health planning, 103
maladjustment, 143-144, 147-149
size, 675
solidarity, 149
urbanization and, 142

Family Service Units, England, 152

Farr, Sir William, 82
700 SUBJECT INDEX

 

Fatalism, and accidents, 614-615
handicaps, 627
Federal Child Labor Law, 62
Federal Community Sanitation Program, 414
Federal Food, Drug and Cosmetic Act, 426
Federal Highway Act, 184
Federal Security Agency (Social Security Ad-
ministration), 59, 64, 352
organization, 353
Federal Social Security Act, 58, 63, 187, 607
Federal Surplus Commodities Corporation,
499
Federalism, 177-192
Fetishes, 124
American Indian, 37
Field technical units, as centralizing influence,
178
organization, 246-249
relation to local health department,
247-248
training, types, 261-262
visits, 319-320
Filariasis, incidence, 76
Films, use of, in health education, 329-330,
403
in Bolivia, 113
Filtration (see Water filtration)
Fiscal management, constituents of, 291
in relation to public health, 290-310
Flour enrichment, 500, 510-511
Fluoridation of water, 412, 417, 419, 523-524,
526-528
endorsement of, 523
Fluoride, 126
sodium, in dental caries control, 477
topical application of, 527
Fluorides and caries, 521-524, 526-528
Fly control, Egypt, 110
Folk medicine, 116-122, 127
Folklore, 116-122
Food adulteration (see United States Depart-
ment of Agriculture)
Food and Agriculture Organization, United
Nations, 497
Food and Agriculture, United Nations Con-
ference on, 496
Food and Drug Act of 1906, 64, 426
Food and Drug Administration, 352, 361, 426
organization, 353
transfer to Federal Security Agency, 64
Food, and health of nations, 493-497
and milk control, laboratory services, 397
legislation, 212
consumption, changes in, 499-500
habits, and social change, 498, 509

 

Food—Cont’d
handlers, compulsory examination, 555
production, 29, 31, 77, 78
program, surplus, 499, 503
relationship to obesity, 500, 505
sanitation, 412, 415, 424-428, 445-446
Food-Stamp Plan, 499
Fumigation, 541
Funds, sources of, 292
types of, 292-293
Future of public health, 673-686

G

Garbage disposal, 412
Gastrointestinal disease control, 564
Geriatrics, 594
and nutrition, 504-505
Glaucoma, screening programs, 597
Gonorrhea, world incidence, 76
Government, 159-193
centralization, 177-192
county, disadvantages of, 165-166
functions, 164-165, 166-168
legal status, 165-166
liability of, 165-166
numbers and size, 164-165
officials, 167, 168-169
problems of, 165-166
reforms needed, 169-170
relationship to state, 165, 166-167
subdivisions of, 168
types of government, 167
expenditures, 170-176
Federal, 159-161
intergovernmental relationships, 165, 175-

177, 180-192
local (see also Government, county, munic-
ipal)
cost, 161

functions of, 161, 162, 164-165, 166-168
number of units in United States, 161
types of, 161, 163-164, 167
municipal, 161-164
abolition of, 163
cost of, 161
definition, 161
development, 162
functions, 162
liability of, 162
number of, 161
per cent of population, 161
types of government, 163-164
powers, transfer of, 185
revenues, 170-175
transfers of, 175
SUBJECT INDEX 701

 

Government—Cont’d
services, demand for, 174
state, 159-161
structure, 159-170
township, 161, 169
Grants-in-aid, 58-63, 180-192, 265
amounts, 187-189
as centralizing influence, 180
bases for allotment, 387
definition of, 180
distribution of, 186-190
England, 186
formulas for, 189-190
mental health programs, 624
origin and development of, 181-185
purpose, 180
Graphic aids, in administration, 381-391
in communicable disease control, 557-559
Grotjahn, 132, 133
Guinea worm, incidence, 76
Gunn-Platt Report, 662, 667

H

Handicapped (see also Disabilities)
children, in school health program, 489-490
programs for, 361, 484, 682
definition, 626, 628
employment of, 630, 631-632
health department’s role in remediation,
682
prevalence of orthopedic impairments, 629-
630, 682
rehabilitation of, 626-634
workers, job placement, 601-602
Handicaps, economics of, 630-631
sources of, 627-628
Hard-core families, 147-149
Harris, Elisha, 52
Hatch Act, 181
Hay fever and asthma, incidence and preva-
lence, 591, 593
Health (see also Public health)
agencies (see also Organization charts; Pub-
lic health)
city-county, 65, 339-346
county, 339-345
basis for, 238-239
functions, 342-344
growth, 340-341
needs, 680-681
organization, 238-239, 345-346
origin and development, 65-66, 257, 412
personnel, 345-346
promotion by state, 341
structure, 342

 

Health agencies, county—Cont’d
subsidization, 341 (see also Grants-in-
aid)
Federal, 160, 351-362 (see also United
States)
agencies participating in, 354-357
functions, 351-352, 358-359
organization, 342, 353, 360
international, 362-367
bilateral, 362, 366-367
Cooperation Administration, 362, 366-
367
foundations, 367
multilateral, 362, 363-365
religious, 367
United Nations Children’s Fund, 365-
366
United States governmental, 362, 366-
367
voluntary agencies, 367
World Health Organization, 362, 363-
365
municipal, organization, 346
origin and development, 49
personnel, 345-346
state, functions of, 346-351
organization, 240, 242, 243, 346-351
origin and development, 51-52, 257
participating agencies, 346-347
voluntary, 65, 151, 367, 660-669
centers (see also Hill-Burton Hospital Sur-
vey and Construction Act)
appearance of, 283-284, 325
construction, 59
district, 250, 383-384
location of, 384
coordinator, functions of, 408-409, 491, 505
councils, 151
definition of, 363
education, 127, 343, 402-410
audiovisual methods in, 113, 329-330, 403
definition of, 402-403
dental, 530
for accident prevention, 614, 617
functions of, Federal level, 328, 357, 407
local level, 405-406
state level, 406-407
in Bolivia, 113
in schools, 489
motivations in, 404
occupational, 604-605, 611
organization, 409
personnel, 405-408
public health nurse and, 404
publicity, 403
702 SUBJECT INDEX

Health education—Cont’d
relations between schools and health de-
partments, 408-409
scope, 402-405
techniques, relative values of, 403-404
Education and Welfare, Department of
(see United States)
environmental (see Environmental health)
government and, 26, 159-193
industrial (see Occupational health)
institutes of (see National Institutes of
Health)
instruction (see Health education)
insurance (see Medical care)
international, 69-79, 362-367
officer, functions and duties, 232-235, 269-
271
powers and liabilities, 216-218
qualifications, 269-271
relations, with board of health, 216-217,
230-231
with medical profession, 335, 462, 483
with nursing program, 459
with personnel, 269-270
with state health department, 179
status and tenure, 232
Practice Indices, 255
program functions, 225, 264
religion and, 111, 121
society and, 99-102, 123
units, local, basis of, 238-239
extent of, 65, 340-341
Heart disease control, 188
incidence and prevalence, 519, 593
screening programs, 597
Institute, National, 60
Helminthiases, incidence, 74
Hill-Burton Act (see Hospital Survey and
Construction Act)
History of public health, 36-68, 130
of social medicine, 132
Hogarth, William, 35
Holmes, Oliver Wendell, 49, 105
Home accidents, 616
Hookworm, 412
Rockefeller Sanitary Commission, 65, 412
Horizontal type organization, 241
Hospital Survey and Construction Act, 59, 599
Hospitalization, reasons for increase, 142
resistance to, 114-115, 642
Hospitals, 59
construction, 59
distribution of, 642-643
Public Health Service, 56

 

Housing, 679
accident prevention and, 516
city planning, 434-439
Committee on Hygiene of, 436
community planning, 412, 415-416
health and, 136
local health department in, 438-439
needs, 435-436
principles of healthful, 436-437
program, 437-439

Human relations program, Delaware public

schools, 623

Hygiene, Grecian, 37
industrial (see Occupational health)
Mosaic, 37
Roman, 26, 37-38, 492

Hygienic Laboratory, 57

I

Illness (see also Disease)
changes in types, 590
economic status and, 643-645
incidence of, 642-646
rates by age and sex, 644-645
reasons for, 109-112
Immigrants, problems of, 149
Immunity, active, 544
passive, 544
Immunization against respiratory diseases,
560-561
compulsory, 551-554
requirement for school attendance, 488
Incentive, job, 282-283
Incomes of American families, 641-643
Index, discratic, 387
endemic, 387, 558
vital, 386
Indian Affairs, health program, 362, 453
Industrial health (see Occupational health)
hygiene (see Occupational health)
Industrial Hygiene and Sanitation Office,
Public Health Service, 606
Industrial Hygiene Council, American Medi-
cal Association, 607, 609
Industrial Hygiene, Journal of, 607
Industrial Hygiene Section, American Pub-
lic Health Association, 606
Industrial Medicine and Traumatic Surgery,
Committee on, 606
Industrial Nurses, American Association of,
455
Industrial Physicians and Surgeons, American
Association of, 606
Industrial Revolution, 148, 675
effect on medicine and science, 637, 638
Industrialization, 134, 148
disease and, 142, 146
effect on family, 142
population and, 30
Infant deaths, 101
cost of, 86
health and nutrition, 500-501
program, function of health depart-
ment, 483-484
mortality, 109, 123, 474-475
and nutrition, 494-495
rate, decline in, 470, 674
social class and, 135-138
value of, 86
welfare societies, 471
Infantile Paralysis, National Foundation for,
65
Infection, biological significance of, 534-545
discovery of sources of, 542
methods of, 536-540
Information desk, 316
Injuries, accidental, 615-617
Insect control, 412, 439-441
Inservice training, 261, 286-287
Institute of Inter-American Affairs, 116, 117
Institutes, National Health (see National In-
stitutes of Health)
Institutional inspection, 344
Insurance, disability or life, 614-615
medical (see Medical care, compulsory in-
surance plans)
Interagency cooperation, environmental
health, 415, 445-446
housing, 438
waste disposal, 421-423
water sanitation, 419
Inter-American Affairs, Institute of, 116, 117
International Congress for Mental Hygiene,
622
International health (see Health agencies, in-
ternational; World health)
International List of Causes of Death, 377
International Statistical Classification of Dis-
eases, Injuries, and Causes of
Death, 377
Intestinal infections, 116, 564
Isolation, 542, 549-551
history, 47
limitations, 549
primitive concepts, 120

J
Java, 111
Jewell, Wilson, 52

 

SUBJECT INDEX 703

 

Job analysis, 254
appeal, 281-283
Journal of Industrial Hygiene, 607
Judge, function, 221
Judicial presumption, 209-210, 212
Jury, function, 221-222
Justice of peace, 203
Juvenile delinquency, 134, 143-144, 146, 147

K
Kellogg, W. K. Foundation, 367

L

Labor, child, 148
force, age of, 676
hours of, 677
turnover and health, 607
Laboratories, public health, approval of, 396,
398
consultation service, 396
decentralization of, 399
development of, 395
functions, 395-398
mobile, 401
organization, 399-401
services of, 395-398
in communicable disease control, 557
in noncommunicable disease, 396-397
standards, 398
Lactobacilli, and caries, 519-520
Language barriers, 112-114, 126
Lathrop, Julia, 61
Law, administrative, 201, 209-210
characteristics, 194-195
classifications of, 201-202
common, 197
constitutional, 201
criminal, 202
definition, 194
liability in, 216-218
natural, 196
of limitations, 206
of nuisances, 205-207
of overruling necessity, 207
private, 202
public, 202
purpose of, 195-196
Roman civil, 196
statutory, 196, 201
systems of, development, 196-197
written (see Law, statutory)
Laws and regulations, atmospheric pollution,
432-433
communicable disease control, faults of,
546-547
704 SUBJECT INDEX

 

Laws and regulations—Cont’d
compulsory examination, for
ment, 555, 563
for specific diseases, 554-555
of food handlers, 555, 563
premarital, 554-555
prenatal, 554-555
enabling, 201
enrichment of foods, 510-511
Frozen Desserts Ordinance and Code, 425
housing, 438-439
immunization, 551-554
Milk Ordinance and Code, 425
Ordinance and Code Regulating Eating
and Drinking Establishments, 427
reporting, 546-549
sanitation, 556
treatment, 555-556
vaccination, 551-554
workmen's compensation, 606
writing and passage, 213-216
Leadership, types of, 235, 275
Leading causes of death, 591
Leaves and vacations, 284-286
Ledger form, 300
Legal relationships, 195-196
rights, types of, 195-196
Legislation (see Law)
Leishmaniasis, incidence, 76

employ-

Leprosarium, National, 58
Leprosy, 39, 58
incidence, 74
Liability, 216-218
Library of Medicine, National, 61
Licensing, 210-211
legality of, 210
Liége, atmospheric pollution in, 431
Life, economic value of, 81-90
expectancy (see also Vital statistics)
anticipated, 676
effect of change on, 123, 675-676
England, nineteenth century, 21, 43-44
international comparison, 72, 78
racial comparison, 72
United States, 21, 294
nineteenth century, 48
insurance, 614-615
Local health services, development of, 49, 58,
65-68
extent of, 65, 340-341
recommendations for, 46, 65
units, basis of, 238-239
Local Health Units for the Nation, Emerson
Report on, 226, 262

 

L’'Office Internationale d’Hygi¢ne Publique,
363

London, atmospheric pollution in, 431

Longevity (see Life expectancy)

Lumsden, L. L., 65, 412

M

Maladjustment, family, 143, 147-149
individual, 143-144
Malaria, economic losses from, 77
incidence of, 73-74
opposition to control, 100
Rockefeller Foundation and, 367
United Nations Children’s Fund, 365
World Health Organization, 364
Malnutrition, reasons for, 495
Management, fiscal, 290-310
services, 250-251
Mandamus, meaning of, 200
Man-power shortage, and rehabilitation, 627
Manuals, administrative, 252-253
technical, 252-253
Maps, population, 381-384
spot, 380, 381, 383
statistical, 380-385
Margarine enrichment, 510-511
legislation for, 510-511
Marine Hospital Service, budget, 61
development, 55
hospitals, 56
eligibility for admittance, 56
locations, 56
origin, 48
Mass testing (see Testing, mass)
Massachusetts Bay Colony, health laws, 47
Massachusetts Institute of Technology, 66,
259, 277
Massachusetts State Board of Health, 50
Massachusetts State Department of Health,
51-52
Maternal and child health, 186, 470-492
Children’s Bureau and, 61-64, 359-361
expenditures for, 63-64
Federal contribution to, 61-64
program, agencies needed, 478
international, 364-365
state, origin and development of,
184-185, 471-472
statistical needs, 479
and infant care, 63-64 (see also Emergency
Maternity and Infant Care Pro-
gram)
deaths, cost of, 85
health and nutrition, 500-501
program, 479-483
SUBJECT INDEX 705

 

Maternal health and nutrition pregram—
Cont'd
function of health department, 482
socioeconomic status and, 138
mortality, 123, 472-473
and nutrition, 495
rate, decline in, 470
Maternity and Infancy Act, 507
Maternity and Infant Hygiene, Federal Board
of, 63
Meat sanitation, 412
Medical advisory committee for health de-
partment, 462
Medical care, 635-659
compulsory insurance plans, administra-
tion of, 652
advantages, 656-657
American Medical Association, 654-
655
demand for, 657
disadvantages, 656-657
enacted, 651
England, 651-652
Europe, 651-652
United States proposals for, 653-655
costs of, 641, 643-648
expenditures, average annual, by fam-
iles in United States, 84-89, 644-645,
647-648
facilities, distribution of, 642-643
family structure and, 142
insurance, development,
future of, 656
history of, 48, 55, 649-656
opposition to, 654-655
progress made, 656
labor union sponsored plans, 610, 650
needs, 681
refusal of, 114-115
role of public health, 681
voluntary insurance plans, 655-656
profession, position in society, 116-117, 608
social worker, 466-469
educational qualifications, 467
functions of, 467-469
Medical Care, Committee on Costs of, 643, 654
Medicine (see also Medical care; Physicians)
comprehensive, 25, 132
folk, 116-122, 127
history, 26, 49, 132, 637-640
Institute of Experimental Biology and, 60
man, 117
preventive, 24-25
public health and, 24-25, 131-132, 635, 641
social, 22

rate of, 678

 

Medicine—Cont’d
social science, 22
socialized, 132, 654
therapeutic and public health, 24-25
Mental and nervous diseases, incidence and
prevalence, 591
health, 59, 60, 188, 621-625
centers, relation to health agencies, 625
staff of, 624-625
definition of, 623
National Act, 60, 622, 624
National Institute of, 60, 622
obesity and, 505
problem, extent of, 622-623, 685
programs, extent of, 624-625
psychiatric problems and, 623
responsibility for, 624
World Health Organization and, 364
hospitals, United States Public Health Serv-
ice, 56
hygiene associations, 65
Connecticut, first, 622
Delaware State Society for, 623
Division of, in United States Public
Health Service, 58, 60
International Congress for, 622
movement, 621-622
National Committee for, 622
illness, causes of, 622-623
extent of, 622-623, 685
theories about, 685
patients, number of, 90
retardation, 65
Merit systems, 262, 264-267
Metabolic diseases, incidence, 591
increase in, 591-593
National Institute of Arthritis and, 60
prevalence of, 593
Metropolitan Life Insurance Company, 91,
454, 593, 599
Metropolitanization, 677
Microbiological Institute, 60
Midwives, supervision of, 481
Migratory workers, 65
Milk Ordinance and Code, 425
Milk sanitation, 412, 414, 424-428, 445-446
Milk-borne epidemics, 424-426
Minority groups, power of, 161
Mobile laboratories, 401
Mobility, population, 677
Morale, 267, 274-276, 281-282
Morbidity rates, crude limitations, 592
registration area, 377
reporting of, 374-377
survey (see National Health Survey)
706 SUBJECT INDEX
Morrill Act, 181
Mortality, American Association for the Study
and Prevention of Infant, 471
Bills of, 370
infant (see Infant mortality)
of mothers (see Maternal mortality)
Mosaic hygiene code, 37
Mosquito control, 412, 439-441
Motor vehicle accidents, 615, 618, 677
Mottled enamel (see Caries)

Multilateral health activities, 362, 363-365
Municipalities (see Cities; City planning;
Government, municipal)

Mutual Security Agency, 367

N

Narcotic addiction (see Drug addiction)

Narcotics and history, 570

National Advisory Cancer Council, 597

National Association of Colored Graduate
Nurses, 455

National Board of Health, 53-54

National Committee for Mental Hygiene, 622

National Committee on Alcoholism, 578

National Committee on School Health Poli-
cies, 485, 488

National Foundation (for Infantile Paralysis),
65

National Health Assembly, 226

report on mental health, 624

National Health Council, 667-668

National Health Institutes (see National In-
stitutes of Health)

National Health Service, England, 651-652

National Health Survey, 135, 377, 476, 591-
592, 615, 628, 679

National Institutes of Health, 58-60, 358, 523,
524, 528, 622

National League for Nursing, 453, 455, 465

National League of Nursing Education, 455

National Leprosarium, 58

National Library of Medicine, 61

National Mental Health Act, 60, 622, 624

National Office of Vital Statistics, transfer to
Federal Security Agency, 64

National Organization for Public Health
Nursing, 455, 465

National Quarantine Conventions, 52-53

National Research Council, 523

National Safety Council, 615

National Sanitation Foundation, 427-428

National School Lunch Act, 502

National Tuberculosis Association, develop-
ment, 65, 660-661

 

 

 

Natural increase in population, rates of and
international comparisons, 70-71
Natural selection and public health, 32
Neighborhoods, importance of, 249-250
Nephritis and kidney disease, incidence and
prevalence, 591, 593
Neumann, Solomon, 22, 132
Neurological Diseases and Blindness, National
Institute of, 60
Newspaper publicity (see Public relations,
newspaper publicity)
Nonofficial health agencies (see voluntary
health agencies)
Nostrums, nutritional, 505
Nuclear energy, potentials, 679
physicist, in occupational health, 612
weapons fall-out, 441
Nurses, American Association of Industrial,
455
infant welfare, 471
National Association of Colored Graduate,
455
public health (see also Public health nurs-
ing)
accident prevention and, 617
functions of, 456-458
maternal and child health, 490-492
number of, in United States, 452
qualifications, 458
relationships, 458-462
school, employment of, 491
functions of, 490
uniforms, 315-316
Nurses’ Association, American, 453, 455, 465
Nursing (see also Public health nursing)
Education, National League of, 455
National League for, 453, 455, 462
organizations, 453-455
resistance to, 114-115
Service, American Red Cross Town and
Country, 453
supervision, postpartum period, 482
visits, well-child, 484
Nutrition, 493-512
adult health and, 596
alcoholism and, 574
dentistry and, 506
disease and, 109, 544
education, 502-503
geriatrics and, 504, 505
government responsibility for, 496
infant health and, 500-501
League of Nations study, 493-494
maternal health and, 500-501
personnel, 510
Nutrition—Cont’d
programs, functions of, 509-510
growth of, 506-507
organization of, 507-510
surveys, 508
United States status, 498-500
World Health Organization, 364
Nutritionists in health programs, 507, 509

oO

Obesity, causes of, 504-505
life expectancy and, 500, 504
mental health and, 505
Occupational diseases, 606
health, 27, 595, 604-613
absenteeism and, 607
benefits, 607-609
definition, 605
health education and, 604-605
history, 606-607
illness and injuries, 607
labor turnover and, 607
laboratory services for, 397
law enforcement, 611
malaria and, 77
personnel, 607, 610
programs, 601-602, 609-612
content, 609-610
governmental, 611-612
objectives, 609, 612
private enterprise and, 609-611
safety and, 412
surveys, 611
teaching, 606
unions and, 610
Office layout, 325
Oral hygiene (see Caries)
Ordinance (see Laws and regulations)
Organization, basis of, 244-245
channels of, 236-237, 273
charts, 242, 252
examples, 237-243, 248, 251, 566
coordination and control measures, 251-255
decentralization, 249-251
definition of, 227
levels of, 229
principles of, 227-228
purposes of, 226-227
types of, 241-245
units of, 236-237, 238, 242
Organizational structure, 249-251
Orthodontic services, value of, 529
Orthopedic impairments, prevalence, 629
Osler, William, 36
Overtime, 284

 

SUBJECT INDEX 707

 

P

Pan-American Sanitary Bureau, 362, 365
Parasitic diseases, and World Health Organ-
ization, 364
Parasitoses, incidence, 74
Parent-Teacher Association, 492
Pasteurization, 425
Pediatricians, amount of well-child care, 483
Pediatrics, American Academy of, 483, 490
Pendleton Act, 265
Personal contacts, 315
Personnel (see also Dental personnel; Envi-
ronmental health; Nutrition; Oc-
cupational health; Technical as-
sistance programs)
auxiliary, 682
incentive scale, 282-283
management, 264
public health, 257-289
needs for, 262
qualifications, 260-261, 262
recruitment, 264, 266, 489
working conditions, 281-288
Pettenkofer, 46, 132
Petty, Sir William, 81
Pharmaceuticals, rate of development, 678
Philadelphia, district health map, 380
epidemiological master charts, 386, 388-391
population spot map, 383
principle causes of death, 382
rehabilitation and referral center, 633
tuberculosis deaths, 385
Philosophy of public health, 21-34
Physical fitness, definition, 627-628
Physical Medicine, Baruch Committee on, 632
Physicians (see also Medical care)
adult health program and, 596
distribution of, 642
infant and preschool program and, 483
maternal health program and, 481-482
medicine man versus, 117-121
public health and, 24-25, 635-640
school health program and, 486-487
Pilgrimages and disease, 38-39
Pinel, Philippe, 621
Placarding, 550
Plague, bubonic, 32, 33, 39-40, 540, 542
Plaintiff, definition, 220
Planned Parenthood League, 480
Planning, community, 151
multidisciplinary, 152-153
Plastic sheeting, infant deaths, 619
Plea in Abatement, meaning of, 221
Plymouth colony, 47
708 SUBJECT INDEX

Point Four (see International Health Agen-
cies)
Poison control, 618-619
Police power, 207-209
delegation of, 207-208
Policy making, 229
Poliomyelitis, isolation in, 542
Political organization, culture and, 127
patronage, 258
relationships, world health problems, 76-77
revolution, 676
Politics, 258
Polls, public opinion, 335
Population, census, 370-371
early civilizations, 674
estimates, methods of, 371
explosion, 674, 675
factors in change, 69-72
increase, 27-32, 132
China, 29
in underdeveloped areas, 30
industrialization and, 30
natural, 70-71
public health and, 27, 29, 32
rate of, 27-32
reasons for, 27-32
urbanization and, 30
mobility, 677
urban, 677
world, 674
Position classification, 254, 266-267
Precedent, definition of, 198
Pre-employment compulsory
555-563
Pregnancy and caries (see Caries)
Premarital examinations, 480, 554-555
Premature death, 89
Prenatal care, dental (see Dental care)
compulsory examination, 554-555

examination,

examinations, 480
Prepaid medical insurance (see Medical care)
Preschool child (see Children, preschool age)
Preventable diseases, losses from, 97

savings through public health measures.

90-98
Preventive dentistry (see Dentistry)
medicine, content, 24, 34
definition, 24-25, 34
private practice and, 24-25
public health and, 24-25
types, 515
Preventive Medicine, Board of, 67
Primitive societies, 102
Private enterprise and public health, 604-605
physicians (see Physicians)

 

 

Privies, in Burma, 114
in Thailand, 114
Productivity, human, 27-32, 87
Professional education, 260-264, 366-367, 682
meetings, leave for, 286
Professional Education,
260, 261
Program planning, 26, 27, 102-104, 116, 126,
128, 333-334
Promotion, 267-268
Prostitution, 108, 116, 124
Psychiatric problems (see Mental health)
Public administration, content, 225

Committee on, 66,

health administration, recent changes,
225-226

agriculture and, 125

appraisals, 667 (see also Evaluation

Schedule; National health survey)
as social science, 31, 140
Assistance Law, California, 190-191
benefits of, 80-98
business and, 258, 604-613
definition, 23-24, 34, 131
dentistry (see Dental care;
Dentists)
departments (see Health agencies)
economic improvement and, 31
economics, 80-98 (see also Medical care;
Physicians)
economy and, 125
engineering (see Environmental health)
environment and, 25, 41, 134-140
future of, 673-686
goal, 23-24, 34, 131
government and, 26, 159-193
history, 36-68, 130
eighteenth and nineteenth centuries,
42-46
England, 44-46
English influence on America, 46
Middle Ages, 38-41
pre-Christian period, 37-38
Renaissance, 41-42
United States colonial period, 47-48
inservice training, 261-262, 286-287
laboratories (see Laboratories)
law, communicable disease, 545-556
compulsory examination, 554-555
treatment, 555-556
definition of, 203
extent of use, 218-220
local health organization, 212-213
necessary basic, 211-213
sanitation, 456
sources, 203-204

Dentistry;
SUBJECT INDEX 709

 

Public health law—Cont’d
United States colonial period, 47-48
venereal disease control, 220, 454-455
medical schools and, 259
medicine and, 24, 131-132, 635-640
nursing, 449-465 (see also Nurses; Nurs-
ing)
administrative relationships, 458-464
agencies, 453-455
community council, 463
consolidation of programs, 460-462
definition of, 455
development of, 65, 449-457
functions, 455-458
generalized versus specialized, 451
health education in, 404
local programs, 454
medical relationships, 461-463
national programs, 453
origin and development, 65, 449-451
personnel needs, 451-453
referral, 463
relation to social work, 463
responsibility of health officer, 459
standard procedures, 464-465
state programs, 453-454
supervision, 464
organization (see Health agencies)
personnel, 257-289
needs for, 262
qualifications, 260-261, 262
population and, 27, 29, 32, 125 (see also
Population)
powers (see also Public health law)
Federal, 203-204
state, 204
preventive medicine and, 24-25
private enterprise and, 258, 604-613
physicians and, 24-25, 131-132, 635-640
professional training, 66-67, 260-261
programs (see also Health agencies)
organization of, 339-368
reasons for failure, 112-116
purpose, 23-24, 34, 131
savings from, current, 90-93
potential, 93-97
schools of, 66-67, 260
accrediting of, 260
development of, 260
scope of, 26-27
service (see United States)
significance of, 22, 26, 32-33, 125
social improvement and, 31
problems caused by, 151
statistics (see Vital statistics)

 

Public health—Cont’d
surveys, 667 (see also Evaluation sched-
ule; National Health Survey)
tourism and, 678
training, 66-67, 259-261
field (see Field training)
inservice, 261-262, 286-287
World Health Organization and, 364
Public relations, 311-335
community groups, 332-335
employee training, 324-325
employees’ role in, 315-316
methods, 314-326
newspaper publicity, 326-329
obstacles to, 312-314
purpose, 311-312
radio, 329-330
Publicity in health education, 403-404
Purchasing, central, 246, 306-307

Q

Quacks, 117
Qualifications, professional, 260-261
Quarantine, 542, 549-550
history, 40, 47, 56
interstate, 358
limitations, 549
maritime, 358
National Conventions, 52-53
United States, 56
voodoo, 37
Quitelet, 46

R

Rabies, compulsory immunization, 554
Radio publicity (see Public relations, radio)
Radioactive wastes, disposal, 679
Radioactivity, 441
Radiologic health, 441
Ramspeck Act, 265
Rates (see also Births; Death; Index)

age specific, 593

standardized, 593
Receptionists, 317-318
Records and reports, 253, 343

as centralizing influences, 178
Recreational areas, sanitation in, 412, 416, 418
Red Cross Town and Country Nursing Serv-
ice, American, 453

Redevelopment, urban, 677
Referral, mental health, 625

public health nursing, 463

rehabilitation, 152, 633

social service, 152, 153, 469
710 SUBJECT INDEX

 

Regional distribution of medical facilities,
642
Regionalism, 180
language, 112-113
Registers, 559
Registrars of vital statistics, 373, 392
Registration areas for vital statistics, 371, 377
birth, death, morbidity (see Reporting,
birth, death, morbidity)
Rehabilitation, 27,469, 626-634, 682-683
centers, 632-633
definition, 528
economics of, 630-631
needs, magnitude, 628-630, 682-683
of chronically ill, 600
program needs, 631-634
programs, content, 631-634
voluntary agencies and, 627
governmental, 630
role of health department, 632-633
surveys, 629
vocational, 633-634
Religion and public health, 121, 127
Religious pilgrimages, 111
Renaissance, advances in, 43-44
causes of, 41
conditions in, 41-42
Report forms, types, 557
Reporting, birth, death, morbidity, 211, 371-
377, 392
communicable diseases, 211
legislation, 547-549
morbidity, importance of sources, 542
methods, 547-549
responsibility for, 547
Reports, 253
Research, 59-60
Residence, rate of change, 677
Residency training in public health, 261
Respiratory disease control, 565
Responsibility, administrative, 235-236
fiscal, 307-309
Restaurant sanitation, 427, 445-446
Retirement plans, 287-288
procedures in industry, 601-602
transfer of, 682
Revere, Paul, health officer, 47
Revolution, cultural, 678
demographic 675-676
economic, 676
industrial, 148, 675
political, 676
scientific, 678
social, 676
technological, 678

 

Rheumatic fever, prevalence, 629
Rights, legal, types of, 195-196
Rockefeller Foundation, 367
Rockefeller Sanitary Commission  (hook-
worm), 65, 412
Rodent control (see Vector control)
Roman Empire, 26, 37-38, 494, 674
Rosenau, Milton, 22, 57, 66
Rules and regulations (see also Law)
administrative, 201, 209-210
adoption by reference, 215
importance of, in law, 209-210
personnel, 274
publication, 215
writing and passage, 214-216
Rural areas, problems, 165-166
sanitation (see Sanitation)

S
Safety Council, National, 615
Safety programs, for accident prevention, 614-
615, 618
St. Paul, Minnesota studies of families, 148,
152-154
Sand, René, 132
Sanitary Bureau (see Pan-American Sanitary
Bureau)
Sanitary Commission, Rockefeller  (hook-
worm), 65, 412
Sanitary conferences, international, 52-53
engineering (see Environmental health)
privies, 412, 414
reforms, 45
Sanitary Engineering Center, Taft, 61, 420
Sanitation (see also Environmental health)
costs, 416-417
effect on infant mortality, 470
England, eighteenth and nineteenth cen-
turies, 45-46
industrial, 611
needs, 415-417
problems, Burma, 114
Egypt, 110, 112
Thailand, 114
Program, Federal Community, 414
rural, 416
deterrents to, 414-415
technical assistance programs, 364
Scalar principles, 228, 232, 236-237
Schistosomiasis, incidence of, 74
School absenteeism and malaria, 77
child (see Children, school age)
environment, 485-486
health factors in, 484-485
inspection of, 485
SUBJECT INDEX 711

 

School health—Cont’d
health coordinator, 408-409, 491, 505
councils, 491-492
policies, formulation of, 492
National Committee on, 485, 488
program, 484-492
and the community health program,
491
handicapped children in, 489-490
responsibility for, 484, 490-491
lunch programs, 485, 498, 502-503, 530
nurses, employment of, 491
functions of, 491
Schools, closing of, during epidemics, 488
importance of, in health education, 408-409
in health program, 484
of public health (see Public health, profes-
sional training; Public health
schools)
Schools of Public Health, Association of, 67,
260
Scientific revolution, 678
Scope of public health, 26-27
Sedgwick, William T., 66
Selective service, dental defects, 514
Senescence, 594
Service ratings, 268
Seven “D’s” syndrome, 147
Sewage, disposal of, 421-423
treatment, methods of, 422-423
objectives of, 422-423
Shakespeare and plague, 33
Shattuck, Lemuel, 49-51, 131, 132
Shellfish sanitation, 412, 415, 445
Sheppard-Towner Act, 12, 63, 182, 184, 471,
507
Sick leave, 285
Sickness (see Illness)
insurance (see Medical care, compulsory
insurance plans)
Significance of public health, 21-24, 34, 125
Silicosis screening programs, 598
Simon, John, 45, 46
Slums, 134-136, 435, 677
Smallpox, in Colonial America, 47
vaccination laws, 551-553
Smith, Adam, 81
Smith, Stephen, 52-53, 54
Smog (see Atmospheric pollution)
Smoke control (see Atmospheric pollution)
Social analysis for health, 102-104
case work, 153
clubs, importance of, 321
conditions in eighteenth and nineteenth
centuries, 41, 48

Social conditions—Cont’d
in sixteenth century, 41
deviants, 150
disorganization, 108
evolution, 108-109
factors and communicable disease, 536
and disease, 134, 140
groups, 102-104
improvement and public health, 31
medicine, 22, 130-134
goal or purpose, 131, 133
pathology, 130-134
problems, environment and, 134-140
interrelationship of, 143-144
social class and, 134-148
Aberdeen, 136-138
Cincinnati, 135
Cleveland, 135
England, 148
Liverpool, 135
St. Paul, 148
United States, 134-136
reforms, England, 42, 45-46
relationships, world health problems, 76-79
revolution, 676
science (see also Behavioral science; Cul-
tural; Culture)
public health as, 140
security, 191, 657
Security Act, 58, 63, 187, 471, 507, 607
Security Administration, 352, 353
service, exchange, 464
referral center, 152, 153
worker, 466-469
services of a health agency, 467-469
solidarity, causes of, 149
welfare, 125
program content, 464
Socialized medicine, 132
Society, culture and, 104-109
definition of, 130
health and, 100-106, 123
Socioeconomic status and chronic disease, 137
and health, 136
and housing, 136
and illness, 136
and infant mortality, 135-138
and juvenile delinquency, 134
and maternal health, 136-138
and physique, 138
and tuberculosis, 134-136
Southwood-Smith, 45, 131, 132, 134
Span of control, 228, 241
Specialty board in public health and pre-
ventive medicine, 261

 
712 SUBJECT INDEX

 

Speech handicaps, prevalence, 629
Spoils system, 258
Spot maps (see Maps, spot)
Staff agencies, administrative, 245-249
auxiliary, 246
technical, 246-248
types, 245
minimum, 262
needs, 262-263
officer, qualifications, 246
services, 245-249
Standard methods and procedures, 254
Standards, as centralizing influence, 179
importance of, in law, 209-210
laboratory, 398
Standing orders, 252-253
Stare decisis, 197-198
State and Territorial Health Officers, As-
sociation of, 523
Department of, 362
health departments (see Health depart-
ment, state)
supremacy, 175
States’ rights, 204
Statistical activities, organization of, 392-394
services, centralization, 392-393
Statistics (see Vital statistics)
Stream pollution, 26
control, 412, 415, 419-421
regionalism, 420-421
Strip cities, 677
Subsidies (see Grants-in-aid)
Suburbanization, 414-415, 416, 437, 677
Subventions (see Grants-in-aid)
Suicide, extent of, 685
program for guidance services for despond-
ent, 685
Summons, 220, 221
Superstitions, 116-121
Supervision, as centralizing influence, 179
Supplies, 246
Surgeon General, establishment of office, 58
Surgeons, American College of, Committee
on Industrial Medicine and Trau-
matic Surgery, 606
Surplus food program, 449, 502
Survey, National Health (see National Health
survey)
Surveys and appraisals, 667
Survival of the unfit, 32-33
Syndrome of the seven “D’s”
Syphilis, compulsory examination, 554-555
cost of, for United States, 91
history, 40
world incidence, 76

 

T

Taboos, as cultural barriers, 114-115
Taft Sanitary Engineering Center, 61, 420
Taxes, delinquencies, 173
types, 172
Teachers, compulsory examination, 555, 563
Technical assistance, 100, 362-367
bilateral, 362, 366-367
multilateral, 362, 363-365
nongovernmental, 367
programs, 105, 116, 124, 362-367
field staff (see Field technical units)
manuals, 252-253
Technological revolution, 678
Telephone, use in health department, 322-323
Television, use in public health, 329-330
Tennessee Valley Authority, 352
Tenure, 267-268
Testing, mass, 542
Thailand, sanitation problems, 114
Therapeutic versus preventive measures, 24-
26, 115
Tourism and public health, 678
Townships, 161, 169
Trachoma, incidence, 74-75
Traffic accidents, 615-616
Training for public health (see Inservice
training; Public health, profes-
sional training; Technical assist-
ance programs, personnel, training)
Trypanosomiasis, distribution, 76
Tuberculosis, 109, 151, 134-136, 188
associations, 65, 660-661
case finding, 92
communicable disease control and, 562-563
compulsory examination, 555, 563
cost of control, 562
death rate for children, 477
famous people with, 33
incidence and prevalence, 75, 591, 593, 629
National Association, development of, 660-
661
social class and, 134-136
World Health Organization and, 364
Typhoid fever, compulsory immunization, 554
incidence, 75

U

Underdeveloped areas, 72-79
population increase in, 30, 70-71
Uniforms, nurses’, 315-316
Unit cost accounting, 305-306
United Nations Children’s Fund, 365-366
Conference on Food and Agriculture, 496
United Nations—Cont’d
Food and Agriculture Organization (see
Food and Agriculture)
Relief and Rehabilitation Administra-
tion, 363
Technical Assistance Board, 364
World Health Organization (see World
Health Organization)
United States Bureau of the Census (see

Census)

Bureau of Mines, health program, 352,
362, 600

Children’s Bureau (see Children’s Bu-
reau)

Department of Agriculture, control of
food adulteration, 426
health program, 361
Department of Health, Education, and
Welfare, 64, 353, 361
Department of the Interior, Office of
Indian Affairs, health program, 362
Office of Education, health program, 361
Public Health Service, 54-61, 179, 185,
188-189, 262, 265, 352, 357-360, 407,
425-427, 453 (see also Public
Health Service Act)
Advisory Councils, 359
budgets, 60-61
dental research, 60, 514, 523, 525
drug addiction, 585
food control, 426
functions, 358-359
grants-in-aid, 188-189
Hospitals, 56
Institutes (see National Institutes of
Health)
International Health Division, 362
Office of Industrial Hygiene and
Sanitation, 606
organization, 59, 360
origin and development, 48, 54-61
regional offices, 359
vehicular sanitation, 441
Water Pollution Control Program,
420
University of Michigan, 515, 518, 519
Urbanization, 132, 134-139, 146
development of, 674, 677
effects on family, 142
nutrition and, 498
population and, 30, 677

Vv

Vacancies, filling of, 268-269
Vacations and leaves, 284-286

 

SUBJECT INDEX 713

Vector control, 412, 439-441
Vehicular accidents, 615, 618
sanitation, 441
Venereal disease, 123, 124, 144, 146, 188
blindness and, 74
control by law, 58, 59, 220
distribution, 76
Division, United States Public Health
Service, 58-59
World Health Organization, 364
Verne, Jules, 676
Visiting nursing associations, 453-455
Visual handicaps, prevalence, 629
Vital index (see Index, vital)
statistics, 369-392 (see also Statistical activi-
ties; Statistical services)
administrative uses of, 377-392
and grants-in-aid, 387, 392
diphtheria prevention program, 379, 381
history, 369-370
in international health, 69-72
indices, 386-387
maternal and child health programs, 479
National Office of, 64
needs for, 679
pooling of, 680
purpose, 369
records, 369
registration areas, 371, 377
Rome, 37
sources, 370-377
United States colonial period, 47
Vocational rehabilitation, 633-634
Voluntary health agencies, 65, 151, 367, 660,
669
and rehabilitation, 627
characteristics, 666
financing of, 661, 664-665
functions of, 662-664
in chronic disease programs, 594
international, 367
personnel, 452, 453, 668
trends, 666-669
types, 661-662
Vouchers, 300, 302, 309

WwW
Wald, Lillian, 65
Waste disposal, 421-423
methods of, 421-422
Water consumption amounts, 417-418
culture and, 112
filtration, 418-419
for domestic purposes, 418
needs, 417-418
714 SUBJECT INDEX

 

Water—Cont’'d
pollution control, 412, 416, 419-421
Pollution Control Act, 420
supplies, 417-419
private, 445
public, 418
uses, 417-418
Welch, William H., 57, 65
Well-child care, 483-484
sources of, 483

White House Conferences on Child Health,

62, 226, 493

Winslow, C.-E. A, 23, 25, 132
Witchcraft, 116-120
Witness, in court proceedings, 222-223
Women, social position of, 115, 123
Work, conditions of, 281-288

flow charts, 254

hours of, 677

manuals, 252

Workers, handicapped, job placement, 601-

602
Workhouses, 42-43
Workmen's compensation laws, 606
World health, 69-79, 362-368
problems, 69-79

economic, social and political relation-

ships, 76-79
extent of, 72-76
World Health Assembly, 364

 

World Health Organization, 24, 362, 363-
365 (see also Health agencies, in-
ternational)

Committee on Alcoholism, 574
definition of health, 24
development of, 363
differences from Health Office of
League of Nations, 364-365
drug addiction and, 581, 585, 586
functions of, 364
malaria eradication and, 364, 680
organization, 363-364
priorities, 364
Worm infestations, incidence, 74
Wuchereriasis, incidence, 76

Y

Yap, cultural study of, 111, 115
Yaws control, and United Nations Chil-
dren’s Fund, 365
economic losses from; 77
incidence, 74-75
treatment of, in Colombia and Ecuador, 116
Yellow fever, 37, h41
control, and Rockefeller Foundation, 367
history, 57
in United States, 57

Z

Zoning measures, 205
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