HEALTH ON THE FARM AND IN THE VILLAGE THE MACMILLAN COMPANY NEW YORK + BOSTON + CHICAGO + DALLAS ATLANTA - SAN FRANCISCO MACMILLAN & CO., LiMiTED LONDON + BOMBAY + CALCUTTA MELBOURNE THE MACMILLAN COMPANY OF CANADA, LiMITED TORONTO HEALTH ON THE FARM AND IN THE VILLAGE A Review and Evaluation of the Cattaraugus County Health Demonstration with Special Reference to Its Lessons for Other Rural Areas BY C-E. A. WINSLOW, Dr.P.H. PROFESSOR OF PUBLIC HEALTH YALE SCHOOL OF MEDICINE NEW YORK THE MACMILLAN COMPANY 1931 COPYRIGHT, 1931, By THE MACMILLAN COMPANY. All rights reserved — no part of this book may be reproduced in any form without permission in writing from the publisher. Set up and printed. Published May, 1931. HRA + PRINTED IN THE UNITED STATES OF AMERICA* ~ Dn ) KRY | WS PUBL FOREWORD In the fall of 1929, the Technical Board of the Milbank Memorial Fund invited me to undertake an impartial and compre- hensive survey of the seven years’ experience of the Cattaraugus County Health Demonstration, with a view to summing up the lessons to be derived from this experience with regard to the gen- eral problem of adequate health service for the rural districts. As I conceive this problem of rural hygiene to be the most vital one in the entire field of public health, I very gladly undertook the task. I have been fortunate in associating with myself an unusually competent group of investigators, experienced in health and social surveys, including Professor Ira V. Hiscock, Associate Professor of Public Health in the Yale School of Medicine, Dr. Herbert R. Edwards, director of the Bureau of Tuberculosis of the City Health Department of New Haven, Miss Katharine Tucker, Miss Alma C. Haupt and Miss Margaret Pierce of the National Organi- zation for Public Health Nursing, Miss Margaret Byington of the New York School of Social Work, Dr. F. K. Shuttleworth of the Department of Education, Yale University, and Mr. and Mrs. John H. Watkins and Mr. Harold H. Walker of the Department of Public Health of the Yale School of Medicine. Each of these investigators has spent from a week to two months in the County. Professor Hiscock, Dr. Edwards, Miss Tucker and Miss Haupt, Miss Byington and Dr. Shuttleworth have prepared extensive indi- vidual reports on their special phases of the work and I have at- tempted to summarize their main conclusions as well as my own in the general review submitted herewith. I desire on behalf of the whole survey staff to express our ap- preciation of the uniform courtesy with which all desired informa- tion has been placed at our disposal. Special acknowledgement v V338365 vi Foreword must be made to Dr. R. M. Atwater, Dr. T. P. Burroughs, Dr. J. H. Korns, Miss Laura A. Gamble, Dr. E. K. Kline, Mr. N. M. Fuller and Miss Frances King, members of the County Department of Health staff, for their unlimited patience with our demands, and for hours and days spent in working out data for our purposes; to Dr. C. A. Greenleaf of the School Health Service and to the staff of the Cattaraugus County Tuberculosis and Public Health Association for similar assistance; to Miss Lilla C. Wheeler, Mr. W. A. Dusenbury, Dr. J. A. Taggert and Dr. M. E. Fisher for information with regard to the history and administrative aspects of the program; to Mr. Edgar Sydenstricker of the Division of Research of the Milbank Memorial Fund for unpublished statisti- cal material; to Mr. Homer Folks and the staff of the State Char- ities Aid Association for documentary and other data in regard to the evolution of the demonstration, and to many other persons, within and without the County who have aided us in our some- what complex task. C.-E. A. WiNsLow YALE ScHOOL oF MEDICINE New Haven, CoNN. CONTENTS CHAPTER I. OuTsTANDING LEssoNs oF THE CATTARAUGUS COUNTY HeaLTH DEMONSTRATION 2 : ’ ’ ’ II. THE ProBLEM OF RurRaL HeaLTH i ; . III. CatrarRAUGUS COUNTY ’ > . . 3 ’ IV. THE MiLBANK MEMORIAL FUND AND THE NEW YORK HeaLTH DEMONSTRATIONS . : : : : V. INITIATION OF THE DEMONSTRATION . : . : VI. PROGRESSIVE DEVELOPMENT OF HEALTH MACHINERY IN CATTARAUGUS COUNTY » ' . 3 ” VII. THE PreseNT HEALTH PROGRAM OF CATTARAUGUS CouNTY . : ; ’ : : ; : : VIII. CoMPARISON OF THE CATTARAUGUS COUNTY HEALTH ProGrRAM WITH THAT OF OTHER RURAL COUNTIES IX. Quality oF Basic PuBLic HEALTH ACTIVITIES . ; X. TUBERCULOSIS . : : . y . . . XI. HYGIENE OF MATERNITY, INFANCY AND CHILDHOOD . XII. NURSING : > ’ : - 2 3 . ” XIII. SociAL SERVICE . y . > . ’ . ’ XIV. StaTisTICAL RESULTS OF THE DEMONSTRATION . : XV. THE Cost oF THE CATTARAUGUS COUNTY PROGRAM XVI. PsycHoLoGICAL REACTIONS TO THE DEMONSTRATION . INDEX . . ‘ . ’ 2 . : : : vii in PAGE 20 26 37 42 46 79 96 104 123 142 171 190 206 227 235 269 RR In To TE I = FETS he 3 i | bs By . Ee . CHAPTER I OUTSTANDING LESSONS OF THE CATTARAUGUS COUNTY HEALTH DEMONSTRATION CATTARAUGUS COUNTY, New York, is a highly typical rural county of the Northeastern United States. It has a fairly stable and homogeneous population of 72,000 persons, mainly of native stock, engaged chiefly in small industry and dairying. It is rela- tively prosperous, as compared with rural counties in the South and Middle West, having an average per capita annual income of somewhat under $900, but with a substantial proportion of its people living at a very low economic level. Cattaraugus County ten years ago was fortunate in the posses- sion of a small group of unusually farsighted and courageous lead- ers, inside and outside of political life. These leaders had for some time desired to make a serious attempt to meet the health needs of the people of the County. They had established a county tuberculosis sanatorium in 1916 and in the same year the Olean Chamber of Commerce made the establishment of full- time county health service a part of its program. In 1921, Olean applied for the aid in establishing a demonstration unit under the American Red Cross which was ultimately secured by Mansfield, Ohio. In 1922, the Milbank Memorial Fund announced that it was its purpose “to demonstrate, by codperation with three typical communities embracing a population of half a million people, whether by intensive application of known health measures the extent of sickness in the United States can be further and materially diminished and mortality rates further and substan- tially reduced, and whether or not such practical results can be achieved in a relatively short period of time and at a per capita 1 2 Health on the Farm and in the Village cost which communities will willingly bear.” One of the com- munities to be selected for this demonstration was to be a rural county in New York State. Cattaraugus applied for aid under this program and was selected. In the year 1923, the Cattaraugus County program was definitely launched, with an organized full-time county health department, having bureaus dealing with communicable dis- eases, tuberculosis and statistics, and with a county laboratory service. Later on, in 1925, the nursing service (which had already been well developed) was made a separate bureau and a beginning (never carried to completion) was made in an effort to control venereal disease. In 1926, a full-time Bureau of Maternity, Infancy and Child Hygiene was created (discontinued in 1929). In 1929, a trained sanitary engineer was for the first time appointed. The sequence of events here noted differs from that which has been usual in county health work in the early attack upon tuberculosis and the prompt development of a highly organized nursing program, while sanitation—generally considered the most basic problem of all—was left to the last. Experience in Cattaraugus County has shown that sanitation cannot wisely be minimized in a county health program, even in a Northern state. In parallel with the county health organization itself, there developed three other phases of the program: (4) a county school hygiene service under full-time centralized direction, though with local administration of the actual health examinations; (4) a program of popular health instruction, and (c) a social service organization, both of the latter at first under an unofficial agency, the Cattaraugus County Tuberculosis and Public Health As- sociation. The total appropriation for public health work from all sources, the Milbank Memorial Fund, the State, the County and its local areas (exclusive of the tuberculosis sanatorium, social service and other special activities) rose to $176,000 in 1927 and fell to $160,000 in 1929. The latter figure amounts to $2.20 per Lessons of the Rural Health Demonstration 3 capita, of which $1.00 came from the County and its local units, 50 cents from the State and 70 cents from the Milbank Memorial Fund. The general program of the health demonstration and its gradual evolution seems to have been sound and judicious. Aside from the delay in recognizing the importance of fundamental sanitation and the lack of effective provision for health education in the schools, there has seemed to our survey staff no instance in which seven years’ experience indicates any flaw in the general plan of the program. In actual execution, the Cattaraugus health program, like most human enterprises, falls short of perfection. ‘There is evidence of haste and lack of thoroughness in the tuberculosis work of the earlier years and there is need for a closer and more effective district supervision of nursing service. The relations between the Milbank Memorial Fund as donor, the State Charities Aid Association as contact-agency and the County Department of Health, the County School Health Service and the County Tuberculosis and Public Health Association seem to have been based upon sound principles, and such friction as has occurred has been due to occasional departure from these prin- ciples. The only shadow on the general success of the demonstration has been an attack upon it by the local County Medical Society in 1927 and 1928. The difficulty appears to have been due in part to lack of tact on the part of local demonstration representatives, and in much larger degree to the psychological difficulties inherent in any attempt to develop a new form of organized medical service, which almost invariably tends to develop tension between those who are allied with the organization and those who are not. The only factor peculiar to the Cattaraugus situation, which deter- mined the evolution of latent grumbling into vocal opposition was a purely personal one,—for which neither the New York supporters of the demonstration nor those in charge of its work at Olean were in any sense to blame. The charge, widely cir- culated throughout the medical profession outside the County, that there had been “dictation by lay bodies,” failure in reasonable 4 Health on the Farm and in the Village deference to the local medical profession, “ineptitude, chaos and inefficiency,” were unfounded in fact. Furthermore, the demon- stration staff has at all times had the practical codperation of the majority of individual practitioners of the County in a rather unusually high degree, and has in no way been seriously handi- capped even by the attitude of the officers of the county society. Present Status and Achievements of the Health Demonstration. The 1929 health program of Cattaraugus County is, on the whole, an admirable one, judged even by the most exacting standards. The appraisal score for the County based on the Appraisal Form of the American Public Health Association has risen from 41 per cent in 1923 to over 80 per cent in 1928 and 1929. The budget provided and the services actually rendered check closely with the budget and the services of excellent city health organ- izations. The health program of Cattaraugus is something widely dif- ferent from the service provided for a large county by a full- time health officer, a nurse, a sanitary inspector and a clerk, which has been called a “standard” program by many leaders in the county health movement. When we compare a service costing 20 cents or 40 cents per capita or less and providing 1 nurse for 10,000, 20,000, 40,000, or 60,000 people—the service rendered by 80 to 90 per cent of the county units in the United States—with one costing over $2.00 and providing 1 nurse to 3,000 people, we are dealing with something of another order entirely. The Cattaraugus demonstration stands far above the level of the ordinary full-time county health department. It is comparable with perhaps a dozen really adequate rural health services, such as Los Angeles and San Joaquin, California; Chatham and Clarke, Georgia; Monmouth, New Jersey; Marion, Oregon; Rutherford, Tennessee, and one or two more. Within this group, it probably excels all other purely rural counties in tuberculosis control and laboratory service, and in public health nursing service. It is definitely deficient in prenatal work and is exceeded by Clarke and Rutherford in communicable disease control, by Monmouth in venereal disease work and infant Lessons of the Rural Health Demonstration 5 hygiene, by Clarke in school hygiene, and by Los Angeles in sanitation. It stands well up, however, with this group of banner counties, and in the first three activities listed (tuberculosis, laboratory service and nursing) it has been a pioneer. So far as actual results are concerned, the five years originally contemplated, and even the eight years which have now elapsed, constitute too short a period for the effect of a health program to be fully registered. Sir Arthur Newsholme, K.C.B., M.D., former chief medical officer of the Local Government Board of England and Wales, predicted in 1926, that such would be the case and he was right. It would probably be wise in the future to plan demonstrations of so ambitious a character for at least a ten-year period. It is impossible at the present time to make any com- plete appraisal of what has been accomplished in Cattaraugus County. All that we can hope for is an evaluation of the pro- gram with the certainty that, if it be sound, it will bear fruit during an indefinite period for the future. Nevertheless, even in eight years certain very definite results have been brought about which are capable of statistical demon- stration. ‘The mortality rates for diphtheria, tuberculosis and diseases of infancy have been reduced sharply and suddenly, to a degree involving a deviation from previous trends so pronounced as to be far beyond any reasonable influence of chance. It may be conservatively concluded that there has resulted from the demonstration program an annual saving of § lives by reduction in diphtheria, of 14 lives by reduction in tuberculosis and of 20 lives by reduction in infant mortality, equivalent to a reduction in economic loss to the community of $300,000 a year—or nearly double the entire yearly cost of the health program. A second definite and tangible result of the demonstration is its success in convincing the County authorities of the value of a modern health program and the importance of making financial sacrifices for the results which such a program entails. Mr. John Walrath, president of the County Board of Health, said in 1927 at the close of the original demonstration period: “It has been shown conclusively that it is possible and practicable to wv —-— 6 Health on the Farm and in the Village establish a health department in a rural county in New York State and that such a health department can furnish an effective health service for those living in the county. It has been shown also that county authorities are sufficiently interested in such a service to give it substantial financial support, thus ensuring the continuation of the work.” The demonstration has been “sold” to the political authorities. It has had the active support of the local press and of intelligent leaders of opinion, such as the teaching profession of the County. Most significant of all, a canvass of taxpayers’ opinions by a mail questionnaire indicated a slight but significantly increased tend- ency to favor appropriations for health work, as compared with a neighboring county where no health demonstration has been carried on. The Future of the Demonstration. As pointed out in later chapters, even the 1929 budget of Cattaraugus County which amounted to $160,000 or $2.20 per capita needed expansion to $175,000 or $2.40 per capita to fill in certain serious gaps in the program. It was suggested that with the ending of outside grants to the demonstration as such the desired end might be at- tained by an increase of $20,000 in the combined county and other local funds involving a corresponding increase of $20,000 in state aid, and that grants might perhaps be obtained from outside sources amounting to $26,000 for special efforts to solve the ex- perimental problems of prenatal service, venereal disease control and school health education—problems which have only been attacked in a few rural areas and in none of them satisfactorily solved. The specific steps suggested are as follows: A. The reémployment of a full-time director of maternity, infancy and child hygiene; the establishment of prenatal clinics in Olean and Salamanca (perlsaps at the local hospitals) ; and the development of prenatal service in rural areas in the offices of private physicians on a standard fee basis, the payments to be made from the health budget when necessary. B. The heading-up of a venereal disease program in the person Lessons of the Rural Health Demonstration 7 of the deputy health commissioner (with devolution of some of his epidemiological duties to the part-time deputies); the re- employment of a social hygiene supervisor; the reopening of the Salamanca clinic; and the development of paid venereal disease treatment service by physicians in the rural areas on the same basis as that suggested for prenatal service above. C. The appointment of a county supervisor of health in- struction to develop a real program of health education in the schools. It is most gratifying to note that in the fall of 1930 the County Board of Supervisors did in fact increase its appropriation for county health work by over $10,000 (entailing an equal increase in state aid) a remarkable tribute to the work in view of radical reductions in other county expenditures forced by the economic situation. Outstanding Specific Achievements and Lessons of the Health Demonstration. We may review certain very definite and specific contributions to our knowledge of the problems and pro- cedures of rural health administration which emerge from the history of the seven years’ experience in Cattaraugus. 1. The County Health Unit. First and foremost, this County’s experience has demonstrated that the general program of the full-time county health unit is as applicable to rural New York as to any area in the South or West. It has shown that such a unit is effective and practical and can be supported in an average New York county. It has shown that, with adequate funds, such a unit may be developed to a point far in advance of the type of organization often considered as “standard” for rural areas, and that such development is economically justified by direct returns in the saving of human life. 2. School Health Service. There has been developed in Cattaraugus County a novel and interesting plan of organizing local school medical service under the unifying influence of a county director of school hygiene, and of correlating such service with that of a county health unit. Whether such a program would succeed generally (with possible lack of the codperative 8 Health on the Farm and in the Village personalities present in Cattaraugus) may be open to question. There may be better systems, but the one in operation here has worked well and indicates one method of solving a difficult problem. 3. The Nursing Program. One of the most notable achieve- ments of the demonstration has been the creation of a public health nursing service which, taken all in all, is probably unique in a rural area. It has four outstanding characteristics, any one or two of which may be found in an occasional county, but which are nowhere else found in full combination. First of all, the nursing service provided is practically adequate in volume for the areas served. Secondly, it is admirably organized on a generalized plan with decentralized districts. Thirdly, it is perfectly integrated with the County Health Department pro- gram. Finally, it has been, on the whole, successful in develop- ing various special types of service through the temporary em- ployment of specialized supervisors for the formulation of a program and the training of the staff—a device which promises to be a valuable contribution to the technique of rural nursing. On the negative side, the nursing program of Cattaraugus has emphasized the need for intensive district supervision (as opposed to specialized supervision) as essential to the highest quality of service. 4. Tuberculosis Control. Here, as in its nursing program, Cattaraugus has established a standard for other counties to follow. It has provided case-finding machinery, clinic service, nursing service and institutional facilities which, while in some respects not ideal, are on a par with those of the best cities and are, so far as the writer is aware, superior to those yet provided in any rural area. The Cattaraugus experience has taught us the lesson—so much needed in many other fields of medicine—that there is such a thing as “over-diagnosis”; but it has succeeded to a remarkable degree in discovering early cases and in reducing not only mortality but morbidity as well, and apparently in greater degree. It has revealed facts of extreme interest as to the rela- tively low incidence of tuberculous infection in a rural child population; and it has roused in very definite form the question Lessons of the Rural Health Demonstration 9 whether we must not resort, for further material advance in the control of tuberculosis, to a relatively new technique based upon routine examination of children, rather than on the older plan of working chiefly from the known case to its contacts. 5. Consultation Service. Among the specially significant contributions of the demonstration must be mentioned a highly successful development of consultation service, not only for tuberculosis but for communicable diseases and other conditions as well. In spite of the rift in the medical profession, this service has been widely used and deeply appreciated by the local prac- titioners. 6. Laboratory Service. In the laboratory field, as in nursing and tuberculosis control, Cattaraugus has perhaps carried its program further than any other rural county. It has demon- strated that a laboratory service, far more extensive than that offered by many cities, can be developed in a rural area with great profit to the local medical profession and to the public health program as a whole. 7. Nutrition Studies. The nutrition studies carried on in the County have contributed materially to our knowledge of dietary problems in rural areas and to the technique of dealing with such problems. 8. Care of Crippled Children. The program for the care of crippled children in Cattaraugus County has been unusually comprehensive and successful, and offers another model for rural communities to imitate. 9. Statistical Studies. While somewhat outside the scope of the demonstration as such, this review would be incomplete with- out reference to the studies of the unit costs of the programs in the New York Health Demonstration areas, and to the studies of vital statistics and of the measurement of the results of health activities being made by the Research Division of the Milbank Memorial Fund. These studies are each year adding materially to our knowledge of the technique and the facts of vital statistics, and to the criteria by which public health procedures may be studied and evaluated. The Influence of the Cattaraugus County Program upon the 10 Health on the Farm and in the Village General Public Health Movement. ‘The influence of the demon- stration has, naturally, been most promptly felt in its own state; and nowhere was this influence more needed. New York has for fifteen years had a State Health Department of model ex- cellence; but in county health progress it has been quiescent, while Southern and Mid-Western states have gone forward actively. In his message to the State Legislature on January 6, 1926, Gov- ernor Alfred E. Smith said: “The unit for local public health work should be the county, with a full-time qualified county health officer who should be made responsible for the conduct of local health matters within his jurisdiction, with only such super- vision as the State may be required to give in an advisory capacity. Such an organization has been possible under the law (in New York State) for several years; yet only one county—namely Cattaraugus—has seen fit to take advantage of it, and with the very best results in promoting the physical welfare of the in- habitants.” Gradually, the example of Cattaraugus has overcome the con- servatism which Governor Smith deplored. In 1929, Suffolk established a full-time county unit; and during 1930 Cortland and Westchester have followed, while several other counties are already close to the plunge. The influence of the demonstration has, however, extended far beyond the confines of its own state. No one is better quali- fied to gauge such influences than Dr. W. F. Walker who as recent field director of the Committee on Administrative Practice of the American Public Health Association, has been in direct contact with all progressive health departments throughout the country. Dr. Walker was, therefore, asked to prepare a statement in regard to the matter. His “Memorandum Regarding the Influence of the Development and Administration of the Health Services in Cattaraugus County upon the Organization of Health Work Elsewhere” reads as follows: “While it is difficult, if not impossible, to trace a direct con- nection between the improvement in health service, or change in Lessons of the Rural Health Demonstration 11 the organization of health work in any area, and the fact that a particularly effective service or plan of organization has been previously demonstrated in Cattaraugus County, I am convinced, from my personal connection with the work there and from observation of the work in other counties and districts, both urban and rural, that the Cattaraugus County [Health] Demon- stration has been influential in at least the following ways: “(1) It has shown that to secure an equally adequate health program and effective health service in a rural area, such as Cattaraugus County, requires a per capita expenditure even greater in amount than for an equal population under urban conditions. Though the trend of thought has been in this di- rection for some time, I believe that the Cattaraugus County ex- perience has brought it more forcibly to the attention of health officers and that portion of the public which is interested in the further promotion of rural health work. “(2) The county laboratory as developed in Cattaraugus County has given a new idea of the volume of laboratory work which will be found useful to public health and medical practice in an area such as this, and how the laboratory work should be promoted as an aid to private physicians, in which event it es- tablishes a splendid liaison between the official health department and medical practice. The last few years have witnessed a rapidly increasing appreciation, on the part of health officers in rural areas, of the part which the laboratory plays in the develop- ment of a sound control program, and of the importance of en- couraging local physicians to make use of modern laboratory methods in the diagnosis of disease. “(3) The importance of a codrdination of nursing and social services has been demonstrated in Cattaraugus County and meth- ods of handling the acute and difficult social problems in connec- tion with routine nursing service have been investigated. Rural nurses do not in general have as adequate facilities available for handling social cases as are found in cities, with the result that a considerable amount of time and effort are put into attempts at handling these problems for which the staff are usually not 12 Health on the Farm and in the Village well equipped. The advantage of a social service consultant to the nursing staff, acting much as a specialized supervisor, has shown that many of the difficulties encountered can be success- fully met by the nurse in her ordinary capacity and also provides an outlet through a specialized person to whom may be referred the more difficult cases and those in which the health or nursing aspect may be of secondary importance. This is a phase of health department development which is just beginning to be appreciated by state and rural workers. “(4) The influence of the school health work is felt in various branches of this service. The plan and devices used in interesting rural people in the school health program, and the important items of the service as it applies to their specific schools and children, worked out by Dr. C. A. Greenleaf, director of the School Health Service, from the items of the Appraisal Form, demonstrated the applicability and the effectiveness of objective presentations of conditions in promoting school health service. It is a sort of a blue ribbon contest applied to the school as a whole, including the physical plant, as well as the pupils, in which the stimulus of contest is applied to the parent and the school authorities. “(5) Probably the most far-reaching influence of Cattaraugus County has been the demonstration in the field of rural tubercu- losis work. The county hospital has been in rather general use for some time and has passed through a wave of popularity and in many areas fallen into disrepute because it was insufficiently or improperly integrated with the tuberculosis program of the com- munity. In Cattaraugus County, the use of a special consultant in this field, available to the practising physicians, equipped with X-ray and other modern and essential means of diagnosis, has made the hospital a useful and thoroughly effective instrument in the handling of the tuberculosis program. The institution has risen from simply a place to put cases, in which the atmosphere is surcharged with despair, futility, and in many instances neglect, to an environment in which there is offered a hopeful program for improvement, looking toward the reéstablishment of the in- dividual in the community as a producing element. The vision Lessons of the Rural Health Demonstration 13 of what the tuberculosis program of a county may be under wise guidance, is a lesson of great worth, which literally scores of health officers have gleaned from Cattaraugus County. “(6) It would be too much to expect that any project of the scope and character of the Cattaraugus County Health Demon- stration would do all of its teaching through the presentation of positive results. The experience in the development of the health work in the County has resulted in certain conclusions, which for this particular area are drawn from negative results, but are leading to the avoidance of similar missteps in the develop- ment of programs elsewhere. Three of the activities now well under way or in the process of being developed in Cattaraugus County were initiated late in the program. “(7) Studies of local conditions, during the earlier years be- fore their inception, have proven conclusively that no rural health program can be considered complete, nor can it be effective, unless it pays close attention to the incidence of communicable diseases in the community, develops its epidemiological and con- trol services to handle the emergency demands which com- municable diseases place upon health organizations and functions in this first and foremost capacity of health service—namely, health protection. Coupled closely with the program of com- municable disease control, must be a sanitary service which in- sures effective control of water, milk and food supplies, and the disposal of domestic and municipal wastes. The Cattaraugus experience has again proven the fundamental necessity of these protective measures. In a like manner, the omission of organ- ized child hygiene services, including prenatal, infant, and pre- school care, until the later years of the demonstration, has shown that these organized health promotion activities are a necessity, if satisfactory results are to be assured. The specific teaching in health protection, as it relates to the control of acute com- municable diseases, to the improvement of the environment and to health promotion, is an element of a health program which can- not be satisfactorily supplied as a by-product of any other activity. The experiences of the earlier years of Cattaraugus 14 Health on the Farm and in the Village County have given these negative results, which, through re- éstablishing our faith in the necessity for these services, will be extremely helpful to the health administrators in all rural and urban areas.” The Problem of Social Service. One of the most significant features of the Cattaraugus County Health Demonstration has been its revelation of the extent of the uncared-for social needs of a rural population. The writer is aware that this is no surprise to the expert in social case work, but it is quite certain that this factor has rarely been taken into account by the public health administrator. As soon as an adequate nursing staff was set at work in Cat- taraugus County, however, there was revealed an almost over- whelming burden of economic handicap, of social dislocation and of mental maladjustment which made the solution of health problems in many instances out of the question. With this burden, the nursing staff had neither the time nor the technical qualifications to cope. So, for the first time perhaps, a rural social service staff was organized primarily as an auxiliary to a rural public health staff. At its maximum, this program included four social workers. They have accomplished much, particularly in the supervision of boarding-homes and, in general, in providing better care for dependent children. They have proved so useful to county and local authorities that two case workers have this year been taken over on the county budget. This is a notable achievement and there is much promise for the future under the excellent new law in New York State which replaces the concept of “poor relief” by that of “social welfare”. Even with three or four social case workers, however, it ap- peared impossible to do more than to cope with the most emergent problems of relief, requiring radical remedies of a legal or in- stitutional nature. At no time has the social service staff been able to find time for the really fundamental reconstructive measures which form the essence of modern social work. At no time has it been able to meet with adequacy the legitimate Lessons of the Rural Health Demonstration 15 demands for aid from the nurses; and this has been chiefly due to the need which the staff felt of meeting the most critical de- mands first. In medical terms, therapeusis has been so absorbing as to leave little time for prophylaxis; as in “Alice in Wonder- land”, it has been necessary to run all the time in order to keep in the same place. This experience tempts one to speculate on the real basic needs for rural case work and to suggest that it might be well to visual- ize some desirable proportion of case workers to a given rural population. It seems probable that a ratio of at least one case worker to 10,000 people might be fixed as a minimum ideal; and one dreams of a staff of, say, seven such case workers in Cat- taraugus County, providing a decentralized service, correlated closely with the nursing service in each local district. For the health administrator, the chief lessons would seem to be that a sound public health program demands a sound social service program as its background, that the social needs of the rural areas are far greater than we had conceived, and that funds for social case work may sometimes be more essential for health progress than those directly assigned to the health budget itself. Mental Hygiene. Closely allied to the problems of social welfare, on the one hand, and of the classical health program, on the other, are the problems of mental hygiene. Thoughtful experts are convinced that the burden on a com- munity due to mental and emotional maladjustments of various grades is approximately equal to the burden of all other physical diseases and disabilities taken together—just as the number of hospital beds provided for mental and nervous cases is roughly the same as that for all other cases of disease and disability. Nowhere, in city or rural area, has any adequate machinery been provided for dealing with these diseases and disabilities on a preventive basis. It seems certain that we must look in the future for far-reaching developments in this field, in the organ- ization of routine mental examination of children, of child guidance and behavior, and mental hygiene clinics, of psychiatric social service and of psychiatric wards for “first-aid to the 16 Health on the Farm and in the Village mentally injured.” This problem is so vast and the difficulties as to funds and personnel which lie in the way of its early solution are so great, that it has seemed impossible to consider it in detail in the present study. The fact that, in 1929, Cattaraugus had 396 per 100,000 of its population in state hospitals for the insane, as against a rate of 418 for New York State as a whole, probably does not indicate a low actual incidence of mental disease. The limited facilities now provided for Cat- taraugus County by the state clinics are clearly inadequate, and as a prerequisite to sound progress there should be developed a comprehensive state program such as has at present been at- tempted only by Massachusetts. It would be highly desirable, however, for such a county as Cattaraugus to make at least a beginning in the recognition of its mental problems; and this could, perhaps, best be accomplished by providing a psychiatric social worker to serve jointly with the social service staff and the nursing staff of the County Department of Health. Through such a worker the extent of the local needs could at least be visual- ized and the County prepared to take its part in the developments of the future. The Major Lesson. The one great outstanding lesson of the Cattaraugus County Health Demonstration is the urgent im- portance, the great difficulty and the high cost of adequate health service for rural communities. In every country, statesmen are realizing that the major problem of public health service is the extension of the facilities of modern medical science to the rural areas, so that health may come to the farm-dweller at least as fully as it has come to the tenement-dweller during the past twenty-five years. Cattaraugus has reémphasized this crying need with new force. It has shown us what a real county health program may be; and no one can study the Cattaraugus ex- perience without feeling that such service as that provided here should be the birthright of every rural inhabitant of the United States. A complete urban health program (which is essentially what the Cattaraugus program is) has proved itself just as prac- tical, just as essential, and just as fruitful among the hills Lessons of the Rural Health Demonstration 17 and valleys of Western New York as in the tenements of a great city. It has also proved itself to be just as costly and, indeed, some- what more costly than an urban program on account of the factors of distance which are involved. If we are to think in terms of vital need, we must recognize that an adequate rural health program cannot be provided in a state like New York for much less than $2.50 per capita. Furthermore, Cattaraugus experience has shown that there are problems of rural social service, as pressing and as far from solution as those of public health; while the wide field of mental hygiene opens up far- reaching vistas in the background. Against these needs we must balance resources. We find nearly one-third of the rural counties of the United States with per capita incomes of less than $250 per year and over two-thirds with incomes falling below $500 a year. It is this limitation which has held us back so far. It is this limitation to which we owe the fact that, of some 2,500 rural counties in the United States, only 500 have any form of organized health service, only about fifty have budgets and personnel of any reasonable ade- quacy, while perhaps a dozen have health organizations compar- able with those we consider essential in a city. There is obviously but one way out of this difficulty—state aid. The vicious circle in which we move at present and the mode of escape from it are clearly indicated by Dr. John A. Ferrell of the International Health Division of the Rockefeller Founda- tion in the following passage (Journal of the American Medical Association, July 9, 1927): “The economic status of the people in any community has a direct bearing on the whole problem because there is a limit beyond which it is impracticable for the individual to pay or for his community to pay. Where there is a high average of sick- ness and physical disability, there is likely to be a low average of income. This in turn makes for low standards of living, low productivity, inability of the individual to pay for medical service or to pay taxes with which to provide service at public 18 Health on the Farm and in the Village expense. Thus, in states, cities and counties having a high per capita income the individual does not need so urgently health facilities financed by the community, and yet it is in such com- munities that it is practicable, without excessive taxation, to supply such facilities. The same situation applies also to edu- cational, social and recreational facilities. In poor communities the converse situation holds true to a depressing and perplexing degree. “We are confronted, then, with the question not only as to the per capita amount of public funds that should be spent for the conservation of health, but also how the cost should be dis- tributed between municipality, county, state and nation. It is perfectly obvious that if one group of communities has a per capita annual income under $200 a year and another group $1,000 or more, there will be a tendency for individual and physician to move from the poor communities to the prosperous ones. If this should proceed far enough, it would result, on the one hand, in the virtual abandonment of extensive rural areas where there now are producers of raw materials and consumers of manu- factured products. On the other hand, there would occur ultimately excessive congestion of population in the communities that are now prosperous. Shall rural America be sacrificed to industrial America? From a far-sighted standpoint, is it in the interest of the welfare of the nation, or even of the industrial communities, to permit this to go on until the country may be weakened by the consequences? Should state and nation take steps to correct the trend and equalize facilities and opportunities, particularly with respect to health, before political strength is concentrated in the populous centers of industry?” This is not, let us remember, a question of expenditure but of investment. The Cattaraugus demonstration has shown that an adequate public health program pays for itself twice over in its direct contribution to the vital resources of the communities con- cerned. Dr. L. L. Lumsden, senior surgeon of the United States Public Health Service (Public Health Reports, Vol. xlv. No. 19, May 9, 1930), estimates that about $5,000,000 a year is now Lessons of the Rural Health Demonstration 19 expended in the United States for rural health service, that $20,000,000 should be so expended and that the financial return from such expenditure would approximate $1,000,000,000 from saving of economic loss due merely to wage losses caused by preventable illness alone. The writer would increase the figure of $20,000,000 to $100,000,000, since Dr. Lumsden’s computa- tion is based on a budget of only 45 cents per capita; but, even so, the return on the investment is sufficient. The dividend, as Dr. Lumsden says, will range from 100 to 3,000 per cent depend- ing on local conditions, being greatest in areas where the dis- ability due to such conditions as malaria and hookworm disease is most acute; but 100 per cent (approximately the gain in Cat- taraugus) is probably a safe minimum. There are more than mere financial questions involved, how- ever. Surely, the farm-dweller has his right to the guarantee of “Jife, liberty and the pursuit of happiness” and, of this guarantee, health forms an essential and a necessary part. Surely, the most prosperous nation in the world’s history must find a way to equalize the distribution of the fruits of medical and sanitary science through all its areas. The major lesson of the Cattaraugus County Health Demon- stration is the inspiration which it offers toward the attainment of such an end. CHAPTER I THE PROBLEM OF RURAL HEALTH Urban and Rural Health. The modern public health move- ment in its comprehensive sense is a product of the period be- tween 1900 and 1925. The great sanitary awakening, based on an empirical recognition of the dangers of filth, occurred in the third quarter of the Nineteenth Century. The scientific foundations of bacteriology and public health were laid in the last quarter of that century. The development of a broad social program for the prevention of all preventable disease has come only during the past twenty-five years. Thanks to this program, health has come to the cities. Any urban community which chooses to appropriate the necessary funds, to appoint an expert health officer and to give him the usual legal powers, can build up effective machinery for health promotion; and many of them have already done so. The re- sults have been nothing short of spectacular. Thus, to take only one example, in 1893, the death rate of New York City was nearly 25 per 1,000 and that of the rest of the State was about 17. By 1923, the rate for the City had dropped to 12 while that for the rest of the State was still 14. In rural communities, no such striking progress has been made. Rural death rates were never so high as those which took toll of the urban population in the past, but they remain almost un- affected by the progress of sanitary science and, in many instances, are today higher than those which now prevail in cities with their teeming tenement populations. Only about one-fifth of the rural population of the United States have the benefits of any organized health machinery, and, even in the 500 counties which boast of full-time county health services, budget and personnel 20 The Problem of Rural Health N21 are generally far below any reasonable standards of efficiency. Nor is this situation characteristic merely of the United States. Recent meetings of the Health Committee of the League of Nations have shown increasing emphasis upon the urgent prob- lem of rural health. In every country of the world the major administrative health need is the extension of modern health services to the country districts. The chief difficulties in the path of rural health service are of two types, administrative and economic. In the first place, the isolated rural community cannot possibly develop a self-sufficient health unit. The ultimate minimum of effective sanitary organi- zation includes a full-time health officer, at least three public health nurses and a sanitary inspector, which will cost $15,000. Therefore, no population group of less than 6,000 persons can possibly develop an adequate health service at reasonable cost. It is essential, then, either to replace local health units by a county organization or to unite such local units into larger ones in some other way. The second, economic, problem is an even more serious one. Public health, as Dr. Hermann M. Biggs told us, is purchasable; but it takes money to purchase it. There is no use, whatever, in blinking the fact that the farm dweller has today just as much illness as the city dweller, and perhaps more, and that he has just as much—perhaps greater—need for health protection. Furthermore, it costs more to furnish the same degree of protec- tion to the rural population on account of the greater distances involved in travel of nurses, doctors and inspectors, and the neces- sity for operating clinics and conferences in relatively small units. If an adequate health program costs more than $2 per capita in the city—as we know it does—it will cost still more in the country. Economic Status of Rural Areas. On the other hand, while we gain nothing by ignoring the farm dweller’s need for public health, it is impossible to ignore the co-relative fact that he fre- quently lacks financial capacity to meet his needs. To give a picture of the actual situation which must be met, I have presented in Table 1 a comparative analysis of the economic status of the 22 Health on the Farm and in the Village rural counties in the United States. The data are derived from a volume entitled “The National Market, 1926” prepared by the Crowell Publishing Company of New York as an aid in plan- ning sales campaigns. This volume gives, for each county in the United States, an estimate of per capita income which is based on a combination of six different factors (the number of income tax returns, number of passenger cars, total value of products, population, number of dwellings and number of retail outlets). After some study I am inclined to believe that this is perhaps the best single index of economic status available and it is, in any case, closely correlated with other indices taken by themselves. Ihave computed, for instance, the correlation between the Crowell index and the per capita savings and the proportion of income tax returns for each state, from the “Market Data Handbook of the United States” by P. F. Stewart (United States Department of Commerce, Domestic Commerce Series No. 30). The respective correlations are + 0.663 * .05 and 0.876 + .02. In Table 1, p. 24, I have arbitrarily considered all counties having less than 100,000 population in 1920 as “rural” counties. It will be noted that less than 2 per cent of the large urban counties fall below the $500 limit as against 70 per cent of the rural counties. Only 25 per cent of the urban counties fall below $750 as against 89 per cent of the rural counties. The rural counties in nearly all the Southern states and in the Dakotas show incomes most commonly under $250. The farm- ing states of the Middle West have most of their rural counties in the $250-$499 group. The rural counties of the industrial states fall generally in the $500—$749 group, while California, Connecticut, Massachusetts, Nevada, Rhode Island and Washing- ton are the only states in which counties having average incomes over $750 are relatively common. In view of the poverty of the average rural county, it seems reasonably clear to the writer that there is only one answer to this problem—the development of a system of state aid to rural health work. It is this principle which has actuated the notable work of the Rockefeller Foundation and the United States Pub- The Problem of Rural Health 23 lic Health Service in the development of full-time county health departments, particularly in the Southern states, and which was embodied in the 1923 law of New York for grants-in-aid to rural health enterprises; and temporary aid from foundations or from the Federal Treasury has been conditioned upon ultimate assump- tion of the burden by joint contributions from county and state. Significance of the Cattaraugus County Health Demonstration. There is much yet to be learned about the essential bases upon which a sound program of rural health must rest. What is a rural health program of minimum adequacy? How should it be set up? What should be its relation to other public and private agencies and to the local medical profession? What will it cost, and how much of this cost can the area itself be expected to bear? What will be the concrete results of such a program? The answers to these questions will vary in different geographical areas; but a careful study of even a single experiment in reasonably adequate rural health service cannot fail to yield conclusions of substantial value. Cattaraugus County, New York, is an outstanding example of a county which has tried to answer this question of adequate rural health service. It has been aided by a wisely conceived system of state aid and by the generosity of a farseeing foundation. It has made mistakes and achieved successes. It has, on the whole, succeeded in building up one of the outstanding rural health services of the United States. Both its achievements and its limitations are pregnant with lessons for other communities. In this summary report and in the special reports which ac- company it, my colleagues and I have attempted to tell the story of Cattaraugus’ pursuit of health, objectively and critically. The Milbank Memorial Fund has, to date, spent over $550,000 in Cattaraugus County, and, while this expenditure and the financial efforts made by the local community itself may be justified by the local results attained, the demonstration should bear fruit in many other areas. We shall, therefore, consider the Cattaraugus program not merely, or primarily, as a local enter- prise, but rather as an experiment which may throw light upon Table 1. Distribution of per capita income by rural counties! in each state of the United States — 1926. NuMBER OF COUNTIES HAVING AVERAGE PER CAPITA INCOME AVERAGE BETWEEN Livits STATED STATE INCOME TOR STATE Under | 5350-499 | $500-749 | $750-999 | $1090- ($1250 and TotAL Rural Counties 2 872 1156 575 217 56 24 Urban Counties 3 2 32 53 33 11 All Counties 872 1158 607 270 89 35 Alabama . $300 55 9 1 Arizona 655 4 7 2 1 Arkansas . 275 58 13 1 California . 1255 8 28 16 Colorado . 772 1 38 20 3 Connecticut . 917 1 3 Delaware . 797 2 Florida . 497 18 22 8 4 1 Georgia. 279 138 11 4 Idaho . 549 16 26 1 1 Illinois . 889 11 48 37 1 Indiana 516 3 76 8 : Towa 539 2 73 20 3 Kansas. . 511 2 81 18 2 1 Kentucky . 401 68 44 5 1 1 Louisiana . 436 13 44 3 1 Maine . . 704 6 6 3 Maryland . 817 8 12 2 Massachusetts 1067 2 3 Michigan . 715 1 46 30 2 Minnesota 586 23 33 6 1 Mississippi 252 62 16 4 Missouri 550 58 50 4 Montana . 526 34 17 Nebraska . 491 21 63 8 Nevada. Ln 861 4 11 2 New Hampshire . 769 1 6 2 New Jersey 946 8 4 New Mexico . 452 2 19 7 1 New York 1250 1 19 17 6 North Carolina . 336 63 29 8 North Dakota 366 29 20 2 2 Ohio . . 708 17 52 6 1 Oklahoma . 420 21 44 8 2 Oregon . 756 26 9 Pennsylvania 834 1 18 17 8 Rhode Island 1066 1 1 1 1 South Carolina . 2u 42 3 South Dakota 279 51 14 3 Tennessee . 361 73 18 Texas 518 11 148 59 20 2 6 Utah 577 22 5 1 Vermont . 651 4 7 3 Virginia . 414 50 42 4 2 Washington . 852 12 21 3 West Virginia 531 3 33 10 5 1 Wisconsin . 625 40 28 2 Wyoming . 876 11 6 3 1 1 All counties of under 100,000 population classed as rural. counties, see upper lines of table. 12 Under 100, For comparison with larger (urban) $ Over 100,000. The Problem of Rural Health 25 the wider problem of health service for rural districts in general. It is not the successes and failures in Cattaraugus County which are important, but the principles and the techniques and the limitations derived therefrom, which apply in a wider sense to rural health problems as a whole. CHAPTER III CATTARAUGUS COUNTY* Geography and Climate. Cattaraugus County lies in the southwestern part of New York State, some forty miles south of Buffalo. It is bounded on the west, north and east, respectively, by Chautauqua County, by Erie and Wyoming Counties and by Allegany County, New York, and on the south, by Warren and McKean Counties, Pennsylvania. From east to west, it measures 39 miles and from south to north, about 37 miles. Its area is 1,343 square miles. With no real mountains, Cattaraugus lies for the most part fairly high above sea level and its area is diversified by many hills. “The glacier-smoothed contours of its hills rise to various heights above these valleys and the effect as one observes the County in travelling through it is of alternate hills and valleys in irregular but continuous succession—a sort of land version of mid-ocean swell and hollow. The County contains luxuriant reminders of a once mantling growth of timber and many open and verdant stretches of uncultivated country, as well as farmed areas and areas dotted irregularly with grouped or scattered habitations. The whole expanse is threaded by many slight streams of water, none of them swiftly moving, and for forty-six miles by a visitant from Pennsylvania, the Allegheny River.” The main city, Olean, is approximately 1,400 feet above sea level. The highest point in the County, about five miles from Olean and called Flatiron Rock, is 2,387 feet. The only large river is the Allegheny, which enters from and returns to Penn- 1 Data in this section courteously furnished by Dr. Reginald M. Atwater, Com- missioner of Health of Cattaraugus County (in part quoted from his admirable report for 1928). 26 Cattaraugus County 27 sylvania across the southern border. Lime Lake, in the north- eastern portion of the County, is the one sizable body of water. Creeks, many of them in summer hardly the size of brooks, are found throughout the County. Cattaraugus Creek, the largest of these streams, which outlines the larger part of the northern boundary, flows much of the time at the base of tall cliffs. In a normal year, the County has 190 hours of sunshine a month, or about 48 per cent of the possible total. The prevailing winds are southwest, and the mean temperature about 45° F., varying from a mean of 24° in winter to one of 66° F. in summer. It is commonly said that “the season is too short for successful farming.” The mean annual precipitation is 39 inches, and the mean relative humidity, 77 per cent at 8 A.M, and 72 per cent at 8 p.m. There is no Weather Bureau station in the County and these data are based on observations at Angelica (Allegany County), Jamestown and Buffalo. History. The authentic history of the County begins in 1687 when Seneca Indians, forced from their original home by French attacks, came to Cattaraugus. Other members of the same tribe followed after the attacks of General Sullivan in 1779, and during the whole of the Eighteenth Century the County was an Indian settlement. The descendants of these Senecas still occupy the Allegany Indian Reservation which extends for forty miles along both banks of the Allegheny River. Another group of the same tribe occupies the Cattaraugus Reservation, a small corner of which extends into the northwestern corner of Cattaraugus County. The first white settlement was established in 1804; but the de- velopment of the County proceeded slowly. Six years after this first settlement, the actual count of inhabitants was 458. Clear- ing the land was a discouraging process, and prospective settlers were tempted by the facilities which the river offered of getting easily to more promising lands further west. Westward bound emigrants were originally routed through Cattaraugus, taking to the river on rafts near Olean, but in 1825 the opening of the Erie Canal, between Albany and Buffalo, terminated the use of 28 Health on the Farm and in the Village this route. Those who stayed in Cattaraugus were for the most part men who were glad to take advantage of the easy terms offered by the Holland Land Company, which held the original grants. The population of the County has still many of the psychological characteristics of a hardy and individualistic pioneer stock. The production of black salt, from the ashes of burnt timber, was the first enterprise. Lumbering followed, on so ruthless a scale that few traces are left of the pines which once covered the land. Game and fish supplemented the attempts at agriculture. Various crops were tried with indifferent success and the cleared lands were gradually given over to grazing. Dairying followed naturally and is the chief industry today. The first railroad, a branch of the Erie, was built from Penn- sylvania as far as Salamanca in 1851. In 1866, the tracks for the Buffalo & Pittsburgh were laid, and in 1872, the Buffalo, New York, & Philadelphia line, passing through Olean and thence north to Buffalo, was completed. This was later known as the Buffalo & Washington, and is now part of the Pennsylvania system. In 1877 and 1878, other lines connecting points in the County with Buffalo, Jamestown, Rochester and Bradford were completed. At the present time, three main lines, the Erie, the Pennsylvania, and the Buffalo, Rochester & Pittsburgh, cross the County. The first oil well in Cattaraugus County was drilled near Lime- stone in 1875, sixteen years after the first oil well in the country, the Drake Well at Titusville, Pennsylvania. Production still continues on a small scale, but has never been of such far-reaching importance as across the line in Pennsylvania. A large proportion of the pioneer settlers of the County came from the New England states, English, Welsh and Scotch stocks being largely represented. It is perhaps significant that, during the Civil War, men from Cattaraugus served in 180 different regiments. There were over 3,500 such men in the Union forces. With diversity of origin, customs and habits, without cause to fear Indian invasions, the pioneers did not hesitate to settle Cattaraugus County 29 sparsely throughout the County. As a result, religious organ- izations were scattering and without much unity. The schools, on the other hand, received more attention. In 1811, five commissioners were appointed to complete a system for the organization and establishment of the common school. Three commissioners in each town were provided to superintend schools and examine teachers, and three inspectors in each district were to engage teachers and provide for the local necessities of the schools. The whole system was to be placed under a state superintendent. This plan was in force until 1821. At the present time, only 2 per cent of the popula- tion 10 years of age and over is illiterate. In 1925, 97.5 per cent of the children from 7 to 13 years of age were attending school. On the Indian Reservation, the first school was established by the Quakers and continued with moderate success from 1816 to 1820. While the suspicious attitude of the Indians caused the Friends to discontinue it temporarily, they continued a friendly, helpful policy which subsequently led to the reopening of the school. It is still maintained at Tunesassa, and receives children from a number of reservations. At the present time the legislative power of the County is vested in the Board of Supervisors, of whom there are 49, having a two year term. All taxes, including those for schools, are levied by this group. Population. According to the 1925 State Census, the popula- tion of the County was 73,778, including two cities with a com- bined population of 31,210. Preliminary reports from the Federal Census indicate a population of 72,649 for the County in 1930. Olean has now a population of 21, 752 and Salamanca a population of 9,570. There are 13 villages, seven with popula- tions under 1,000 (the smallest being Perrysburg village with 315), four with populations between 1,000 and 2,000, and two with populations over 2,000 (Franklinville village, 2,017 and Gowanda, 3,040). In addition, there are 33 towns with the following distribution of population: under 1,000, 17 towns 30 Health on the Farm and in the Village (Elko with 160, the smallest); between 1,000 and 2,000, 10 towns; over 2,000, 6 towns (New Albion, 2,004,Portville Town, 2,410, Randolph Town, 2,422, Persia, 2,507, Franklinville Town, 2,945, and Allegany, 3,784). Table 2. Population of Cattaraugus County, 1810— 1930. YEAR POPULATION 1810 458 1814 337 1820 4,000 1825 8,643 1830 16,724 1835 24,896 1840 28,872 1845 30,169 1850 38,950 1855 39,530 1860 43,886 1865 43,158 1870 43,909 1875 47,298 1880 55,806 1890 60,866 1900 65,643 1910 65,919 1920 71,323 1925 73,778 1930 72,649 There are 54 settlements in the County which are not in- corporated, varying from a handful of houses, with a post office or store, to sizable communities. Nineteen of the 33 towns are without incorporated villages. The urban population has shown a fairly steady increase, corresponding to the increase for the County, while the number of village inhabitants has changed little in 25 years. The popula- tion density ranges from 50 to 60 per square mile. There are 1,146 inhabitants in the two Indian reservations, 972 in the Allegany Reservation and 174 on the section of Cattaraugus Reservation lying within the County. There are few negroes, the number in 1925 being 379. ‘There Cattaraugus County 31 are practically no Chinese or Japanese. Only about 8 per cent of the inhabitants are foreign born. Table 3. Country of origin of foreign-born residents in Cattaraugus County, 1925. COUNTRY OF ORIGIN NUMBER Torar . 0. wise 6,343 Germany. =. ove 1,294 Poland... ov 0. 1,030 aly Lie 2 vc 816 Canada, +. « «si 537 Austria. + J vl. . 517 Ireland. oc cs 468 England’... vee 441 Sweden. . . . . . 350 Allother .. + . . '« 890 As far as sex distribution is concerned, there are 51 males to 49 females. The age distribution has not altered materially since 1910. The census in 1920 and in 1925 did not record any persons 100 years or more, but in 1910 there were three. Table 4. Age distribution of 100 per- sons in Cattaraugus County, 1910 and 1925. AGE 1910 1925 UnderiS. . . ... 28 29 IStodd ii 5 i, 45 44 45t0 64 . . . « 19 19 6Sandover. . . . 8 8 The total number of families in the County, as shown by the 1920 Census, was 18,223, making an average of 3.9 persons per family. The number of dwellings was 17,056, one-third of which were rented. Economic Bases. In 1927 the assessed valuation of property in Cattaraugus County, including real, personal, and franchises, was $60,253,154. One-third of this was in Olean, which has 29 32 Health on the Farm and in the Village per cent of the total population, and 10 per cent in Salamanca, which has 13 per cent of the total population. The most recent information available locally regarding Federal Income Tax returns is for the year 1922. ‘There were 4,101 returns made, 258 of which were for incomes of $5,000 or more. According to the 1920 Census, there were 278 industrial es- tablishments employing 8,383 wage earners yearly, with products valued at $65,935,774. In 1924 a survey was made of all in- dustries averaging 20 or more employees during the previous year. While this survey was made primarily to determine the status of medical services, certain economic facts may be extracted from it. Sixty-three establishments were found to have employed 20 or more persons, providing work for about 89 per cent of the factory workers. The accompanying Table § indicates, in a gen- eral way, the type of industries concerned. Turning to agriculture, the main industry of the County, the Census states that in 1920 there were 5,305 farms occupying 7§ per cent of the total area of the County. The farms ranged in Table 5. Distribution of establishments and employees in industrial groups, in Cattaraugus County, arranged in order of number of employees 24. R INDUSTRIAL GROUP EE | Te |PRERo me TOTAL..." lw ee 63 8,518 100 Metal, radii . . 3 3,278 38.5 Leather (including tanneries) . . 7 1,270 14.9 Wood (including furniture fac- tories) = best, LL Cin, 13 1,229 14.4 Chemicals, oils (including oil refineries) 2 1,042 122 Textiles (including silk mills) | 3 550 6.5 Food . 9 506 6.0 Stone, glass, clay (including tile and brick works) MAC) 6 375 44 Printing and paper goods . 4 188 22 Clothing, laundry 2 80 0.9 Nore: After the headings, in parentheses, is placed the type of industry which locally predominates in each group. Cattaraugus County 33 size from 17 with less than 3 acres to 9 with 1,000 acres or more. The average size was 120 acres, about one-third of the farms having between 100 and 175 acres. Slightly more than half the farmland was classed as improved and a fourth of it as woodland. About 90 per cent of the farmers were native-born and white, and 84 per cent of the farms were operated by their owners. The value of all farm property was placed at $45,327,838, making the average value per farm $8,550. The farmland alone is valued at $6 to $100 per acre. Much of the timber, once the County’s major asset, has been cut away, but logs as a source of ready cash help to piece out the economic picture and supply some of the county industries. In 1900 and 1910, the per cent of farmland that was classified as improved was slightly over 62. In 1920, it was 53. The total values, however, of land, buildings, and implements had increased, the increase in implements being particularly marked. Table 6 compares the agricultural products in 1910 and in 1920. Table 6. Value and amount of farm products in Cattaraugus County, 1910 and 1920. Farm Propucrs 1910 1920 Dairy products (aot indlnding home us), vane. SC. ah $2,678,930 $6,883,815 receipts o alae eile me 2,608,086 6,806,719 Dairy cattle, number . . . . . . . 59,779 80,253 fotalvalue ~... .. . «nici $2,873,749 $6,789,442 value per head . 48 85 Average piodacilen of milk, “gallons per COW. Ll . a . : 489 Milk produced, gallons . . . . . . . 25,734,114 Milksold, gallons. . . « « « + & >» 24,061,450 Creamsold, gallons . . . . : . . . 158,045 38,666 Butter fat sold, pounds . . . . . . . 505,298 38,062 Butter produced, pounds . . . . . . 549,026 369,239 Buttersold, pounds, . Lo. 292,327 252,811 Value of cultivated crops (hay, wo, fruits, vegetables, etc.) . . $4,182,033 $8,308,872 Maple trees, number. . . . . . . . 377,192 321,978 Maple sugar,pounds. . . . . + « 283,532 128,832 Maple syrup, gallons. . . . . . . . 274,581 77,338 34 Health on the Farm and in the Village As the foregoing indicates, dairying is the predominating in- dustry. Milk and cream, in large quantities, are shipped to Buffalo, Baltimore, New York and Philadelphia. Several con- densories maintain canning plants inside the County. As Dr. Reginald M. Atwater, county commissioner of health, has said, “Grazing dairy cattle form a decorative pattern for Cattaraugus hillsides that is economically significant. Some of these cattle are from fine, pure-bred stock. Profitable dairying is the stabilizing element in the money-making ventures of the County as a whole and influences the trend of county prosperity very fundamentally.” “The National Market” assigns to Cattaraugus County a per capita income figure of $874, which places it among the richest 10 per cent of the rural counties of the United States. Among the 43 rural counties of New York State, it ranks twelfth, there being 11 richer and 31 poorer counties. An analysis of the proportion of income-tax payers from the Market Data Handbook of the United States for 1920 shows Cattaraugus with one person in 33 paying an income tax, the County ranking sixteenth among the rural counties of the State, 15 counties having a higher proportion of taxable incomes and 27 a lower proportion. Data for savings bank deposits from the same report give a some- what different picture. In per capita savings bank deposits, Cattaraugus, with a deposit of $240 per capita, ranks thirty- first, with 30 rural counties having higher deposits and 12, lower deposits. There is no doubt that many individual farmers’ families in Cattaraugus County live on a margin (or lack of margin) that makes financial provision for emergencies out of the question. An unofficial observer says of such families: “When I say they were without cash, I mean without a nickel. I think one reason for families on farms being so short is that owners of small dairy herds, unable to produce sufficient feed for the cows on their land and unable to get credit for it, deplete the family cash supply very seriously to feed the cows, especially in winter.” To summarize, Cattaraugus is a highly typical county of the Northeastern United States. It has a reasonably stable popula- Cattaraugus County 35 tion, chiefly of native stock, more than half of its people living under strictly rural conditions. Somewhat more than one-third of the inhabitants are engaged in industry (metal working, leather, wood working and oils and chemical trades being the chief crafts represented) and nearly as many in agriculture, chiefly dairying. Health Situation in Cattaraugus County Prior to 1923. In the year 1922, when the story of the demonstration begins, the health organization of Cattaraugus was—like that of all New York rural counties at that time, and of most of them today— exceedingly inadequate. There was, of course, no general county health organization at all. Each city and town and village had its part-time health officer and each school its part-time medical inspector; but the activities of the former were generally limited to control of acute epidemic diseases and response to complaints of nuisances, that of the latter to rather perfunctory annual ex- aminations of school children. The outstanding figure in local public health was Dr. C. A. Greenleaf, school medical inspector of Olean, and this City had four public health nurses—one em- ployed by the schools, one by the Board of Health and two by the Red Cross—and a dental hygienist. One school nurse was employed in Salamanca, and there was a Red Cross nurse in Gowanda and one in Portville. The only step taken by the County as a whole was the erection of the Rocky Crest Sanatorium for tuberculosis, opened in 1916, and one public health nurse was attached to this institution. There was a rather active Olean Tuberculosis Society which maintained a children’s camp and the county tuberculosis as- sociation, of which Dr. Greenleaf was president, had an executive secretary working throughout the County. This association, however, had done little except to agitate for the sanatorium. The construction of the sanatorium and the development of the county association were largely due to the stimulation of the State Charities Aid Association, which has played so notable a part in such movements throughout New York State. The data in regard to the County obtained by the Milbank Memorial Fund in 1922 showed a total of $25.01 per capita ob- 36 Health on the Farm and in the Village tained in county taxation, of which $18.06 was spent for educa- tion, $1.09 for charities and $1.33 for health (including sana- torium maintenance). An additional sum of $.20 was spent for health by voluntary agencies. In 1922, sanatorium beds for tuberculosis amounted to 55 per 100 annual deaths. ‘The ratio of public health nurses to population was 11.2 per 100,000. There were 124 patients in attendance at the tuberculosis dis- pensaries and 1,071 nurses’ visits were made on behalf of this disease. There were two infant welfare consultations held under the auspices of the State Department of Health with four con- ferences a month and 135 children registered. Seventy-nine per cent of the school children had been medically examined and 28 per cent of the defects discovered had been corrected. The general death rate of the County had averaged 14.2 for 1919-1921 (12.9 for the cities and 15.3 for the rural area). It had fallen as low as 11.7 in 1903 and risen to 18.3 in the 1918 in- fluenza year. The tuberculosis death rate averaged 74.0 per 100,000 for 1919-1921; and the infant mortality for the same period averaged 80.9. Aside from Dr. Greenleaf, who has already been mentioned, and Miss Lilla C. Wheeler of Portville, who had been a central figure in all movements for the good of the County, the leaders in these early stages of health work were Mrs. Florence Bradley, secretary of the Olean Board of Health; Mr. John Walrath of Salamanca, Mr. Allan B. Williams of Olean, treasurer of the County Tuberculosis Association; and Mr. John Sloane of Olean. As early as 1916, the Chamber of Commerce of Olean had visualized the establishment of full-time county health service as part of its program and when the American Red Cross announced in 1921 that funds would be available for a child health demonstration, Olean applied for the grant, largely under the influence of Dr. Greenleaf. Cattaraugus County was among the two or three applicants which received most favorable con- sideration; but Mansfield, Ohio, was finally selected. The socially minded citizens of Cattaraugus bided their time for a better opportunity. CHAPTER IV THE MILBANK MEMORIAL FUND—AND THE NEW YORK DEMONSTRATIONS The Milbank Memorial Fund. We must now turn from the hills of Cattaraugus County to a group of offices and committee rooms on Manhattan Island where deliberations were in progress which were to link up with the aspirations of the forward-looking citizens of Olean and Portville and to bring health and healing to many a remote farmstead. Elizabeth Milbank Anderson, daughter of Jeremiah and Elizabeth Lake Milbank, was born in New York City in 1850 and there lived a life characterized by a continuous succession of good works. She was a generous friend to Barnard College and, from 1904 on, gave freely to the New York Association for Im- proving the Condition of the Poor and the Children’s Aid Society for the promotion of the cause of public health. In the year 1905, she established the Milbank Memorial Fund “to improve the physical, mental and moral condition of humanity,” which has to date expended over six million dollars and has aided some 131 different organizations. At home and abroad, grants from this Fund have aided in the promotion of public health and social welfare, always with an instinct for pioneering along new lines and with a keen sense of the importance of establishing sound foundations for progress by rigorous scientific experimentation. The Department of Social Welfare of the New York Association for Improving the Condition of the Poor, the New York Com- mission on Ventilation, the Trudeau Laboratories, the National Committee for Mental Hygiene, the Home Hospital for the Treatment of Tuberculosis, and the Judson Health Center 37 38 Health on the Farm and in the Village were the more outstanding agencies in the organization and early financing of which the Milbank Memorial Fund participated. In the year 1921, following Mrs. Anderson’s death, the Fund extended its activities and a new policy was adopted which in- volved concentration on a few major projects rather than con- tinuance of small grants to many independent agencies. At this period it had become clear that progress in any one of the various special fields of health promotion must depend upon a balanced community health program under competent permanent expert leadership. The demonstration of tuberculosis control initiated by the Metropolitan Life Insurance Company at Framingham, Massachusetts, in 1917, under the direction of the National Tuberculosis Association, had exerted a powerful in- fluence upon the thinking of health workers and was to be followed by a demonstration—chiefly along the line of child health—at Mansfield, Ohio, begun in 1922 with funds provided by the American Red Cross and under the direction of the National Child Health Council.* The directors of the Milbank Memorial Fund decided to devote a major part of their resources to work along the line of the es- tablishment and aid for a limited period of years of demonstrations of a wider scope and in larger population areas. It was hoped thus to indicate the possibilities of a complete health program which the communities concerned would subsequently maintain and which should serve as an example to other communities of the values of modern public health work. Program of the New York Demonstrations. The essential objective of the new Milbank program was to help communities of different types repeat the Framingham Demonstration on a larger scale. The following questions are specifically set forth in the report of the Milbank Memorial Fund for 1922: “With ade- quate resources, can tuberculosis as a theoretically controllable disease be practically reduced to a minimum as a cause of illness, 1 The Commonwealth Fund Demonstrations were begun later—at Fargo, North Dakota, in 1923; in Clarke County, Georgia, and Rutherford County, Tennessee, in 1924, and in Marion County, Oregon, in 1925. Milbank Memorial Fund and the Demonstrations 39 destitution and death? Can favorable results obtained in smaller population units be demonstrated on larger and more varied groups? What is the relative utility of special measures for disease control? What constitute the major elements of an effective community health program in which tuberculosis con- trol is properly integrated? What is the cost of such a program? Can normal American communities gradually assume and per- manently maintain adequate machinery for disease prevention and health conservation?” To work out the details of such a program, a Technical Board was created, made up of the following members: Hermann M. Biggs, M.D., Mr. Bailey B. Burritt, Livingston Farrand, M.D., Mr. Homer Folks, Mr. John A. Kingsbury, James Alexander Miller, M.D., William H. Welch, M.D., and Linsly R. Williams, M.D.; and a larger Advisory Council of some forty members was appointed which has met annually to consider the progress of the work under the chairmanship of Dr. Welch. It was decided to undertake demonstrations in three areas of New York State—one, a rural county of 50,000 to 75,000 popula- tion; one, a city of about 100,000 population, and one, a special section of a large metropolitan area having a population of about 200,000. In accordance with the Milbank policy of working through established and permanent organizations, the State Charities Aid Association was invited to serve as the central operating agency for the upstate demonstrations. The Fund set aside $325,000 a year for five years to cover the cost of all three demonstrations. In the 1923 report of the Fund, its purpose was restated as follows: “to demonstrate, by cooperation with three typical com- munities embracing a population of half a million people, whether, by intensive application of known health measures, the extent of sickness in the United States can be further and materially di- minished and mortality rates further and substantially reduced, and whether or not such practical results can be achieved in a relatively short period of time and at a per capita cost which communities will willingly bear.” It was emphasized that 40 Health on the Farm and in the Village “during its existence, the Fund has not undertaken to set up any independent operating agencies, but has sought to reach its social objectives by the utilization and temporary provision of activities where none exist but are needed.” In another place, the fact is reiterated and stressed that “the demonstrations are con- ducted by and not on the people in the demonstration centers.” Furthermore, it was stated as “of basic importance that the program be developed in a manner and at a rate which shall not exceed the ability of the local health authorities and of the voluntary agencies to take over as rapidly as the desirability and feasibility of such action on their part may be demonstrated.” It was expected that the demonstration program would in- clude activities directed to the following phases of public health: Tuberculosis. Communicable diseases. School hygiene. Mental hygiene. Industrial hygiene. Sanitation and food inspection. Health conservation and life extension. It was estimated that such a program would cost $3 per capita per annum. At the meeting of the Advisory Council on November 15, 1923, the projected policies were very fully discussed, and although the first of the demonstrations was by that time well under way, it is of interest to note the ideals which actuated those who were responsible for it. Dr. W. H. Welch stated that the undertaking as a whole represented the “first effort made on a varied and large scale, in which there is going to be anything ap- proaching an adequate application of existing knowledge about the problems of public health.” Mr. Homer Folks pointed out “that whatever was done should be thoroughly grounded in the institutions and the life and public affairs of the community in which the work was to be done, and should not be regarded as a strange something imported into the community.” Dr. Haven Emerson went even further in emphasizing as a criterion of success Milbank Memorial Fund and the Demonstrations 41 that the people in the demonstration areas should be “taught to do as much for the protection of their own health as is now done for them.” He continued, “A radical change is needed in the common attitude towards public health service. It has been thought of as something which chiefly concerns our public and private health agencies. It must be made a part of our annual personal budgets.” The aims and aspirations expressed at this time will be of fundamental importance to us as criteria in judging the results actually attained eight years later. CHAPTER V INITIATION OF THE RURAL HEALTH DEMONSTRATION Selection of Cattaraugus County. As soon as the general plan of the Milbank demonstrations was announced in May, 1922, the forward-looking group of persons in Cattaraugus County, who had tried to secure the American Red Cross demonstration a year before, recognized another opportunity to realize their ideals. Miss Lilla C. Wheeler was present at the meeting of the Committee on Tuberculosis and Public Health of the State Charities Aid Association in New York in May, 1922, when the Milbank program was announced. On her return to Cat- taraugus, she at once got in touch with Mr. Walrath and Dr. Greenleaf. They called a meeting of other interested citizens and a resolution was drawn up calling the attention of the Board of Supervisors to the benefits which this possibility offered. There was no time to call a regular meeting of the Board, but Mr. John Walrath and Dr. Greenleaf saw the 48 supervisors personally and obtained the signature of every one of them to an urgent telegram inviting the Milbank Memorial Fund to select Cattaraugus for its demonstration. On October 12, 1922, at a special session, the Board of Supervisors unanimously adopted a series of resolutions which closed as follows: “Whereas, it seems clear that our County, if selected, would through this demonstration, with the substantial aid of the Milbank Memorial Fund, be taking the most direct, certain and economical method of greatly increasing the health, happiness and well-being of its people, “Therefore, Be it Resolved, that the Board of Supervisors of Cattaraugus County approves the general purpose of the said 42 Initiation of the Rural Health Demonstration 43 demonstration; that it favors the selection of Cattaraugus County for the undertaking, and that, if this county is selected, the Board of Supervisors will establish a general health district and a health officer for such a district, pursuant to the provisions of Chapter 509, Laws of 1921, the inclusion within such general health district of the cities of Olean and Salamanca to be optional with the authorities of said cities as provided by law.” Four days later, on October 16, 1922, the Cattaraugus County Medical Society at a special meeting unanimously adopted the following resolution: “Whereas, the Milbank Memorial Fund will initiate and help finance an intensive Health Demonstration in a rural county of New York during the next five years to show what can be ac- complished in the prevention of tuberculosis and in promoting the general health and physical vigor of the people, “Therefore, Be It Resolved, that the Cattaraugus Medical So- ciety approve this demonstration and that if Cattaraugus County is selected, it will cooperate in every way that it can to make the demonstration a success.” Many other counties in New York State were also actively in- terested in securing the aid of the Fund in the prosecution of their plans, and the selection proved by no means an easy problem. It was felt by the Fund that the following must be essential require- ments for the demonstration areas: “1. Local desire for the demonstration and local assurance of codperation, harmony and coérdination of effort. “2. Local responsibility for participation in, and leadership of, the demonstration—especially on the part of public authorities. “3. Local assumption, in the beginning or as early thereafter as possible, of financial and operating responsibilities for newly initiated or freshly developed activities of proven merit.” The possibilities of the various counties which applied were carefully studied by a group of statisticians from the standpoint of vital statistics and by a group of social workers from the stand- point of local social conditions. Many of the counties were promptly eliminated as insufficiently rural in makeup, or were +4 Health on the Farm and in the Village disqualified on account of abnormalities of population, abnormal mortality rates or notable deficiencies in provision for local health work. The choice lay finally between four counties, Cattaraugus, Dutchess, Jefferson and Saratoga. Special surveys were made of each of these counties. Finally, in view of all the facts, and on recommendation of the State Charities Aid Association, the Technical Board and the Advisory Council, Cattaraugus County was selected as the first demonstration area on November 20, 1922. It appeared to the Fund as an unusually autonomous, relatively isolated, typically rural district with a reasonably stable population, largely of native stock. It showed mortality rates which for some years had remained practically stationary. It had considerable per capita appropriations for education and an active County Health and Tuberculosis Association. It was concluded that “its business, financial and political leaders are unusually interested in health work. In addition, there seems to exist in the district unusual codperation between public and private social and health agencies.” Initiation of the Rural Health Demonstration. In January, 1923, the demonstration was formally initiated by the act of the County Board of Supervisors through the creation of a general health district—the first organized county health unit in New York State. This action was taken under a permissive law which had been passed by the State Legislature in 1921. The rural areas of the County alone were included by the action of the Board of Supervisors, but the cities of Olean and Salamanca soon elected to join the health district, making it county-wide in extent (in theory, at least). A County Board of Health was appointed by the Board of Supervisors, consisting of Mr. John Walrath of Salamanca, president, Mr. William C. Bushnell of Little Valley, Mr. William A. Dusenbury of Olean, Dr. Myron E. Fisher of Delevan and Miss Lilla C. Wheeler of Portville. As no properly qualified local candidates were available, this Board appointed Dr. H. A. Pattison of the National Tuberculosis As- sociation to serve as temporary county health officer until in March, Dr, Leverett D. Bristol, formerly state commissioner of Initiation of the Rural Health Demonstration 45 health of Maine, was appointed county health officer and director of the demonstration, with headquarters at Olean. During this first year of partial operation, operating expenses were at first small (rising to a rate of about $6,500 per month at the end of the year), but cost of equipment was high, $15,599.67. Of the total expenditures of approximately $60,000, the County Board of Supervisors appropriated $11,717.65 (not all of it spent) and the balance was provided by the Milbank Memorial Fund. The financial data given in this chapter do not tally with those given in Chapters VII and XV because they do not include expenditures by local health and school authorities within the County and do include Milbank funds provided for the social service and other enterprises of the County Tuberculosis and Public Health As- sociation. It will be noted that the initiative in this undertaking and the responsibility for its conduct lay precisely where they belonged— in the hands of the official governmental representatives of the people of the County. It was a demonstration by and not on the people. CHAPTER VI PROGRESSIVE DEVELOPMENT OF HEALTH MACHINERY IN CATTARAUGUS COUNTY 1923. Before considering the health program of Cattaraugus County as it exists today, it will be desirable to review the salient points in the history of its development. The first year of the demonstration was largely devoted to the preliminary organiza- tion of the County Department of Health. After a study of transportation facilities, it was decided to establish headquarters at Olean, rather than Little Valley, the county seat, or Salamanca, which is nearer the geographical center. The contemplated set- up of the department included six bureaus—to deal respectively with communicable diseases, laboratory diagnosis, tuberculosis, statistical records and reports, maternity, infant and child hy- giene, and health education and publicity. The first four of these were organized before the end of 1923 under Dr. Bristol and the last (health education and publicity) was developed through the medium of the County Tuberculosis and Public Health As- sociation. Under the state law which provided for the creation of a general health district, the local health officers in the various towns, villages and cities remained in office as deputy health officers, exercising their local functions under the general super- vision of the County Department of Health. The County was divided into six administrative districts with local offices at Olean, Salamanca, Franklinville, Cattaraugus, Ellicottville and Randolph. Each district office consisted of at least three at- tractive and well-equipped rooms, one of which served as an office for the public health nurses of the district, one as a waiting room and one as an examination or clinic room. Quarters for three of these centers were provided rent free. 46 Development of Health Machinery in the County 47 Dr. Bristol himself directed the Bureau of Communicable Diseases and a change was secured in the State Sanitary Code so that case reports were sent by local health officers to the County Health Officer instead of directly to Albany. The City Labora- tory of Olean was taken over as a County Laboratory in May and its director, Dr. Joseph P. Garen, was made a full-time bureau chief. The Bureau of Records and Reports was placed in charge of Mr. Fred L. Thompson. For the Bureau of Tuberculosis, Dr. Stephen A. Douglass was called from Ohio, assuming the directorship in November. He was also made superintendent of the sanatorium at Rocky Crest. A tuberculosis case-finding survey had already been undertaken by the nurses, and consultation clinics were organized to be held weekly or monthly in each district with the aid of a portable X-ray machine. Some patients travelled forty miles to take advantage of this opportunity for examination. Three local physicians were provided with scholarships for summer courses in the diagnosis and treatment of tuberculosis at Saranac Lake. Meanwhile, the problem of bovine tuberculosis was attacked under the direction of the County Farm Bureau, with funds pro- vided by the Board of Supervisors and the Milbank Memorial Fund and with the counsel of an advisory committee of experts (Doctors Veranus A. Moore, William H. Park and Theobald Smith). Active testing of cattle began in the late summer and by the end of the year there were only 800 out of 80,000 head of stock in the County which had not received at least one test. The nursing program of the demonstration was set up on a generalized basis and by the end of the year the acting director (Miss Berneta N. Platt) had six staff nurses at work. In addition to this staff, there were seven more public health nurses in the County, either school nurses or Red Cross nurses who were codperating more or less closely with the demonstration. The problem of school health was a somewhat difficult one, since, under the New York State law, school medical inspection, school nursing and other health services for school children are functions of local educational authorities. In conference with 48 Health on the Farm and in the Village the superintendents of the supervisory rural school districts and with the superintendents of schools of Olean and Salamanca, a plan was worked out for a county school health service to be organized on a basis of voluntary coéperation. Dr. C. A. Green- leaf was appointed as county director of school health by the Board of Supervisors and provided with a supervising nurse and clerical assistance, the cost of this central organization at Olean being paid by the Milbank Memorial Fund. The actual physical examinations were made by physicians paid by the local school districts, but uniform record forms were prepared and data analyzed in Dr. Greenleaf’s office. Nursing service was provided by the generalized nurses of the County Board of Health except where local school nurses were already employed. By the end of December, 6,647 children had been examined in 249 rural schools. The general task of health education and publicity was, as we have noted, placed in the hands of the local voluntary health agency, the Cattaraugus County Tuberculosis and Public Health Association. This organization (supported by the annual Christmas seal sale) was already an active one. It was reorgan- ized in April on a dues-paying basis with a large county-wide membership, and its work was strengthened by the appointment of John Armstrong (previously editor of the Olean Times) as executive secretary. The headquarters of the Association were at Salamanca. An active campaign was at once begun, including lectures, moving pictures and weekly news letters for the news- papers of the County. In all, 589 news releases were prepared in 1923. The Tuberculosis and Public Health Association also in- terested itself actively in starting a camp for undernourished children in the Allegany State Park, and in a campaign for the care of crippled children. 1924. During the second year of the demonstration, the following important changes were made, from the standpoint of general organization: : (a) In compliance with an amendment to the state law, the County Board of Health was increased to seven members, the two Development of Health Machinery in the County 49 new appointees being Dr. M. L. Hillsman of Little Valley and J. W. Watson of New Albion. (b) Miss Laura A. Gamble of Toronto was appointed super- visor of nurses (April). (c) Miss Eva Cushman was placed on the staff of the Tuber- culosis and Public Health Association, acting as consultant on social problems to the Board of Health (April). (d) Miss Sybil Guckes was placed in charge of the Bureau of Records and Reports, Mr. Thompson, who had previously held that position, being made business manager of the County Board of Health. (e) Dr. William C. Jensen was appointed associate director of the Bureau of Tuberculosis and associate superintendent of the Rocky Crest Sanatorium (July). The Supervisors had appropriated $16,500 for the County Board of Health for 1923-1924 (the fiscal year of the County begins in November) in addition to $8,500 for the carrying out of the bovine anti-tuberculosis program, and over $40,000 for repairs and maintenance of Rocky Crest. By this year, however, state aid for county health work was available under Chapter 662 of the Acts of 1923. The actual expenditure of county ap- propriations for the County Board of Health in 1924 was $13,562.09 and $3,697.50 was obtained from the state grant. The Milbank Fund increased its appropriation for the demonstra- tion from $48,564 in 1923 to $88,071 in 1924, which, with local official and voluntary expenditures, brought the demonstration total up to $118,580. In the field of tuberculosis control, the year was a very active one. One hundred and forty-four clinics were held, at which 2,928 examinations were made, and a consultation service for pri- vate practitioners was inaugurated with considerable success. The number of new cases recorded was astonishing. While only 77 new cases of tuberculosis had been reported in 1922 and 79 in 1923, 343 were reported to the State Department of Health in 1924. ‘This meant an increase in ratio of new cases to annual deaths from under 2 to about 7. Such a condition can, of course, 50 Health on the Farm and in the Village only be temporary and, as will be later pointed out, there is some reason to believe that positive diagnoses were made more liberally than conservative clinical judgment might dictate. The great volume of real need which was revealed, however, suggested that complete hospitalization might be impossible. There was, there- fore, developed a plan for a policy of home care under nursing supervision, to which we shall return in a later section of this report. The Milbank Memorial Fund made some valuable studies of the costs of tuberculosis work, which indicated the cost of a clinic examination to be $3.60. The total annual cost of tuber- culosis work in the County was in this year (1924) approximately 76 cents per inhabitant, 52 cents for sanatorium treatment, 19 cents for the control work of the County Board of Health and § cents for the work of the Tuberculosis and Health Association. Two more local physicians were, this year, sent to Trudeau for postgraduate instruction. The nursing staff, under Miss Gamble, was increased by the end of the year to 13, including Miss Gamble and 12 field nurses. By this time, all of the six projected local stations were in operation, with an additional substation at South Dayton. The nurses paid 16,855 visits during the year at a cost of $1.87 per visit. A specially valuable step was the development of local committees of laywomen in a number of different districts to furnish the nurses with volunteer assistance and moral support in their work. The school health organization of the County was, as we have seen, first organized on a purely voluntary basis. During the 1924 session of the State Legislature, a law was passed specifically permitting county boards of supervisors to establish school hygiene districts. Under this law, Dr. Greenleaf’s organization was placed in May on an official basis, so far as the five rural school districts were concerned; in July and August, respectively, the Olean and Salamanca districts joined in. During the period from September, 1923, to December, 1924, a special attempt was made to conduct medical examinations of children in the rural schools and practically the whole rural school population was covered. Dr. Greenleaf’s report gives results for 7,944 children, Development of Health Machinery in the County 51 in whom 15,372 defects were found, only 11 per cent of the children being given a completely clean bill of health. About one-fifth of the defects found were considered sufficiently serious to demand medical attention. These examinations were made according to a standard form prepared by Dr. Greenleaf, but since the actual examinations were made by a large number of local physicians, the quality of the work varied widely. In the field of routine public health procedure, the only events of the year requiring special mention were the inauguration of a Wassermann test service by the County Laboratory and the initiation of a diphtheria immunization campaign in Olean. No intensive local program for the health of mothers and in- fants was undertaken aside from the work of the public health nurses. In February, however, a special campaign was staged as a part of the State Health Department program and, with the aid of physicians and a special nurse from Albany, 11 child health consultations were held during the month in various parts of the County. The Tuberculosis and Public Health Association conducted a special survey to discover crippled children, with the result that 175 such children were found in the County. Five orthopedic clinics were held and a fund of $4,000 was raised by voluntary subscription for the care of these unfortunates. A step of the first importance was taken in Miss Cushman’s appointment as social case worker under the Tuberculosis and Public Health Association. As our later discussion will em- phasize, the development of anything like adequate public health nursing service inevitably reveals unsuspected social problems which the nurse has neither time nor training to handle effec- tively; so that organized social service is a necessary corollary of organized nursing in a rural district. One significant event of the year was the holding of a course for health officers during the period from April 3 to June 14. This course was one of the series conducted by the State Depart- ment of Health (under Dr. Frederick W. Sears). The course in Cattaraugus County was, of course, carried on in cooperation with the demonstration staff and was attended by 23 local health 52 Health on the Farm and in the Village officers (including about two-thirds of the total number of health officers in Cattaraugus County). Finally, there may be mentioned three special studies made by the Milbank Memorial Fund during the year: (a) A study of nutrition in 100 rural families by Miss Ruby M. Odell (to which reference will be made in a later chapter). (b) A survey of industrial hygiene problems in the 63 plants, each employing twenty or more persons, by Miss Evelyn McKay. (¢) An analysis of specially reclassified Census data as to the movement of the county population between 1910 and 1920. This study showed a loss of 3,843 in the rural districts and an increase of 9,245 in the two cities during that decade. The migration to the cities was chiefly in the age groups § to 24. This age group decreased 12 per cent in the rural districts, while it increased 40 per cent in the two cities. 1925. The third year of the demonstration was a relatively quiet and uneventful one. From an administrative standpoint the most important change was the resignation of Dr. Bristol (who became director of the Bellevue-Yorkville Health Demonstration in New York City) and the appointment of Dr. Stephen A. Douglass as county health officer on February 1. Dr. Jensen was promoted to be director of the Bureau of Tuberculosis. Dr. Garen, director of laboratories, was given the title of deputy county health officer with the intent that he should devote a part of his time to communicable disease and venereal disease control. Miss Frances King succeeded Miss Guckes as statistician. The nursing work of the department was made a separate bureau (still under Miss Gamble). By this time the bureau was staffed by a director, two specialized supervisors (one in tuberculosis, one in social hygiene), twelve staff nurses and a nutrition special- ist. The social hygiene supervisor was in part supported by a special grant from the American Social Hygiene Association. The total nursing group at work in the County now included, besides these fifteen nurses and Dr. Greenleaf’s nurse, eight public health nurses employed by local agencies—a total of twenty-four, or 1 to 3,000 inhabitants. Development of Health Machinery in the County 53 The total appropriations for the demonstration in this year amounted to $136,393.78, an increase of $18,000 over the pre- ceding year. Of this sum, the Milbank Memorial Fund was con- tributing $100,681.06, the high peak of its appropriation. The County appropriated about $17,000, but nearly half of this sum came back to it in the form of state aid—the actual contribution of the County being $8,837.72, or nearly $5,000 less than for 1924, and the state grant amounting to $8,075.00. The Mil- bank Memorial Fund gave $5,000 during the year for a much- needed permanent pavilion at the Children’s Health Camp in the Allegany State Park. The campaign for immunization against diphtheria was vigor- ously pushed forward, one of its more dramatic episodes being a display at the State Fair of the dog team which had made itself famous by carrying antitoxin through the snow-bound wilds to Nome. About 10 per cent of the school children of the County were immunized during the year. The tuberculosis mortality showed its first sharp drop this year, from about 50 deaths a year, which had previously been maintained as a fairly constant level, to 35. By the end of the year, there were 538 cases of tuberculosis listed in the County, giving the enormous ratio of over 15 known cases for each annual death. Of these cases, however, 51 per cent were classed as arrested and only 14 per cent as active. An active cam- paign was now inaugurated for the detection of tuberculosis among school children. Three groups were selected, those who were found to be 10 per cent or more underweight on the height-weight scale, those who were recognized as habitual absentees for other than reasons of truancy or economic conditions, and those who were reported by teachers as ex- hibiting suspicious symptoms. It was planned to have all these children examined by Dr. Jensen and his associates and by the end of the year 1,278 such examinations had actually been made. The results of the first 736 examinations of underweight children in Olean were most striking as in- dicated below. 54 Health on the Farm and in the Village Condition Found Per Cent of Group Diseased tonsils $3.2 Cervical adenitis 30.3 Tuberculosis 6.6 Goiter 5.6 Heart disease 4.5 The plan for home supervision of tuberculosis cases was in theory set upon a definite basis according to the schedule in Table 7, although the plan was never actually carried out. The capacity of Rocky Crest had by now been increased from 40 to 54 beds. Dr. Veranus A. Moore, dean of the State College of Veterinary Medicine, Cornell University, Ithaca, New York, who was acting as expert advisor in regard to the bovine tuberculosis program, reported that 7.7 per cent of the cattle examined were reactors in 1923, 4.9 per cent in 1924 and 2.5 per cent in 1925. Education in regard to nutrition was actively carried on by Miss Ruby M. Odell through the medium of the Home Bureau, the schools and the nursing staff. A special study of the distribution of the time of the general- ized nursing staff conducted at this time yielded the results shown in Table 8. 1926. The fourth year of the demonstration was marked by notable developments, particularly by the initiation of organized programs for maternity and infancy and for the control of communicable diseases and by the inauguration of a system of sanitary inspection. From an administrative standpoint, the Table 7. Theoretical schedule proposed for home care of tuberculosis in Cattaraugus County. Type or CASE NursiNG Visits CriNic Visits Active lil, Cin rials Weekly Monthly Quiescent . . =i Monthly Monthly Apparently arrested . . . Bi-monthly Bi-monthly Arrested . oral. Every 3 months Every 6 months Development of Health Machinery in the County 55 Table 8. Distribution of the time spent in official duties by the general- ized nursing staff of the Cattaraugus County Board of Health in 1925. SERVICE Hours Group Toran Per CENT Home visits, education and demonstration . . . . 4,070 Home visits, bedside care . 2,194 Ofcevisits , . . . . . 265 6,529 28.8 Clinics, diagnostic . . . . 942 Clinics, other .. . . . . 246 1,188 3.2 Workinschools , . . . 1,302 5.8 Office work, general . . . 3,372 Office work, records . . . 3,109 6,481 28.6 Meetings"... . . . 1,202 54 Mravel., Ci vie vie 4.842 213 Cooperative visits . . . . 1,109 49 Mota... ae aia 22,653 100.0 Regular working time . . 20,584 Overtime. . = . . . . 2,069 10.0 important events were the creation of a special health committee of the Board of Supervisors (B. J. Both and S. P. McLoughlin of Olean, L. K. Oyer of West Valley, H. K. Congdon of Randolph and H. P. Hogan of Salamanca) to maintain closer contact be- tween the governing body of the County and the Board of Health; the appointment of Dr. Doris A. Murray of the Maryland State Department of Health as director of a new Bureau of Maternity, Infancy and Child Hygiene (July) and of Miss Mabel J. Rue as educational director and supervisor of maternity, infancy and child hygiene on the nursing staff (February); the appointment of R. M. Asquith as sanitary inspector (April); the transfer in April of Mr. Armstrong to the County Board of Health as di- rector of a Bureau of Public Health Education (his position with the Tuberculosis and Health Association being taken by Mr. Rowan Whealdon) ; and the replacement of Miss Odell as nutri- tion specialist by Miss Genette Wierman (August). The appropriations by the Board of Supervisors for the demon- stration were, for this year, increased to $27,234, matched by an equal amount from the state treasury, more than three times the sum provided from these sources in 1925. The Milbank appropriation was reduced from $100,681.06 to $90,504.45. 56 Health on the Farm and in the Village The most important new step taken this year was undoubtedly the initiation of work for the health of mothers and infants. It has been noted above, that in February a specialized nursing supervisor was provided in this field and that in July a full-time medical director of maternity, infancy and child hygiene was appointed. Up to this time the only organized work in the County along this line had been that done by the nurses of the county staff and of Olean city. Dr. Murray initiated a program of child health conferences, although on a relatively small scale, and active educational work was carried on. During the re- mainder of the year, 740 children attended the medical confer- ences, including 336 under two years of age. A second important new step was the development in February of an educational campaign in the field of social hygiene, with the cooperation of the State Department of Health, the United States Public Health Service and the American Social Hygiene Association. A concrete result of this activity was the opening of a second venereal disease clinic at Salamanca in March. During the year, 41 sessions were held at this clinic and 104 at the original clinic in Olean. The appointment of Mr. Asquith as sanitary inspector repre- sented a somewhat tardy recognition of the fact that even a Northern county has very real sanitary problems which cannot be dealt with effectively by part-time local health officers. Mr. Asquith began systematic sanitary surveys in April (covering 26 per cent of the 33 towns in the County before the end of the year) and inspection and scoring of dairies was initiated in June. In this year, too, the vast problem of mental hygiene (which had from the first been visualized as a part of the demonstration program) was attacked. In 1924 and 1925, a field agent of the State Commission for Mental Defectives had spent considerable time in the County and had made some 50 psychological examina- tions. Occasional clinics were held by a physician attached to the State Commission and regular mental hygiene clinics were held in Olean and Salamanca by the staff of the Gowanda State Hospital. In September, 1926, Miss Frederika Graves was ap- Development of Health Machinery in the County 57 pointed as a psychiatric social worker attached to the County Tuberculosis and Public Health Association; but she served also as director of the Social Service Department of the Association (which now included two other social workers beside herself) and the pressure of social case work proved so great that little time was left for mental hygiene. The volume of clinic-work performed is indicated by the fact that 72 examinations were made during the year by the State Commission and 50 by the psychia- trists from Gowanda. In the fields of work previously well established, the year was marked by normal progress. The tuberculosis clinics were re- organized on an appointment basis and the new Children’s Health Camp at Allegany State Park was dedicated in June. One hundred and forty-one children were enrolled during the summer. An encouraging sign of advancement was noted in the fact that, of the new cases of tuberculosis recorded this year, 40 per cent were classed as incipient and only 14 per cent as ad- vanced. In 1923, only 17 per cent of new cases were incipient and 29 per cent were classed as advanced. It was also gratifying to note that 55 per cent of the clinic cases were referred by physicians, as against 17 per cent in 1923. The public health nursing staff of the County had by now in- creased to 27, of whom 19 (director, 4 specialized supervisors and 14 staff nurses) belonged to the demonstration staff. With the appointment of Miss Rue as educational director, an arrange- ment was made with Teachers College, Columbia University, for a three-months’ field training course for public health nurses and the first group of students began their work in July. Minor points of interest in the work of the year were the hold- ing of 15 special clinics for school children having defects of vision (with the generous aid of a local oculist) ; and the exten- sion of the diphtheria immunization campaign to children of preschool age, with the result that some 30 per cent of all children under ten years of age were known to be immune by the end of the year. ‘The work of the laboratory was developing steadily. In 1922, 4,451 examinations were made, about half by the County 58 Hedlth on the Farm and in the Village Laboratory of Olean and half in the State Laboratory at Albany. In 1926, 7,692 examinations were made, all by the County Laboratory. An interesting development of the year was the inauguration of an active campaign for the reduction of automobile accidents. Its most spectacular feature was the placing of conspicuous crosses along the highways at each point where a fatal accident had taken place during the past three years. The first quantitative appraisal of the health work of the County was conducted by Dr. W. F. Walker of the American Public Health Association, with the result that the County re- ceived a score of 727 out of a possible 1,000 points. Reference will be made to this and subsequent appraisals in a succeeding chapter. Among the special events of the year may be noted the meeting held in the County by State and Local Committees on Tuber- culosis of the State Charities Aid Association in June and the visit of some 75 sanitarians to the County following the meeting of the American Public Health Association at Buffalo in October. In May, Sir Arthur Newsholme (former chief medical officer of the Local Government Board of England and Wales) visited Cattaraugus and studied the demonstration in some detail. Sir Arthur said in his report that “the demonstrations now in process differ from any previous voluntary effort known to me in the comprehensiveness of their program and in their intimate affilia- tion to existing local official and voluntary effort.” He empha- sized the need for better treatment of dental defects and for a more comprehensive program of maternity care. His comments on the latter point are so suggestive as to deserve quotation. He conceived that the demonstrations would “only experience a full measure of success:— “1. When every prospective mother has offered to her medi- cal advice and examination either by her own doctor or on his instigation at a prenatal center. “Action is needed to persuade physicians to take their part in this, and I am confident this can be done. It must be on such Development of Health Machinery in the County 59 a scale as will enable the very poor, those in straitened circum- stances, and the well-to-do all to participate. “2. When every mother is attended in parturition (2) with full diagnosis of her physical condition as a prospective mother, and (b) with absolutely satisfactory medical aid and nursing, determined by such previous knowledge. “This will mean action for securing more general skilled attention in pregnancy, for consultant services in difficult parturition, and for further provision of hospital beds for parturition, without any directly inhibitory conditions as to pay- ment, imposed in the emergency. This does not necessarily imply gratuitous treatment; but it does involve a careful graduation of payment to means, or possibly the making of provision on a codperative basis.” Another most significant paragraph in Sir Arthur’s report deals with the danger of expecting too prompt results from the demon- strations. He says: “I should give here a word of warning against expecting a completely successful issue in the next four or five years. During that time great strides will be made; but it does not appear reasonably to be possible in less than ten years that this important experiment will have had time to prove its im- mense possibilities of good in actual local accomplishment.” On the debit side of the ledger for 1926, must be set the de- velopment of an unfortunate breach between the local medical society and the demonstration. The reasons for this controversy will be discussed more fully in a succeeding chapter. In this brief historical summary, we need only note that at its September meeting the County Medical Society adopted a resolution criticis- ing the program of work and the methods of the demonstration. In December, the Society, following a two-months’ study by its Public Health Committee adopted a report of this Committee containing the following paragraph: “Your Committee on Public Health recommends that the society go on record as favoring the present day public health movement; as favoring the county health unit as the most practical unit in public health admin- istration; as expressing its appreciation to the Milbank Memorial 60 Health on the Farm and in the Village Fund for enabling Cattaraugus County to test the value of the county health unit idea; as expressing its confidence in the County Board of Health, and as favoring the codperation with the County Board of Health of the organized medical profession of the County.” 1927. Nineteen twenty-seven was the fifth year of the demonstration, completing the full period originally planned. Mr. John Walrath, president of the County Board of Health, says in his annual report: “It has been shown conclusively that it is possible and practicable to establish a health department in a rural county in New York State and that such a health depart- ment can furnish an effective health service for those living in the county. It has been shown also that county authorities are sufficiently interested in such a service to give it substantial financial support, thus insuring the continuation of the work.” The chief change in staff during the year was the resignation of Dr. Douglass in November and the appointment in his place as county health officer of Dr. Reginald M. Atwater, who had joined the staff in July as Dr. Douglass’ assistant. There was a small epidemic of 11 cases of smallpox originating in the Indian Reservation with a single case in Olean, but the outbreak was promptly checked by a vaccination campaign in which 1,595 vaccinations were performed. The tuberculosis program was studied by Dr. Allen K. Krause, director of the Kenneth Dow’s Foundation for Tuberculosis Research at the Johns Hopkins University, and Dr. Veranus A. Moore reported that the propor- tion of bovine reactors had been reduced to less than 1 per cent, with a resulting increase of a million dollars in the value of the dairy cattle of the County. The most important progress of the year was made in the field of maternal and infant hygiene. Dr. Murray pointed out that 67 per cent of the infant deaths of the County occurred during the first month of life and that only 3 per cent of the rural confinements in the County were hospitalized. A pre- natal conference was opened at Ellicottville in May, but attend- ance was too small to encourage further progress along this line. Development of Health Machinery in the County 61 The nurses redoubled their efforts, however, carrying 257 pre- natal cases in 1927 as compared with 115 in 1926. About one half of all the nursing visits of the staff were, this year, made on prenatal, infant and preschool cases. One hundred and twenty- seven child health conferences were held, with an average at- tendance of slightly over 11 children at each conference. These conferences were served by some 19 local physicians. Special emphasis was laid on the “Summer Round-up”, an attempt to secure medical examination of children entering school, and 28 per cent of the entering group in the rural schools were thus examined. Four hundred girls in the upper school grades were given instruction in infant hygiene. In the County Tuberculosis and Health Association, Miss Susan M. Boyd was appointed director of social service in March. A county-wide advisory committee was appointed to assist in this field of work and a confidential exchange was opened in Olean. As pointed out above, it was originally contemplated that the Milbank Memorial Fund should be relieved of further re- sponsibility for the financial support of health work in Cat- taraugus County by the end of 1927. It was reasonably clear, however, by this time that the “demonstration” stage of the undertaking was by no means completed. The existing budget seemed too considerable to be taken over in foto in 1928 by state, county and local appropriating bodies and needs for expansion rather than limitation of the program were obviously revealed. On June 27, therefore, the Board of Health requested the Fund to continue its aid for a further period. The County Tuberculo- sis and Health Association and 39 other organizations, including the County Home Bureau, the County Farm Bureau and the Salamanca Chamber of Commerce, passed formal resolutions supporting this request. The County Medical Society (which had again reversed its attitude of the previous December) ‘was the only dissentient, passing a resolution in August favoring termination of outside aid and the continuation of the County Board of Health on a much reduced basis. (The significance of this action will be discussed in a later chapter.) The County 62 Health on the Farm and in the Village Board of Supervisors rejected this proposal and, in response to the general demand of the County, the Milbank Fund continued its aid on a slightly reduced basis, granting $78,575.31 for 1928, as against $85,207.66 for 1927 and $90,504.45 for 1926. The total demonstration budget for 1927 as in 1926 had been slightly under $160,000. 1928. Changes in personnel in the sixth year of the demon- stration included the appointment of Dr. J. A. Taggert of Salamanca and Mr. V. R. Lynde of Delevan as members of the Cat- taraugus County Board of Health, to succeed Messrs. Bushnell and Watson. The County Laboratory, which had hitherto been managed by a separate board, was placed under the County Board of Health. Dr. Frederick A. Hemsath was appointed director of the Laboratory and Dr. John H. Korns, director of the Bureau of Tuberculosis and superintendent of Rocky Crest. The con- centration of responsibility for the Laboratory was made possible by an amendment to the state law governing health districts, effective March 24, permitting Boards of Supervisors to transfer the powers and duties of boards of managers of county sanatoria and county laboratories to county boards of health. The county appropriation for the Board of Health was again $56,060 (of which one-half came back from the State), but the Milbank grant was further reduced. The salary of the health officer was, this year, paid wholly out of county funds—a point of some importance, psychologically, in emphasizing the autonomy of the demonstration. The outstanding event of the year was a disastrous epidemic of typhoid fever in Olean. When Olean had joined the county health district, it had been understood that the County Health Officer should not actually exercise jurisdiction in the City in any way, except that he should direct the tuberculosis work in the City, and that the County Laboratory should be available for city use. Responsibility for the general sanitary conditions in Olean, therefore, rested solely and entirely with the local city authorities. What actually happened was as follows: In February, 1928, Development of Health Machinery in the County 63 there was an outbreak of about 1,000 cases of enteritis in Olean which was attributed by an engineer of the State Department of Health to an auxiliary city water supply derived from wells on the north bank of the Allegheny River at South Olean. The main supply for the City is derived from Olean Creek at North Olean and is filtered through a rapid sand filter and chlorinated. The State Department considered the auxiliary well supply as highly dangerous because the wells themselves were liable to flooding and because the suction line from the wells to the pump- ing station on the south bank passed under the river, so that any break would result in the drawing in of highly polluted river water. The City discharged untreated sewage into the river just above this point. The Department had, therefore, repeatedly recommended the continuous and effective chlorination of this auxiliary supply and after the February outbreak urged its dis- continuance and was assured that it had been discontinued. During the first and second weeks of September a still more severe outbreak of enteritis occurred in Olean which was estimated to include some 10,000 cases, from six of which dysentery bacilli were isolated. In a number of families questioned, more than half the individuals had been affected. On September 12, the County Health Officer called the attention of the Olean Health Officer and the State Department of Health to the situation. On September 13, the Olean City Health Officer stated that the city water was not at fault and the Water Commissioners allowed this statement to go unchallenged. On September 29, cases of typhoid fever began to be recognized and on October 3, a representative from the State Department of Health ar- rived to take charge of the situation. During the next six weeks, 212 cases of typhoid fever developed in Olean, about 1 per cent of the population, with 18 cases in other towns con- tracted in Olean. Two emergency hospitals were opened with a capacity of 60 beds. The American Red Cross chapter organized the private duty nurses (over one hundred of them being on duty at the height of the epidemic) and the county public health nursing staff rendered invaluable assistance. It was the policy of 64 Health on the Farm and in the Village the City to pay for private duty nursing and for drugs and other hospital expenses growing out of the epidemic, and approximately 6,000 anti-typhoid vaccinations were performed, about one-third of these in the schools. City appropriations for these purposes and for subsequent damages paid to sufferers have, by July, 1930, exceeded $400,000. On November 8, the State Commissioner of Health, Dr. Mat- thias Nicoll, Jr., reported to the Olean Common Council that the epidemic was due to pollution of the suction lines from the auxili- ary well supplies at South Olean. These wells had been continued in intermittent use, in spite of the warnings of the State Depart- ment of Health and in spite of the fact that examinations of the city supply by the Water Department had shown pollution in half the samples examined during July, August and the early part of September. Furthermore, Dr. Nicoll found that, while tests for excess chlorine were recorded as having been made daily, they had actually been made only at infrequent intervals. Finally, it transpired that a man fishing in the river had, on September 8, reported to the City Water Superintendent having heard, near the submerged wells, a curious sound like the sucking of air into a pipe. On September 10, the Water Superintendent had found the suction pipe of one of the wells broken and had cut off this well, but without at that time reporting the fact either to the City Board of Water Commissioners or to the City Health Officer. The State Commissioner, of course, suggested appropriate steps for protecting the water supply of Olean, but, in order to obviate similar disasters, here or elsewhere, he recommended that a qualified sanitary engineer be appointed to the staff of the County Board of Health and that the responsibility of the City Health Officer to the County Health Officer should be made definite and effective, and not purely theoretical as in the past. Certainly, the whole episode demonstrated in a striking fashion the need for such trained and responsible leadership as a county health department can offer. The Olean Health Officer and Board of Water Commissioners resigned, and prompt action was Development of Health Machinery in the County 65 taken by the County Board of Health by appointment in De- cember of Mr. N. M. Fuller, who had been trained at the Massa- chusetts Institute of Technology, as county sanitary engineer. The sanitary inspector, appointed in 1926, had resigned in 1928 and was, in any case, an inspector and not a professionally trained sanitarian. Among other events of the year may be mentioned an epi- demic of 16 cases of mild scarlet fever in the Children’s Home at Randolph. This led to an active Dick testing and immunizing campaign. It was of considerable interest to note that, of 175 children who were Dick-tested, 55 per cent were susceptible, the ratio falling from 79 per cent under 10 years of age to 54 per cent between 10 and 14 and to 43 per cent at ages over 15. Diphtheria immunization was also pushed forward, so that, by the end of the year, 60 per cent of the population in the age period 6 to 11, and over 25 per cent of the population at ages 2 to 14, were immune. During the four years, 1925-1928, there were 86 cases of diphtheria among the unimmunized children and 3 among the immunized and it was computed that this difference in rate corresponded to a saving of 25 cases of diphtheria a year during the four-year period. It is of considerable interest to note that the case fatality of diphtheria in Cattaraugus County is low, about 6 per cent, a fact which is correlated with a relatively late age incidence of the disease—in turn presumably related to the lesser opportunities for infection in a scattered rural population. A beginning was also made during the year in the protection of infants against measles by the use of convalescent serum. In the field of tuberculosis control, a somewhat more con- servative attitude was adopted with regard to the positive di- agnosis of tuberculosis. Only active cases were reported to the State Department of Health and cases on the register were re- classified, with the transfer of 277 of them to the “apparently cured” class. Most of these cases had been classed as “minimal” and many of them had never had any clinical symptoms. A special social case work supervisor was added to the nursing staff during the year. 66 Health on the Farm and in the Village In the field of school hygiene, gratifying progress was reported in the extension of daily health inspection and instruction in hygiene. It will be noted that in a county with 268 village and rural schools, 232 of which were one-room schools, the difficulties in the way of organized health work are very considerable. By 1928 it was estimated that 211 of these schools had a system of daily health instruction in force. The inferior health status of the rural school child was strikingly brought out in a study by the Division of Research of the Milbank Memorial Fund during this year. It appeared that underweight children in the Olean schools increased from about 4 per cent of the school population at age §, to about 11 per cent at age 13. In the village schools, the proportion of underweights rose from about 10 per cent at age §, to about 15 per cent at age 13. Heart conditions, diseases of the lungs, orthopedic defects, skin diseases, defects of teeth and eyes and tonsils, were all much more common in the village schools than in Olean, although the reverse was apparently true for diseases of the nervous system and speech defects. Another study made by Mr. Edgar Sydenstricker, director of the Fund’s Research Division, dealt with the results of improved medical inspection as shown by examination, in 1926-1928, of a group of children as to the presence of corrected defects in comparison with a comparable group examined in 1923-1924 at the beginning of the demonstration. The very gratifying results obtained are indicated in Table 9, as tabulated by Miss Jean Downes of Mr. Sydenstricker’s staff. Table 9. Results of two successive examinations of children in village schools of Cattaraugus County. Per CENT DEFECTS FOUND CORRECTED AGE or CHILDREN Tonsils Permanent Teeth Eyes 1923-1924 | 1926-1928 | 1923-1924 | 1926-1928 | 1923-1924 | 1926-1928 9 8.0 15.4 19 7.7 3.9 7.1 10 8.1 18.7 4.1 14.1 29 nd 11 7.4 20.7 3.6 19.8 5.9 12.0 12 77 22.2 5.0 19.8 6.3 15.6 13 8.5 16.1 6.4 20.9 11.0 11.0 Development of Health Machinery in the County 67 Sir Arthur Newsholme again visited the County in May, 1926, and reported very favorable impressions of the work. He called special attention to the need of better provision for the care of defects of eyes and teeth and for the care of tonsillar and adenoid conditions among children of school and preschool age. Even the briefest summary cannot omit mention of the annual report of the County Board of Health for this year (1928), pre- pared by Dr. Atwater and issued under the title, “Public Health in Cattaraugus County.” This document seems to the writer the most effective health department report with which he is familiar, altogether admirable in its clarity, soundness, and literary quality. Dr. Atwater also prepared, for the 1928 annual report of the Milbank Memorial Fund, an excellent review of the health services provided by the County as affecting the average citizen at suc- cessive periods of his life, which gives so valuable a picture that it will be quoted in full. “Prenatal. Unborn,” says Dr. Atwater, “the average Cat- taraugus County individual is one of 1,500 prospective citizens who, as things now stand, annually receive attention equivalent to the services of one public health nurse. At this rate the average baby before birth will get one hour of prenatal attention from the nursing service, as it carries out the prenatal recom- mendations of family physicians or staff doctors. His mother has the benefit of numerous and largely attended classes on pre- natal care under the auspices of the health department, as well as the benefit of an increasing tendency for regular medical super- vision, growing out of the educational program. If his life is in jeopardy from the spirochzte of syphilis, he may have the benefit of prenatal arsphenamine from a public clinic. His mother is more likely to receive adequate hospital care at con- finement because of the follow-up program for cases with ob- stetrical complications. But the first real inadequacy he meets is in the lack of sufficient obstetrical beds. Unless his parents can afford to pay moderate hospital rates, he will scarcely benefit from the additional safeguards in a maternity hospital. A large 68 Health on the Farm and in the Village block of the rural population of Cattaraugus County, comprising eighteen townships, has but 10 per cent of the births in a hospital. His prospects are ninety-seven out of a hundred of having a physician in attendance at his birth. ‘Two per cent of the births in the County are attended by midwives and but one per cent are without trained attendant. “In the process of being born, this average individual, who is one of 1,500 born annually, has a good chance to benefit by ar- riving in a home where a proper set of maternity supplies are on hand and where a layette has been thoughtfully prepared for his coming. He shares 2,500 visits from the public health nurse with other neonatal citizens and may even be fortunate in being one of the forty cases in the year where the physician is assisted at delivery by a public health nurse. Certain it is that his chances of services from the public health nurse at the time of birth ought to be increased. This particular inadequacy is partly being met just now by the services of three nurses who are giving exclusive attention to the hygiene of pregnancy, parturition and the puer- perium. “Infant. Having duly arrived,” Dr. Atwater continues, “this average baby will have one visit from a public health nurse during the post-partum period and will have access to the child health conferences in his district. Last year, one in every four of the babies outside Olean attended these conferences with an average of two and a half visits per child. He will also have access to toxin-antitoxin. Last year eighty-four children under one year received the prophylactic. More effective means will have to be found to increase this prevention among infants. Substantial aid is given in the promotion of breast feeding, the use of cod liver oil, and in teaching the mother how to prepare the doctor’s feeding formulas. “Preschool. By the time the baby reaches his first birthday, he has been the recipient of considerable public health effort. As he enters the preschool age, he has access to further child health conferences and to nursing supervision in a fashion that is be- coming increasingly well articulated with his doctor’s advice. Development of Health Machinery in the County 69 His defects are sought out and a persistent effort is made to secure necessary corrections. His mother is urged to make his diet conform to the best standards. The desirability that he be trained in good mental habits is emphasized by the public health nurses and by other clinic contacts. As he prepares for entrance to school, his mother has the opportunity to bring him to the preschool round-up for examination and detection of defects. He is likely, before he is sick, to see a doctor periodically for an examination. “School. On entering school at five or six years this child comes under the supervision of the educational authorities, who provide a medical examination. This examination,” Dr. Atwater reports, “is attended by the public health nurse and the child’s record becomes a permanent form that follows him through his school career. On this form are recorded any defects and the results of efforts made to correct them, together with weight records, nutrition and communicable disease history. “As a school child he meets health ideas in many forms. The stories which he reads and the pageants in which he takes part are skillfully adapted to his expanding mind. The morning in- spection, the nutritional advice, the frequent health talks by pub- lic health nurses, and the exhibition of careful methods in school clinics, all educate the child in what he should expect good medical work to be. At its best, this educational approach captures his mind with the idea of prevention and the proper dependence on scientific medicine. “Passing on through school, this child receives the benefit of fairly close supervision of his communicable diseases by local and county authorities. He has his opportunity to take toxin-anti- toxin in school clinics, has the privilege of vaccination against smallpox, has provided for him convenient access to curative sera and diagnostic tests, as well as medical consultations. If he is a boarding home child, he receives more attention than the usual public ward through regular sanitary inspection of his home and general health supervision. “In all, this school health effort is a reasonably adequate pro- 70 Health on the Farm and in the Village gram if one is prepared to expand the method year by year until much more can be accomplished. “At this age the average child has access to the health camp, if he is underweight or otherwise in need of the benefits of out- door life. If he is crippled, there is a committee of responsible citizens who obtain fairly adequate funds, supplemented by state aid, for his rehabilitation. His tonsils may be removed by pri- vate physicians or through coéperative efforts between doctors, hospitals, nurses and private charities at the public or semi-public tonsil clinics. In short, the Cattaraugus County boy has a fair chance at these attempts to give him a sound and perfect body. It is certainly true that additional resources available in this direc- tion could be most effectively put to use. “Among the families supervised during the last two years, health progress was definitely impeded by the financial situation in 15 per cent. Among these were many families who were able to make the grade until the costs of illness interfered, thus demon- strating the economic values of health and the need for effective prevention. “Adult. As an adult, this average individual becomes one of the County citizens who receive benefits from all the divisions of activity. He finds that the public water supply is supervised by state and local authorities through routine laboratory an- alyses and field studies. His milk supply is protected within the limits of existing regulations. He and his dependents receive nursing service. His children receive oral prophylaxis and benefit from well-baby conferences, nutrition programs, venereal disease clinics, mental clinics, orthopedic clinics, and the manifold benefits from an adequate public health laboratory. “If his family income is insufficient, the nurse or social worker stands ready to help him. His social adjustments, particularly as they relate to health, are made easier through the Social Service Department of the Cattaraugus County Tuberculosis and Public Health Association. He profits from a constructive educational campaign maintained by public as well as private organizations, Development of Health Machinery in the County 71 which help him to understand and codperate in securing more complete health benefits. “Some of these services are inadequate in degree of present at- tainment,” says Dr. Atwater. “The venereal disease work, for example, and the numbers reached with toxin-antitoxin, as well as the bedside nursing, could be increased several fold with profit. Other needs which are scarcely met at all may be listed: hospital beds available to rich and poor; provision for hospitalizing com- municable diseases and for the correction of defects; obstetrical care for mothers unable to afford the ordinary costs, and the care of sick people in the country whose care by doctors represents a difficult problem to physician and patient alike. “The services which the average Cattaraugus County person receives are intended in no way to replace the private physician,” Dr. Atwater continues. “The doctor’s place is extremely im- portant and one of expanding possibilities in this new day of better health. The relationship between the private practitioner and the public health workers is characterized by codperation in a common task, not by competition in any sense. Only by thus codperatively using all means at hand, is it possible to reduce the enormous amount of disability that comes from improper hy- giene, the accumulations from neglect of medical care, uncor- rected defects and chronic disease that might have been pre- vented by proper foresight.” 1929. The seventh year of the demonstration was marked by three important changes in personnel. Mr. R. A. Sprague of Salamanca succeeded Mr. Lynde, representing the Board of Super- visors as an ex officio member of the County Board of Health. Dr. E. K. Kline came from the laboratory of Jefferson County, Alabama, to succeed Dr. Hemsath (May); and Dr. Travis P. Burroughs, formerly health officer of Ashford town, was ap- pointed deputy county health officer and director of the Bureau of Communicable Diseases (June). In these, as in other appoint- ments, the effort to find the best available man for a given job, whether he could be found in the County or must be sought out- side, seems particularly commendable. The Board of Super- 72 Health on the Farm and in the Village visors increased its appropriation to $66,000 (of which half came back in the form of state aid) and the Milbank Memorial Fund appropriated a total of $63,442.88 for the demonstration pro- gram as a whole, of which $41,850 was devoted to the work of the County Board of Health. The most important event of the years was the passage of a new state law (Chapter 371 of the Acts of 1929) which radically reorganized relations between county and local health depart- ments. This law (in counties where there was a county board of health, abolished local health officers in towns and in villages having populations under 3,000, and established a definite respon- sibility of local health officers in larger communities to the county health department. The County Board of Health was em- powered to appoint full-time and part-time deputies and to re- move local health officers, subject to review by the State Depart- ment of Health. Under this law the positions of 20 of the 23 local health officers in Cattaraugus County were abolished when it became effective April 8, leaving local health officers only in the cities of Olean and Salamanca and in the village of Gowanda. For the execution of the new authority vested in the County, Dr. Bur- roughs was appointed deputy county health officer with several local part-time deputies in various areas of the County. The only epidemic of the year was an outbreak of mild small- pox centering in Olean. There were 53 cases but no deaths; and over 8,000 vaccinations were performed, with the result that 90 per cent of the school children of Olean were protected from the disease. Examinations in the County Laboratory reached the high figure of 18,631, giving a ratio of 25 examinations per 100 population and 282 per physician in the County. The scope of the work was also broadened to include studies of undulant fever and Vincent's angina, as well as examinations of swimming pools in Olean. There were by this time 22 known typhoid carriers in the County under observation. The outstanding progress of the year was along the line of sani- tation which had, hitherto, been relatively neglected. Mr. Fuller undertook his duties as sanitary engineer in February and, in view Development of Health Machinery in the County 73 of the lesson of the Olean outbreak, devoted himself first and fore- most to the problem of public water supplies. There were 20 such supplies in the County, of which only 7 were of satisfactory quality. By the end of the year, 6 more were reported as im- proved, the 13 supplies considered satisfactory, serving 90 per cent of that part of the population served by public supplies. Emergency chlorination was provided to deal with any local trouble which might develop. A particularly active effort was also made to improve the quality of milk supplies and to bring them into harmony with the pro- visions of the new state milk code which had become effective in July, 1928. Substantial progress was made, but it was pointed out by Mr. Fuller that only a marked increase in pasteurization would suffice to eliminate the danger of milk-borne infections. In connection with tuberculosis, the only significant departure was the inauguration of an intensive family case study in Ellicott- ville. The first 141 children examined showed a surprisingly small ratio of infection, only 13 per cent of the group (all over § years of age) being tuberculin-positive. Dr. Atwater in his annual report noted three special population groups in which tuberculosis was so unduly prevalent as to demand special atten- tion: the Indians, a group of about 1,000 persons of Polish ex- traction, and the employees in a certain cutlery works where a serious silica dust hazard was present. Dr. Doris A. Murray, director of the Bureau of Maternal and Infant Hygiene, resigned in September and her place was not filled, chiefly for financial reasons. The nurses, however, in- creased somewhat the amount of time devoted to this phase of work, 47.6 per cent of their visits being on behalf of prenatal cases, infants and preschool children. The infant mortality rate showed a gratifying further drop to §3. The general work of the nursing staff was this year rendered heavier by the resignation of the supervisor of social case work and by the fact that the tuberculosis nursing carried on by the Olean Tuberculosis Association was turned over to the county nurses. The Milbank Memorial Fund’s Division of Research made 74 Health on the Farm and in the Village an important study of the infant mortality problem, which re- vealed the grave errors in the official rates due to the inclusion of births and deaths of non-residents in hospital centers serving out- lying rural districts. Birth certificates filed in Cattaraugus and in five adjoining counties of New York and Pennsylvania were ex- amined for the years 1916, 1920, 1925, 1926, and 1927. The true resident birth rate of Cattaraugus County was found to be somewhat lower than the recorded rate, but differences between rural and urban areas within the County itself were much more seriously in error. Correction for residence decreased the urban birth rate by 23 per cent and increased the rural birth rate by 19 per cent. Correction for residence (both as to births and deaths) decreased the 1927 infant mortality rate of the County as a whole by 9 per cent for 1927—diseases of early infancy being most markedly affected (as a result of selection of unfavorable maternity cases for hospitalization). It is particularly signifi- cant to note that divergencies between recorded rates and resident rates become increasingly great from year to year with increasing tendency to hospitalization. The sixth annual appraisal of the county health program by Dr. W. F. Walker showed a score of 828 for 1928, the highest value yet recorded. The Milbank Memorial Fund’s Research Division computed that the average expectation of life at birth had increased in Cattaraugus County from 57.57 years in 1920— 1922 to 59.79 years in 1926-1928. That conditions were by no means ideal, however, was indicated by Dr. Atwater’s urgent plea for more adequate care of venereal disease in the rural districts and for better provision for prenatal care and delivery service. A gratifying evidence of increasingly cordial relations with the local medical profession is seen in the fact that Dr. Korns held 80 con- sultations in regard to 71 different patients with 25 practicing physicians of the County. Successive Appraisals of the Health Program. The general progress of the demonstration can be conveniently summarized by citing Dr. Walker’s successive appraisals as shown in Table 10. (See also Figs. 1 and 2.) Development of Health Machinery in the County 75 Table 10. Tabulation of scores (per cent of maximum) for eleven major public health activities in Cattaraugus County (New York), 1923-1929. (W. F. Walker, American Public Health Association.) 1 2 Activities Moll Pre ip oe ee vole pen ALL ACTIVITIES . 41 53 65 73 77 83 81 Vital statistics . 33 33 93 100 100 100 100 Communicable disease . . . 41 50 66 75 83 84 81 Venereal disease . 38 42 62 86 66 62 62 Tuberculosis . . 83 96 100 100 100 100 96 Prenatal ©. . °. 27 43 45 60 67 79 75 Yofant 0. . . 11 48 57 57 59 77 72 Preschool . . . 0 20 38 48 84 100 100 School . . . . 35 56 62 67 74 82 82 Sanitation . . 43 43 49 59 61 62 61 Laboratory . . 73 74 79 80 87 100 100 Health instruction. . 40 90 100 100 100 100 100 1 Dr. Walker’s first appraisal was made in 1926 for the yer 1925. Data for 1923 and 1924 have been prepared by Miss Frances King of the County Health Department staff on a comparable basis from records on file in the office. 2 Appraisal made by Professor Ira V. Hiscock in connection with the present survey. General Summary of Development of the Demonstration. The present program as a whole and its qualitative aspects will be discussed in later chapters. It is clear, from what has al- ready been said and from an examination of the successive ap- praisal scores that there has been built up in Cattaraugus County an extraordinarily complete and well-rounded program. The various activities may be grouped under five main head- ings so far as ordinarily accepted quantitative standards are con- cerned: A. Activities which have been carried to a point of practi- cally complete development as indicated by the appraisal score— tuberculosis control (since 1924), vital statistics and popular health instruction (since 1925), and laboratory service and pre- school work (since 1928). In the case of preschool work and popular health instruction, we know that the appraisal standards are low and a perfect score does not mean quite what it does in the case of other items. B. Activities which have been carried to a point of reasonably CATTARAUGUS COUNTY APPRAISAL SCORE, BY YEARS o 100 APPRAISAL SCORE 1923 1924 1925 1926 1927 1928 1929 Fic. 1 94 BVI aq7 us puv wiv] ag uO ¢wIE Development of Health Machinery in the County 77 effective development (scoring 80-90) —communicable disease control, school hygiene. C. Activity carried to a fairly high point and since allowed to become less effective—venereal disease control (peak in 1926). D. Activities which have attained only moderate develop- ment—infant and prenatal work (appraisal 70-80). E. Activity still showing a relatively low score—sanitation. The program seems in general to have been conceived with re- markable soundness and clarity. The one criticism which the writer would offer is that the magnitude of the problems of en- vironmental sanitation were not quite fully realized. Sanitation and food control were provided for in the original five-year plan with a budget allotment of $4,500 a year; but even this very modest provision was pushed aside by what seemed to be more urgent needs. The reduction in venereal disease control and the defects in infant and prenatal work have been due to no fault in conception but rather to temporary local financial limitations. Health on the Farm and in the Village 78 z og NOILONYLSNI HLITV3H AdOLVHO8aY NOILVLINVS 301Au3S HLIV3H TTO0HJS 3Y¥VD TTOOHIS3¥d 3¥VD’ LNVJNI 3¥VD IVLVN3¥d “041NOD 29 8¢ 3SV3SIA IVIYINIA i wv JOHLNOD i I I | | joe €8 TOHLNOD SISOTNdY¥38NL | | 1 3SV3SIa 3T8VIINNANOD QoI €€ SOILSILVLS VLA AN3D¥3d NI 6261 ¥€261 ALNNOD SNONVHVLLIVD NI S3ILIAILDY HLIOV3H JIgnd 40 S3¥02S CHAPTER VII THE PRESENT HEALTH PROGRAM OF CATTARAUGUS COUNTY General Organization. The general organization of health work in Cattaraugus County can be best understood by reference to the organization chart presented in Fig. 3. It will be noted that there are three state departments which play a part in the program, the State Hospital Commission, the State Department of Education and the State Department of Health. The State Hospital Commission holds monthly mental hygiene clinics within the County, the State Department of Edu- cation exercises general supervision over the school hygiene pro- gram and the State Department of Health holds monthly mental hygiene clinics and orthopedic clinics. During 1929, 78 cases were seen at the two mental clinics, 35 from Olean, 24 from Sala- manca and 19 from other areas of the County. The State Health Department also maintains a public health nurse to work in the Indian Reservation and supervises (through its district state health officer) the work of the County Board of Health. Within the County, there are three official agencies and one unofficial agency concerned with public health on a county-wide basis. School hygiene is directed by a district committee on school hygiene (whose organization and functions will be dis- cussed in a later paragraph). The tuberculosis sanatorium at Rocky Crest (with a capacity of 50 beds) is managed by a spe- cial board appointed by the County Board of Supervisors. Its work will be discussed in Chapter X. The County Board of Health is also appointed by the County Board of Supervisors and its functions will be considered in a later paragraph. The one voluntary county-wide group is the Tuberculosis and Public 79 80 Health on the Farm and in the Village Health Association (affiliated with the Committee on Tubercu- losis and Public Health of the State Charities Aid Association) which maintains a summer health camp (see Chapter X, and a service for the care of crippled children (see Chapter XI). Its headquarters are at Salamanca and it is the local sponsor for the Christmas Seal sale. In addition to these county-wide organizations and their sub- divisions, the only three purely local activities in the health field are public health nursing services carried on by the local Red Cross in Olean and by local nursing committees in Portville and Gowanda. It will be noted as our discussion proceeds that centralization is not in some respects quite so complete as the chart would indicate. Yet the organization which has been achieved is a real triumph, to one familiar with the chaotic medley of small local authorities and voluntary agencies which usually share the responsibility for pub- lic health work in New York and New England. The plan as a whole is simple, logical and coherent and may well serve as a model for other counties. The School Hygiene Program. It will be noted that the County, from an educational standpoint, is divided into two urban (Olean and Salamanca) and five rural districts. Under the state law of 1923 a district committee on school hygiene was set up for the County as a whole. It includes eight members, the superintendents of the two city school systems, the supervisors of the five rural districts and the county commissioner of health. There seems, incidentally, to be some legal ambiguity as to whether this eighth member is the county commissioner or the district state health officer. The extent of the problem to be dealt with may be gauged by the fact that there are 293 public schools under the jurisdiction of this committee, of which 266 are rural and 228 one-room schools. The total registration during the 1928-1929 school year was 14,397, with 4,001 children in Olean, 1,900 in Sala- manca and 8,496 in the remaining areas. The medical director of the County School Health Service, STATE OF NEW YORK CATTARAUGUS COUNTY CITIES, VILLAGES. AND TOWNS ORGANIZATION CHART HEALTH ACTMTIES IN CATTARAUGUS COUNTY OFFICIAL VOLUNTARY STATE HOSPITAL COMMISSION STATE DEPARTMENT STATE DEPARTMENT MENTAL CLINICS DISTRICT COMMITTEE ON SCHOOL HYGIENE COMPOSED OF SUPERINTENDENTS STATE CHARITIES AID ASSOCIATION OF CITY SCHOOLS, 5 ROCKY CREST COUNTY BOARD OF EDUCATION OF HEALTH COMMITTEE ON TUBERCULOSIS. AND HEALTH | OFFICER PUBLIC HEALTH | “BOARD OF | [RIiiEs|[¥67&] [TUBERCULOSIS AND ~| SUPERVISORS Een PUBLIC HEALTH ASSOCIATION FIELD SECRETARY AND CLERK RURAL DISTRICT SUPERVISORS, SANATORIUM OF HEALTH COUNTY . I COMMISSIONER HEALTH CRIPPLED SANATORIUM STAFF 0 F T OF HEATH | MEDICAL SUPERINTENDENT COUNTY HEALTH : CAMP CHILDRENS 4 NURSES COMMISSIONER DEPUTY NURSE Por HEALTH GOMM|SSIONER' RESERVATION 2 URBAN | | MEDICAL DIRECTOR? . CLERK I [ I [ [ [ 1 1 TN LABORATORY SANITATION COMMUNICABLE TUBERCULOSIS PUBLIC HEALTH STATISTICAL PUBLIC VENEREAL SERVICE DISEASE SERVICE NURSING SERVICE HEALTH DISEASE DISTRICTS DIRECTOR SERVICE SERVICE DIRECTOR EDUCATION SERVICE DIRECTOR DIRECTOR? INSPECTOR , CLERK 4 ASSISTANTS DIRECTOR CLERK DIRECTOR CLERK | SUPERVISOR 14 STAFF NURSES PART TIME 3 CLERKS PHYSICIANS 35 MEDICAL H.O. HO 6 DISTRICT STATIONS LOCAL INSPECTORS RURAL OLEAN SALAMANCA AND 2 SUBSTATIONS BOARDS > DEPUTIES | (DEPUTY) | (DEPUTY) 56 TRUSTEES PART TIME3 3 NURSES . BAL, q OLEAN CITY VOLUNTARY N VENEREAL COMMUNICABLE REGISTRATION | | MATERNITY | | PLUMBING COWANCA OLEAN PORTVILLE NURSING RED NURSING LNG DISEASE oy wo INSPECTOR COMMITTEE | | CROSS | | COMMITTEE ANITA NFANCY RT TIME AN SICIAN Nugse INSPECTOR } NURSE PART TIME (OF | [2 NURSES| | PART TIME OF | PERSON | NURSE CLERK | NURSE’ | DEPUTY HEALTH OFFICER IS A FULL TIME EMPLOYEE, BUT DEVOTES PART OF HIS TIME TO DIRECTION OF BUREAU OF COMMUNICABLE DISEASES. 2 SUPERINTENDENT OF SANATORIUM ALSO DIRECTOR DIVISION OF TUBERCULOSIS. 3 THE COUNTY MEDICAL DIRECTOR IS ALSO MEDICAL INSPECTOR FOR THE OLEAN SCHOOLS. 4 SCHOOL NURSES IN GO! NURSES ALSO AS THREE. DO GENERAL PUBLIC HEALTH ORAL HYGIENISTS, OLEAN & DISTRICT NO. 3. 5S REST OF TIME DEVOTED TO SCHOOL NURSING. WORK AND Ti WANDA, OLEAN SALAMANCA, PORTVILLE. GOWANDA AND PORTVILLE THE “TOTAL |S THEREFORE COUNTED The Present Health Program of Cattaraugus County 81 Dr. C. A. Greenleaf, is responsible to the district committee on school hygiene. He is provided with an office in Olean and one clerk. He also serves as medical inspector for the Olean schools and there are 55 additional part-time medical inspectors serving the other schools of the County. They are appointed and paid by the local school boards, but are responsible to Dr. Greenleaf for a certain uniformity of procedure and for full reports of all work performed, these reports being tabulated and analyzed at the central office. The city of Olean employs a school nurse and an oral hygienist for its schools; the city of Salamanca, a school nurse; the village of Gowanda, a nurse who devotes part of her time to schools and part to general community service; while two rural districts also employ oral hygienists. The scope and results of the school health work will be discussed in Chapter XI. The County Board of Health. The County Board of Health is composed of seven members, including an ex officio appointed representative of the Board of Supervisors, plus six members ap- pointed by the County Board of Supervisors for terms of six years. ‘The term of one member expires each year. Two mem- bers must be physicians, but three of the members in Cattaraugus are at present physicians. The chief executive, with the title of county health commissioner, is Dr. R. M. Atwater, a man of exceptionally high qualifications, both from a professional and a personal standpoint. Under him is a deputy commissioner, Dr. Travis P. Burroughs, who serves also as director of the Bureau of Communicable Diseases. The central office at Olean has six fully organized bureaus under full-time heads as follows: com- municable diseases, Dr. Travis P. Burroughs (devoting part of his time to work of deputy commissioner) ; tuberculosis, Dr. J. H. Korns (also director of the Sanatorium); laboratory, Dr. E. K. Kline; sanitation, Mr. N. M. Fuller; public health nursing, Miss Laura A. Gamble; statistics, Miss Frances King. The work of these bureaus is discussed in Chapters IX, X and XII. It suf- fices to note that three of them (tuberculosis, laboratory and statistics) exceed in performance the standard of the Appraisal Form; and that a fourth (communicable diseases) has 82 Health on the Farm and in the Village for the past three years scored 80 per cent or better. Sanitation is still imperfectly developed, as a result of the fact that it has been fully organized only for one year. Nursing service is not, of course, separately summarized on the Appraisal Form, but 10 of the 47 items in the form relate to nursing. On these 10 items the Cattaraugus service scores 152 out of a possible 187 points or 81 per cent, the chief deficiencies being in infant and preschool work. Popular health instruction is now carried on by various mem- bers of the staff whose primary interest lies along other lines. This problem will be considered in Chapter XVI. Venereal Disease Control. Finally, there remains the venereal disease program which must be discussed in some detail, as it will not be treated elsewhere. There has never been a fully organ- ized bureau for this important work, but in the middle period of the demonstration (1925-1927) there was a special supervising nurse serving as a specialist in this field with the financial sup- port of the American Social Hygiene Association. Dr. L. J. Atkins, clinician of the Olean clinic, was particularly active in the work at this time. Under this stimulation the appraisal score for venereal disease work rose to 86 per cent in 1926 and when the nurse was removed it fell again to 62 in 1928 and 1929. Reporting (required by name since July, 1929) is practically nonexistent, the only knowledge of cases coming from reports on laboratory findings. During 1929, the only activity for venereal disease control in the County (aside from the important work of the nurses and the general educational program of the State and County Depart- ments of Health) was the maintenance of clinics in the two large centers of population. The clinic at Olean is financed by the City Department of Health and its follow-up work is done by the city nurse; it is held twice a week (afternoon for women and children, evening for men) at the City Building; the clinic at Salamanca was held, during 1929, once a week in the evening at the district health station. It was financed by the County Board of Health and served by its nurses. One local physician conducts The Present Health Program of Cattaraugus County 83 the Olean clinic while several local physicians rotated at Sala- manca. The Salamanca clinic has been completely discontinued since June 1, 1930. The volume of work handled at the clinics is very small, only 63 patients being registered at Olean and 42 at Salamanca during the year 1929, or a total of 105—about one-fifth of a normal expectancy. Of the total of 105 cases treated at the two clinics, 67 were from the cities of Olean and Salamanca themselves and 31 from the rest of the County, with 7 from outside the County or unknown. The ratio of visits to new cases is excellent, indicating good medical service and good nursing follow-up, since patients will not return to such clinics unless these essentials are fulfilled. Records of the success of efforts to bring back to the clinics or under the care of a private physician patients discon- tinuing treatment are unfortunately lacking. Judging from the studies conducted in various communities by the American Social Hygiene Association and the United States Public Health Service, we may assume that there are something like 1,500 persons suffering from venereal disease at any given time in Cattaraugus County. The two public clinics care for an average of less than SO cases a month and figures courteously furnished by Dr. Thomas Parran, Jr., New York State Health Commissioner, based on a questionnaire sent out by the State Department of Health, show that on a given day in 1930, 270 cases of venereal disease were actually under the care of 52 physicians of the County. Only 15 physicians failed to reply and it seems probable that less than a third of the cases actually existing are receiving medical attention. The problem of venereal disease in rural areas is an extraor- dinarily difficult one and has nowhere, perhaps, been adequately solved. The cost of furnishing even itinerant clinic service to the remoter areas through any central organization would be a prohibitive one and, even if it could be met, the psychological obstacles in the way of resort to a specialized venereal clinic are very great in small communities where the fact that everyone knows everyone else gives opportunities for gossip lacking in a 84 Health on the Farm and in the Village metropolitan community. We are inclined to believe that the only way to solve this question is through the utilization of the services of local physicians in their private offices. In any case, no real progress can be made unless some competent medical authority is in position to give time to the upbuilding of an adequate program. ‘We would urge that the following steps be taken, in the belief that the solution of this problem would be one of the most important contributions Cattaraugus could make to its own people and to the cause of public health: A. That Dr. Burroughs should, as rapidly as possible, transfer some part of his work in the routine control of communicable disease to his local deputies and should then devote a portion of his time to the planning of a definite and purposeful program for the control of venereal disease. B. That a list should be prepared of those physicians in the County who are willing and able to treat venereal cases and who will undertake to do so for a fixed fee; that the nurses should make a specific effort to find venereal cases and persuade them to consult their local physician or to attend a clinic; and that the County Board of Health should set aside funds to pay private physicians for such service when rendered to persons unable to pay the fee themselves. At present this plan is in force to a limited extent. Arsenicals are provided free to selected physicians in certain rural areas and in a very few instances the physicians’ fees have been paid by the Board of Health. The extension of this practice would re- quire special funds, but it seems to offer the only practical solu- tion of the problem. Central and Local Services. Returning now to the County Board of Health as a whole it should be noted that its central staff was until the latter part of 1930 housed in two separate locations, neither of which can be considered ideal. The County Laboratory and the Bureau of Tuberculosis were in the City Building, with crowded and inadequate quarters. The County Health Commissioner, with the rest of the bureau chiefs, was located on the fourth floor of a business building. It is gratify- The Present Health Program of Cattaraugus County 85 ing to note that a prominent resident of the County, Mrs. Nancy Bartlett Laughlin, has recently presented to the County Tuber- culosis and Public Health Association, for use as a community center for the county health and welfare agencies, property on the corner of Second and Laurens Streets. The location is admir- able and the building extraordinarily well suited for housing the County Department of Health, the supervisory office for school hygiene, the County Department of Public Welfare, the Olean Community Chest, the local Red Cross Chapter and perhaps other voluntary agencies. This building was occupied during the past summer. We may now turn to the local or district services of the Depart- ment. In arural area it is essential that centralization of authority should be accompanied by decentralization of service, and this fact has been fully realized since the inception of the demon- stration. Decentralization in Cattaraugus County takes two distinct forms. On the medical side, Dr. Atwater is represented by five local deputies: the health officers of Olean, Salamanca and Gowanda * who are his deputies ex officio and two part-time deputies named by him for the rural areas. The deputies at present officiating are as follows: Dr. H. C. Allen, Gowanda; Dr. P. H. Bourne, Salamanca; Dr. M. E. Fisher, Delevan, Farmers- ville, Freedom, Machias, Yorkville; Dr. H. W. Hammond, Franklinville, Ischua, Lyndon; Dr. J. A. Johnson, Jr., Olean. Prior to 1929, the relationships of the city health officers to the County Health Commissioner were little more than nominal, as evidenced by the tragic episode of the Olean typhoid epidemic. The new law of 1929, however, clarifies the situation and, with this clarification and with the development of the work of the recently appointed rural deputies, the situation should be satis- factory. So far as public health nursing is concerned, the division of the County is a different one. For this purpose the County is divided into six districts, each with a district station headquarters, 1 Gowanda, lying in part in two counties, retains its village health officer. 86 Health on the Farm and in the Village and in two of the districts there are substations as indicated in Table 11 and in Fig. 4. Table 11. District stations, sub- stations and number of public health nurses on duty in each, in Cattaraugus County. DISTRICT STATIONS SuBSTATIONS | No. NURSES! Cattaraugus . . South Dayton 2 Ellicottville . 1 Franklinville . . Delevan 2 Randolph 2 Olean, rural area . 2 Salamanca . 4 1 Including senior nurses. There is one county nurse assigned to Olean City for tuber- culosis work alone. The Bureau at present (July, 1930) includes a director, an educational director, two senior nurses and twelve staff nurses, a total of sixteen. In addition there are five public health nurses in Olean (two employed by the Department of Health, one by the Board of Education and two by the Red Cross), one in Salamanca (employed by the Board of Education), one in Gowanda (employed by the City, partly for school and partly for general work) and one in Portville (employed by a local committee). Including the State Department nurse on the Indian Reservation, this makes a total of twenty-five public health nurses, or one for slightly less than 3,000 persons in the population. This is a very high ratio for a rural area and the generalized program of the County Department of Health is excellently conceived. It seems unfortunate, however, that more than one-third of the public health nurses of the County are still not in organic connection with this program. The actual results of the nursing work will be discussed in Chapter XII. In summary, it may be said, that the County Department of Health is admirably organized and is staffed by a personnel of The Present Health Program of Cattaraugus County 87 DISTRICT ORGANIZATION CATTARAUGUS COUNTY ps DERYAN ® pnoLsh ® COUNTY DEP'T OF HEALTH. @ DISTRICT CENTERS [0 SUBCENTERS === DISTRICT BOUNDARIES A TUBERCULOSIS SANATORIUM Fic. 4 (ROCKY CREST) 88 Health on the Farm and in the Village unusually high quality. In general, the various health activities have been soundly planned and developed to a high degree. There are at present three outstanding deficiencies in the program: A. The fundamental problems of sanitation are not yet adequately solved. Little serious attention was paid to this question until a year ago. Now, an excellent beginning has been made, but only experience can show whether the staff is adequate for wholly satisfactory results. B. The prenatal and infant hygiene program has never been fully developed and, since the resignation of the director of this bureau, the work has materially suffered. C. So far as the venereal disease program is concerned, a beginning was temporarily made in 1926 under the stimulus of Dr. Atkins and a specialized nursing supervisor, but this service has since fallen to a low level. Budget. Considerable time has been spent on the attempt to prepare a complete analysis of the total health budget for 1929 and the results are presented in tabular form in Table 12. It should be noted that this table includes only the basic items usually summarized in comparative studies of public health ex- penditures. The following items should be added for a more complete picture: Tuberculosis Sanatorium, county appropriation $46,000 Garbage collection and disposal and plumbing in- spection, Olean, city appropriation 22,650 Tuberculosis and Public Health Association, voluntary contributions and Milbank Memorial Fund grants 11,725 Open Air Schools and Camp, Olean Anti-Tuberculosis Association 4,689 Garbage disposal, Salamanca, city appropriation 450 Total $85,514 It should also be noted that the sums spent by the State De- partments of Health and Hospitals for mental clinics are ex- The Present Health Program of Cattaraugus County 89 cluded; but the Indian nursing service is included. The rubric at the head of Table 12 refers to the responsible authority in charge of the work, rather than to the ultimate source of funds. The budget of the County Board of Health, of course, receives contributions both from the State and from the Milbank Me- morial Fund—the county school hygiene budget from the Mil- bank Memorial Fund (see Chapter XV). The figures in the columns for rural health boards and rural school medical service are estimates made by Miss Frances King. The rural board of health item covers only the first third of the year, after which date the rural boards of health were abolished. Table 12. Health Budget for Cattaraugus County, 1929. County OLEAN SALAMANCA Bsa Locke Nurs- se | 3 3x] 2 |2x]| 2 2858 ome | TO 30538238) 5 || EE ee mR 3 | Ea | 8 | Ea 3 22358 ToraL «+ oo. .|$107,849($9,140($11,142($5,549/$1,515/$2,150($3,100($9,530($10,467|$160,442 Central administration. | 18,554 2,701 380 21,635 Health stations . . . 6,406 6,406 Vital statistics . . . 4,263 800 5,063 Health education . . 2,100 2,100 Communicable diseases 2,941 1,901 415 1,550 6,807 Venereal diseases . . 1,147 1,075 2,222 Tuberculosis . . . . 5,224 5,224 Maternal, infancy and child hygiene . , . 4,743 337 5,080 School hygiene . . . 6,940 3,749 450 8,220 19,359 Laboratory. . 0. . 11,200 11,200 Sanitary engineering . 5,487 951 720 1,550 8,708 Nursing . . . . .| 45,784 2,200] 3,377| 1,800 1,700 1,310| 10,467 66,638 The total budget amounts to $160,442 or $2.20 per capita, a remarkably high figure for a rural area and one comparing favorably with standard urban programs. No one has yet dared to formulate a really adequate standard budget for a rural county, but the Cattaraugus showing is so good as to invite comparison with the generally accepted standards of the American Public Health Association for cities. This comparison is pre- sented in Table 13. 90 Health on the Farm and in the Village _ Table 13. Per capita comparison of expenditure by functions for health activities in Cattaraugus County and in urban areas. FuncrioN URBAN STANDARD CarrarAUGUS, 1929 TOTAL: 12 + + el a ie vile wieiin $2.17 $2.20 Admipistration . 0... Se oa $ .14 $ .39 Popular health instruction he 04 .03 Vifalstatistics . . . . . « « . .05 .07 Communicable diseases . . . . . .09 .09 Muberculosis =... aa eee .08 .07 Venereal disease , . . + viv» .09 .03 Hygiene of maternity and infancy . . 10 .07 Schoolhygiene . . . « . . . 22 27 Sanitation, food and milk control . . 20 J1 Yaboratorfes . 0. se Cl el 10 A5 Nursing. ois alog weds i .86 92 Communicable disease hospitalization. 20 .001 1 The cost of hospitalizing one or two cases of communicable disease a year in hospitals outside the County is very small and is tabulated under communicable disease control, so far as it enters into the health budget at all. It is most interesting to see how closely the figures check in general. Out of all items, 6 are nearly identical. For adminis- tration and for laboratory service, figures are high. Adminis- tration must necessarily be costly for a relatively small population unit distributed over a relatively enormous area and including, as the Cattaraugus budget does, two municipal offices and six district stations, with heavy travel costs. In response to a special request for information in regard to this latter point, Dr. Atwater says: “The mileage of the County Commissioner of Health for the year ending June 30, 1930, was 7,000 miles and that of the Deputy Commissioner, 23,400. All of this was in connection with official business and, as can readily be seen, requires a very considerable amount of time—up to a third of the time of the Deputy and a full month’s service of the County Commissioner of Health.” He adds, “One call today 46 miles from Olean. A call last week §5 miles from Olean.” Furthermore, there are considerable items of administrative expense (such as elabo- rate audits and travel to New York) incident to the relation of the demonstration to the Milbank Memorial Fund. They are, of course, paid by the Fund but help to swell the per capita total The Present Health Program of Cattaraugus County 91 as here computed. Finally, an appreciable item of administrative expense is involved in the status of the demonstration as a model health unit attracting numerous visitors. In the summer months there is scarcely a day without one or more guests, public health officials, representatives of national health agencies and foreign traveling fellows from the Rockefeller Foundation and similar bodies. Stimulating and valuable as such visits are to the staff, they consume an astonishing amount of time, and the writer has often wondered if it might not be reasonable for those foundations which send out traveling fellows as a routine procedure to make grants to the departments of health which are furnishing a sort of postgraduate instruction. The question of laboratory costs will be considered in Chapter IX. It need only be said at this point that the high cost under this item is fully justified by the unusual volume and type of service rendered. Three activities, on the other hand, have budgetary allotments notably below urban standards; and these three (venereal disease, hygiene of maternity and infancy and sanitation) are precisely those activities which have been noted as definitely deficient. All in all, this comparison shows exactly what one might expect —that adequate public health service in a rural district costs just what it does in a city, plus an excess due to the larger area to be covered. We are convinced, after our somewhat detailed analysis of the situation, that the money now spent in Cattaraugus County is essentially needed for the protection of the health of its people, that no needless activities are provided and that there is no lack of efficiency or economy. Not only should no decrease in total budget be contemplated, but there is urgent need for appreciable, though not large, increases to provide for venereal disease work, maternity and child hygiene and sanitation. It is probable that an increase of $15,000 over the 1929 budget would place the county health organization on a reasonably effective basis. Hospital, Medical and Nursing Facilities. While no attempt has been made to analyze in detail the medical facilities of Cat- taraugus County, it will be worth while to place on record certain of the main features of the situation. 92 Health on the Farm and in the Village The hospital facilities of the County are summarized in Table 14. Table 14. Hospital facilities in Cattaraugus County, 1929. Bep Capacity HOSPITAL LocATION - SE, Medical | Surgical| Mater- | Pediat- | 150) ; nity ric Olean General! . | Olean 26 35 20 25 106 | 20,100 Mountain Clinic | Olean 14 18 10 42 9,855 Salamanca! . . | Salamanca 5 22 4 31 8,672 West Side? . . | Olean 30 Townsend . .|Gowanda 6 3 5 14 2,551 Cattaraugus 3 . | Cattaraugus 11 Maternity Homes. . .| Ellicottville Franklinville 11 11 Machias 1 Registered hospital. 2 Not open in 1929. 3 Open in 1929, now closed. No data available. Only the Olean General and the Salamanca Hospital are registered hospitals and New York unfortunately does not require private hospitals to be licensed. Incidentally, some control of these private hospitals would seem highly desirable in the public interest. In all hospitals the major part of the work is surgical (Olean, 55 per cent; Salamanca, 78 per cent; computed on the basis of admissions). On a basis of payment the division is as shown in Table 15. The total available bed capacity of the County is low. Exclud- ing the maternity homes, we have, in 1929, 204 hospital beds or Table 15. Total number of days of patients’ stay in the hospitals of Cattaraugus County, 1929. SERVICE SALAMANCA OLEAN, GENERAL 157NsED, Boroar . 8,672 20,100 2,551 Privaterooms . . .. .. . 1,963 9,304 2,339 Ward, paycases. . . . . 6,481 10,701 Free beds and special . 64 161 Public charity cases . . . 228 3 51 The Present Health Program of Cattaraugus County 93 one bed for 365 persons. Furthermore, even in the two registered hospitals only 1 per cent of the patient days are free with a some- what higher ratio at Gowanda, while there are presumably no free beds in the private hospitals. The explanation of this fact lies, of course, in the utilization of the hospital facilities of Buffalo, James- town and other large centers outside the County. The minimum ward rate at Olean is $2.50 and at Salamanca, $3, while charity cases can be cared for in Buffalo at $2 aday. The Salamanca Hos- pital is running well up to capacity, with 77 per cent occupancy in 1929, and is planning a new 10-bed maternity ward. The Olean General, on the other hand, had an occupancy of only 52 per cent, but is increasing its volume of service rather rapidly year by year. The ratio at Gowanda is 50 per cent and at the Mountain Clinic, 64 per cent. The Mountain Clinic maintains an out- patient service averaging 30 visits a day and has over a hundred infants under supervision. There are now 68 physicians residing in the County giving a ratio of 1 to 1,063 people, about one-third lower than the ratio for the country as a whole. Some half dozen are not in active practice. There are twenty towns with no resident physician. Forty-three of the 68 are graduates of the University of Buffalo. The classification of physicians by age is shown in Table 16. Table 16. Classifi- cation, by age groups, of physicians in Cat- taraugus County, 1930. AGE NuMBER (PER CENT Under 30 7 10 30-39 12 17 40-49 18 26 50-59 11 16 60-69 14 21 Over 69 6 9 Thus it appears that 9 per cent of the physicians are 70 and over, 30 per cent are 60 and over and 46 per cent are 50 and over, while but 10 per cent are under 30 years of age. 94 Health on the Farm and in the Village There are, so far as is known, 10 chiropractors in the County, 3 in Olean, 3 in Salamanca, and the rest in 4 of the villages. Three osteopaths are practicing in Olean, one of them using the Abrams method of electronic diagnosis. A female herb doctor in Sala- manca has a large practice and a wide reputation for poultices believed by the credulous to be useful for all types of infection. Patients come to her from a wide area, including parts of Penn- sylvania. Another person called Rolling Thunder, an Indian, is said to have a considerable practice during the summer time with the tourist trade. An attempt was made by Miss Katharine Tucker, who had charge of this branch of the investigation, to obtain an approxi- mate idea of the available private duty nursing resources of the County. The local hospitals had lists of 39 graduate nurses which would give a ratio of one nurse to 1,800 population or about half the ratio for the country as a whole. These private duty nurses charge $6 for a 12-hour day (or in some few cases for 24-hour service). There are §5 “practical nurses” known to the Health Department, working either on a 12 or a 24-hour basis and making their own charges without supervision or regulation. Finally, as bearing on the possibilities of securing medical care for the indigent, a word should be said as to the public and private resources for dealing with such problems. We have seen that the amount of free work done in the hospitals of the County is almost negligible. Under the plan of organiza- tion in force up to 1929, there was a superintendent of the poor, with offices at Machias, and 35 local poormasters in the various cities and towns. If a necessitous individual were sick at home, rent might be paid by the County and the money thereby saved used for paying doctor’s bills, but direct help for medical care at home could seldom be obtained. The poormasters, for the most part, held the old concept that no relief should be given at home except under the most urgent pressure. Needy cases were sent to hospitals, often in Buffalo, at public expense when neces- The Present Health Program of Cattaraugus County 95 sary; but personal application was required and the entire system was so organized and administered as to emphasize the stigma of pauperism and discourage public aid for the self-re- specting sufferer. The inadequacy of this program will be discussed in Chapters XI to XIII; but it may be stated at present that provision for the medical care of the poor has been one of the outstanding deficiencies in the health program of the County. There are two notable exceptions—the provision through public and private funds for the correction of defects of school children in Olean and the county-wide program of the Tuberculosis and Public Health Association for the care of crippled children (see Chapter XI). A new law, passed in 1929 and taking effect January 1, 1930, reorganizes the entire system of poor relief. Itsets up each county as a welfare district with a county commissioner of public wel- fare and provides for a public welfare officer in each town to replace the poormaster. It makes the welfare district “responsible for providing necessary medical care for all persons under its care, and for such persons otherwise able to maintain themselves, who are unable to secure necessary medical care” and states that “such care may be given in dispensaries, hospitals, the person’s home or other suitable place.” Physicians may be specially appointed to care for sick persons in their homes. “When no physician is so appointed, the public welfare official shall employ a physician or physicians to visit sick persons in their homes when- ever necessary.” If this law is carried out in the spirit as well as in the letter, it should raise the entire program of the medical care of the needy to a new and modern level. CHAPTER VIII COMPARISON OF THE CATTARAUGUS HEALTH PROGRAM WITH THAT OF OTHER RURAL COUNTIES Development of the Full-time County Health Program in the United States. The provision of health service for rural areas in the United States has been, essentially, a development of the past decade—see reviews by Dr. John A. Ferrell of the International Health Division of the Rockefeller Foundation (Journal of the American Medical Association, September 29, 1923, and July 9, 1927), by Dr. W. G. Smillie of the Harvard School of Public Health (Journal of the American Medical Association, September 24, 1927) and by Dr. L. L. Lumsden of the United States Public Health Service (Public Health Reports, May 9, 1930). In 1914, there were only three full-time county health depart- ments in the United States. At that time the International Health Board of the Rockefeller Foundation, in its attempt to control hookworm disease, realized the essential need for per- manent local health machinery and made the development of full-time county units a definite part of its program; and this Foundation and the United States Public Health Service have since furnished invaluable moral support and financial aid to forward-looking state health officers in the furtherance of the program. By 1920, there were still only 43 full-time county health units in operation, but during the last ten years progress has been rapid, as indicated by Table 17. The last figures in the table on p. 97 are those given by Dr. Lumsden. Dr. Ferrell, in a personal communication, states that 96 Comparison with Program of Other Rural Counties 97 Table 17. Growth of full-time county health units in the United States, 1914- 1930. N ER OF Year Counries 1914 3 1920 43 1923 214 1926 307 1927 337 1928 414 1929 467 1930 505 on December 21, 1929, there were units in operation in 488 out of a total of 3,075 counties in the United States. The proportion of actual rural population covered by full-time health service is estimated by Dr. Lumsden at 24 per cent, ranging from 0 per cent in Wyoming and Iowa to 53 per cent in North Carolina, 56 per cent in Louisiana, 7 per cent in South Carolina, 59 per cent in Ohio, 60 per cent in Maryland and 81 per cent in Alabama. Financial Limitations to the Development of County Health Work. The great limitation to the progress of county health work is, of course, the financial one; and data cited in regard to the economic status of the rural population in Chapter II make it clear that this limitation cannot be ignored. Dr. Smillie, in the paper cited above, has used the same data as to economic status quoted in Chapter IT and has divided the counties in 20 states into four economic groups. He then computes the percentage of counties in each economic group which have developed county health units as shown in Table 18. It seems obvious that the development of county health service in the poorer rural counties is faced by almost insuperable dif- ficulties. Even the results so far achieved have been accomplished in the vast majority of rural counties only by outside aid. Dr. Lumsden states that, of 505 counties or districts under full-time 98 Health on the Farm and in the Village Table 18. Economic status of rural counties in the United States hav- ing a county health unit, 1926. Number of counties in each economic group. Economic STATUS BEST Goop Far Poor Ten states with county health programs over period of 10 Vemrs ho ne er 54 18 9 2 Ten states with county health programs over period of 5 years 30 10 8 6 health officers at the beginning of the present calendar year, 444 or 88 per cent are receiving financial assistance from their state boards of health, from the United States Public Health Service, from the Rockefeller Foundation or from two or more of these agencies. The Problem of Adequacy. It is such considerations of “the power to pay” which have led those interested in laying the foun- dations of the county health movement (particularly in the Southern states) to establish very modest standards of attainment. Thus, Dr. Ferrell said in 1923, “An expenditure of from 25 to 50 cents per capita will usually support a creditable staff.” Again, in 1927, he said, speaking of the poorer counties, “with the health authorities of such sections, the question is not whether $3 or $5 per person per year is too much or too little for the community to spend for health service, but rather how they can manage to obtain enough money from local, central and outside sources to pay for a service representing as little as 50 cents per person annually.” Similarly, Dr. Smillie points out the dangers of encouraging even the minimum “standard” unit (a full-time health officer, a nurse, a sanitary inspector and a clerk) in counties having a total annual income of $2,000,000 or less. Nevertheless, it seems to the writer that the time has come to separate the problem of what the rural county needs from the problem of what it can pay for at the moment. If a man is starving, he is starving, whether he happens to have money in his pocket or not. It will help to clear thinking to recognize Comparison with Program of Other Rural Counties 99 that the “standard” county unit may be “creditable” and may be all and more than many poor rural counties can afford, but that it is by no means adequate to meet the basic essential health needs of the populations concerned. Comparison of the Cattaraugus County Program with That of County Health Services in General. It is from this standpoint of fundamental adequacy that the Cattaraugus demonstration is particularly significant. For the purpose of placing it in relation to the general picture of county health service, we have obtained, through the courtesy of Dr. Ferrell, data as to the total expenditures and the num- ber of nurses employed by 442 full-time health units in counties of under 100,000 population in operation in the United States in 1929. ‘This represents over 90 per cent of all such counties. We have grouped these counties according to the Crowell income classes used in Chapter II and have computed the per capita ex- penditure for each county in Table 19. The counties spending over $1 per capita for public health work are as follows: in the income group under $250 per capita, Carlisle, Kentucky ($1.08), Menifee, Kentucky ($1.11), and Lake, Tennessee ($1.02); in the $250-499 income class, La Salle, Louisiania ($1.06), Tensas, Louisiania ($1.11), and Rutherford, Table 19. Health budgets of 442 rural counties having full-time county health departments, in relation to per capita income of these counties, 1926. NuMBER OF COUNTIES IN EAcH Crass, CLASSIFIED ACCORDING TO HeartH BUDGET, PER CAPITA IN CENTS PER CAPITA INCOME Under $.26 $.26-.50 $.51-.75 $.76-1.00 Over $1.00 Morar...» 125 222 64 17 14 Under $250. . . 57 92 23 3 3 $250-499 . . . 30 77 19 8 3 $500-749 . . . 29 33 18 1 3 $750-999 . . . 6 17 4 1 3 $1000-1249. . . 2 3 2 1 0 $1250 and over . 1 0 1 3 0 100 Health on the Farm and in the Village Tennessee ($1.11); in the $500-749 income class, Wexford, Michigan ($1.04), Lewis and Clarke, Montana ($1.13), Eddy, New Mexico ($1.06), Durham, North Carolina ($1.11), and Forsyth, North Carolina ($1.10); in the $750-999 income class, Chaves, New Mexico ($1.16), Cattaraugus, New York ($1.41), and New Hanover, North Carolina ($1.08). The table indicates that 28 per cent of these counties spend for their public health organization less than 26 cents per capita and that 79 per cent spend less than 51 cents per capita. Irrespective of local conditions, and of any possible economies in operation, this means that four-fifths of the full-time county health units in the United States are organized on a level which cannot pos- sibly be considered adequate for the needs of their populations. In no market, by any stretch of economy, can you buy $2.00 worth of service for $0.50. The other 21 per cent of these counties spend a sum which may, in many cases, in reasonable measure, meet the most essential health needs; and the 7 per cent of counties which spend over 75 cents per capita should be rendering good service. It must be remembered that the cost of living varies greatly in different regions and that an appropriation of 75 cents per capita in rural Tennessee may be the equivalent of a much larger sum in New York. Fourteen counties, or 3 per cent of the total, spend over $1.00 per capita for their health programs, Cattaraugus leading with $1.41. Itshould be noted that this figure refers to county health appropriations only and does not include the local services which we have included in our analysis of the Cattaraugus budget. A second helpful criterion of the adequacy of a health service is the ratio of public health nurses to population; and figures in regard to this point have been computed and are summarized in Table 20. The four counties having a ratio of less than 5,000 inhabitants per nurse are Calvert, Maryland (1:4600); Cattaraugus (1:3600) ; Durham, North Carolina (1:4900); and Forsyth, North Carolina (1:4100). The Cattaraugus figures (as in the Comparison with Program of Other Rural Counties 101 case of the budget) include only the county nurses. The actual ratio, including the various local nurses, is materially better. Table 20. Ratio of nurses to population in 442 rural coun- ties with full-time county health departments. NUMBER Toral/COUNTIES . VF.” 442 Counties with Under 5,000 people per nurse . 4 Over 5,000 and under 10,000 . 35 Over 10,000 and under 15,000 . 59 Over 15,000 and under 20,000 . 46 Over 20, ,000 and under 40, 000. | 194 Over 40, 000..." Ll 104 We know very definitely from experience in urban com- munities, and in certain rural areas that one public health nurse is needed to care with adequacy for 2,000 people. It is quite clear that a single nurse in a population of 20,000 or 40,000 or 60,000 people is not really functioning as a public health nurse at all. She may be an educator, an organizer, a clinic director, but she cannot possibly do real public health nursing. Yet this is the sort of situation which exists in two-thirds of those counties in the United States which have full-time health services. In only 9 per cent of such counties is there anything approaching a real public health nursing service (one nurse to less than 10,000 people). In general, then, it appears from this comparative analysis that: There are about 3,000 counties in the United States, Some 2,500 of these counties are essentially or largely rural, Of the 2,500 about 500 have full-time health services, Of the 500, less than 50 have health budgets and health per- sonnel in any sense adequate for a full health service, Of these 50, Cattaraugus and perhaps a dozen others have health machinery comparable with that which is believed essential in an urban community. 102 Health on the Farm and in the Village Comparison of the Cattaraugus Program with That of Certain Counties Having Highly Developed Health Machinery. On the other hand, the program of Cattaraugus County is by no means unique or beyond the range of practical experience elsewhere. Through the courtesy of Dr. W. F. Walker of the Committee on Administrative Practice of the American Public Health Associa- tion, we have obtained appraisal scores for five other counties with highly developed health services. Those of Los Angeles and Rutherford have already been published and permission has been courteously granted by Mr. Barry Smith of the Commonwealth Fund to use the scores for Clarke and Marion counties and by Mrs. L. S. Thompson to use the score for Monmouth County. In each case where scores for several years were available, we have used the year showing the highest score. In two of the counties, as in Cattaraugus, 1929 would show a slight falling off as com- pared with 1928. Table 21 shows that Los Angeles, Monmouth and Rutherford counties have total scores approximately equal to that of Cat- Table 21. Appraisal scores of health activities in six counties having highly developed health machinery. Los CARRE, |Mouourm. CATTARAU- RUTHER- HEALTH ACTIVITIES A50ELES < Ca. x Te on NE Mig, Jo8D, (1927) (1928) (1927) (1928) (1927) (1928) ALL ACTIVITIES 82 89 82 83 71 81 Vital Statistics . 83 100 75 100 97 100 Communicable diseases . . 74 92 3 | 84 75 91 Venereal diseases . . 42 100 96 62 12 2 Tuberculosis 88 91 80 100 57 70 Prenatal . . . 91 93 97 79 80 93 Tofancy . . 80 79 100 77 83 83 Preschool . . 100 100 100 100 100 100 School. '. .. .. 76 93 81 82 79 77 Sanitation . . 96 70 78 61 61 59 Food and milk . 78 69 57 65 28 65 Laboratory . . 93 96 83 100 81 90 Health instruction . 95 100 80 100 95 100 Comparison with Program of Other Rural Counties 103 taraugus, while Clarke County is higher and Marion County lower. In tuberculosis control and laboratory service, Cat- taraugus excels, but in communicable disease control it falls be- hind Clarke and Rutherford, in venereal disease control behind Clarke and Monmouth, in prenatal work behind Los Angeles, Clarke, Monmouth and Rutherford, in infant work behind Mon- mouth, in sanitation and food and milk control behind Los Angeles. If appraisal scores were available, it is probable that certain other counties, such as Chatham, Georgia, and San Joaquin, Cali- fornia, would fall in the same general class, but the number of such counties would certainly be very small. In summary, then, it appears that Cattaraugus County is one of about a dozen rural or semi-rural counties in the United States which have a reasonably adequate health service. The experience of this small group of progressive counties has shown that the need for a fully organized health service is just as real in the rural as in the urban area; and that this need can be met (with outside aid), even in counties like Rutherford and Clarke which have per capita incomes under $400. The rural units which spend fifty cents per capita or less and provide a ratio of one nurse to 15,000 or more people (including four-fifths of all counties with organ- ized health services) are making a highly creditable attack upon their problem, but it would be fanciful to assume that they are solving it. CHAPTER IX QUALITY OF BASIC PUBLIC HEALTH ACTIVITIES!® Environmental Sanitation. The foundation of any public health program, now as in the past, is a sanitary environment. This fact was realized in planning the Cattaraugus demonstration, but was later minimized in carrying it out. There is a highly valuable lesson here to those of us who live in large cities in the evidence that rural districts, even in the Northeastern states, can- not afford to neglect fundamentals. No sanitary inspector was appointed in the County Health Department until 1926 and this position was not filled by a qualified sanitarian until 1929. There results the somewhat anomalous situation of a community with an appraisal score for sanitation of only 61 per cent, as com- pared with perfect scores for such activities as tuberculosis con- trol and laboratory service. The present director of this Bureau, Mr. N. M. Fuller, is capable and efficient and has a good approach to the public. He has shown a sound sense of proportion in selecting problems to be first attacked and is making encouraging progress in their solution. He is assisted by one milk inspector. Our only criticism of the technique of this Bureau is that (as a result of time limitations) records of contacts with local authori- ties, milk dealers and the like, are not as complete as would seem desirable. It is most important for the protection of the Depart- ment that written records of all steps taken should be fully avail- able. The city of Olean has a plumbing inspector and a second inspector who divides his time between sanitary and milk in- spection and registration of vital statistics. 1 This chapter (as well as parts of later chapters) is based largely upon the special appraisal of Cattaraugus County conducted by Professor I. V. Hiscock with the aid of Mr. H. H. Walker. 104 Quality of Basic Health Activities 105 Water Supply. There are at present 19 public water supplies in the County, serving communities which include 43,400 persons, or 60 per cent of the county population; and the condition of these supplies has constituted, and still constitutes, a real health problem. Again and again, the State Department of Health has called attention to the hazardous character of many of the sup- plies, but in most instances without action leading to very definite results. The Olean typhoid epidemic constitutes, of course, a striking instance of the danger of local neglect of repeated warnings. The history of this outbreak has been detailed in Chapter VI and need not be repeated here. It need only be added that, under the influence of so drastic a lesson, and since the County Health De- partment took control, the auxiliary supply at South Olean has been completely discontinued, the filter capacity at North Olean doubled, prechlorination instituted, new control apparatus in- stalled and a very complete system of laboratory control in- troduced. Sewage discharges into Olean Creek at Cuba and Franklinville have been chlorinated and cross-connections rigidly controlled. The treatment of the water now includes aeration (for control of odors), prechlorination, coagulation, sedimenta- tion, treatment with activated carbon, mechanical filtration and final chlorination. Eight samples from various points in the system are analyzed daily for bacteriological control. The results are altogether admirable, as indicated by the following data. A total of 743 laboratory examinations of the treated water were selected at random for different seasons of the years 1929 and 1930. Of each of these samples, five 10-cc. portions had been examined, making 3,715 portions in all. Colon bacilli were found in only 28 of these portions. In six of the seven months, the ratio of positive portions was under 1 per cent and in the seventh month under 3 per cent. In only 1 out of the 743 samples examined were three or more portions positive in the same sample. Most gratifying progress has been made in the elimination of dangerous cross-connections in the city of Olean. 106 Health on the Farm and in the Village Salamanca has two supplies, one derived from mixed spring and surface sources and one from drilled wells,—both chlorinated and for some time in excellent condition. The general situation is indicated in Table 22 below. It will be noted that in 1929 only Allegany, East Olean, Limestone, Olean and Salamanca had supplies which would pass the United States Treasury Department standard for water to be served on trains operating in interstate commerce; and of these five supplies, that at Limestone cannot be considered permanently safe since its drilled wells are exposed to serious potential pollution. The Machias and East Randolph supplies are very close to the standard and may be considered safe. The public supplies of the County are for the most part derived from springs or wells, the only exceptions being surface supplies in Hinsdale and Olean and mixed ground and surface supplies in Randolph and Salamanca. The ground water supplies are, however, less safe than would be the case elsewhere on account Table 22. Public water supplies of Cattaraugus County. ACCEPTABLE, PHELPS INDEX GRADE AT AREA PoruraTION U.S. PRESENT, IN SERVED TREASURY OPINION OF STANDARD 1929 19302 SURVEY STAFF Allegany . . . 1,200 Yes 0 0 A Cattaraugus! . . 1,170 No 6 13 B Delevan. . . . 480 No 22 13 B East Olean . . . 150 Yes 0 — A East Randolph . 670 No 49 2 A Ellicottville . . 930 No 14 9 B Franklinville . . 1,620 No 34 14 B Gowanda . . . 3,040 No 2 19 B Hinsdale . . . 150 No 201 255 C Limestone . . . 360 Yes 1 2 B Little Valley . . 1,140 No 35 31 B Machias. . . . 530 No 2 2 A Olean... 5. 20,400 Yes .06 .09 A On, .°. .. 250 No 9 3 B Portville . . . 880 No 60 141 B Randolph . . . 1,240 No 13 5 C Salamanca . . . 8,620 Yes 0 0 A Sandusky . . . 250 No 6 — B West Valley . . 320 No 2 1 B 1Main supply, auxiliary supply of better quality. 2 First six months, Quality of Basic Health Activities 107 of the prevailing geological formation which is a laminated shale, with water level relatively near the surface. Such a formation is particularly liable to subterranean pollution, and, furthermore, many of the spring supplies are freely exposed to surface wash. Only three supplies, Gowanda, Olean and Salamanca, are pro- tected by routine purification processes, although four others (Cattaraugus, East Randolph, Franklinville and Little Valley) have emergency chlorinators for temporary use. In addition to the public supplies, there are two private wiles for railroad purposes at Salamanca. The Erie Railroad has a dug well which was found by Mr. Fuller to be subject to gross pollution and is now chlorinated. The Buffalo, Rochester & Pittsburgh Railroad has three drilled wells of good quality. Under the stimulus of the State and County Boards of Health, considerable improvements have been made in certain of the doubtful supplies, notably at Cattaraugus (temporary chlorina- tion of auxiliary supply), Delevan (chlorination ordered), East Randolph (protection of sources, better chlorination), Franklin- ville (abandonment of certain sources, protection of sources, temporary chlorination), Gowanda (new well, under construc- tion; new reservoir, chlorination), Little Valley (provision for temporary chlorination, new well under construction), Portville (protection of sources). Mr. Fuller has now three chlorinators for temporary use in the communities most in need of them. The analyses in Table 22 do not show any marked improvement for the first half of 1930 as compared with 1929, except in the cases of East Randolph and Franklinville. There are two facts to be considered, however, in connection with Bacillus coli indices in supplies of this character. In the first place, many of the small Cattaraugus spring and well supplies are free from any serious possibility of permanent human pollution and there is no doubt that the pollution in such cases is often of bovine origin. Furthermore, in certain cases, notably at Portville, the County Laboratory has considerable evidence to suggest the possibility that colon bacilli may be derived from salamanders living in and adjacent to the springs. 108 Health on the Farm and in the Village We have attempted in the last column of Table 22 to grade the public supplies largely on the basis of personal sanitary in- spection, with due consideration of the opinion of Mr. Fuller and of reports by State Department engineers. We believe that the supplies of Hinsdale and Randolph (total population served, 1,390) are distinctly dangerous, both consisting of untreated surface water exposed to human pollution. At the other ex- treme are Allegany, East Olean, East Randolph, Machias, Olean and Salamanca (total population 31,570) with excellent supplies. These communities include 44 per cent of the total population of the County and 73 per cent of the population which is served by public supplies. Between these two groups, lie eleven of the public supplies which are exposed to possible chance pollution and are not protected by adequate and permanent purification. This includes several of the supplies reported by Mr. Fuller as improved: Cattaraugus, because there is no permanent chlorination; Delevan, because the chlorinator is not yet installed; Franklinville, because chlorination is not permanent; Gowanda, because recent analyses are still too high and indicate uncertain operation (due to use of old reservoir pending construction of a new one) ; Little Valley, because chlorination is not permanent; Portville, because there is no purification process. Of these, Delevan, Gowanda and Little Valley will be much improved when changes now under way are complete. The fact remains that at present these eleven com- munities, with a combined population of 10,440, are not enjoying the safety which modern sanitary engineering makes possible at very reasonable cost. Permanent and adequate chlorination would make most of these supplies safe and sanitary. Except in the case of Hinsdale and Randolph, the danger is not great and immediate, but it is always present. During the years 1928 and 1929, there were two epidemics of typhoid (at Olean and East Randolph) and one of diarrheal disease (at Gowanda) definitely traced to water and three other outbreaks of diarrhea (at Delevan, Little Valley and Great Valley) in which water was a probable cause. So long as present conditions exist the public authorities of thirteen communities in Cattaraugus County are gambling Quality of Basic Health Activities 109 with the lives of their constituents. ‘The County Board of Health has no power to compel the treatment of unsafe public supplies; it can only attempt to persuade and it is doing so. The State Department of Health has had no such power in the past, but it possesses it under a recent law. This power should be coura- geously exercised. The rural population of the County (about 40 per cent) is supplied mainly from private drilled or driven wells or springs. Dug wells are fortunately rare. The wells and springs in this locality (like many of the public supplies) are specially open to pollution, on account of the prevailing geological formation, as has been pointed out above. We have obtained from the County Laboratory two sets of analyses of private supplies, one relating to §§ private wells and springs in the city of Olean; the other in- cluding 88 rural wells and springs on dairy farms supplying Olean with milk and 42 rural wells and springs supplying dairy farms in other parts of the County. The results are summarized in Table 23 and indicate that private supplies in the towns and rural supplies in general are of exceedingly dubious quality. The application of the Phelps Index to samples from various sources is, of course, not theoretically justified, but it serves to give a comparative picture of the general situation. The County, of course, loses rather heavily on its water supply appraisal score. There is no reason, however, to believe that conditions are different from those which obtain in most other Table 23. Analyses of private wells and spring supplies in Cattaraugus County. N WATER SUPPLY Tues Covramnno PHELPS INDEX BOTAL ole: is bv rowtifins ie 185 128 141 Private supplies, Olean . . 35 42 279 Supplies on dairy farms servingOlean . . . . 88 63 71 Supplies on other dairy farms=. Lh, 42 23 104 110 Health on the Farm and in the Village counties. They should be materially better when the excellent work of the County Engineer has had time to exert full effect. Sewerage and Sewage Disposal. There are eight of the larger communities which are provided with sewerage systems, alto- gether serving about 40 per cent of the population of the County. In Olean, Franklinville and Gowanda the proportion served is 80 per cent or over, in Salamanca only 65 per cent. Of the eight sewerage systems, Olean has tank treatment at one out of several outfalls, Franklinville has an inadequate Imhoff tank and chlorina- tion, Allegany has an Imhoff tank. The other five communities, Ellicottville, Gowanda, Limestone, Portville and Salamanca (as well as the greater part of Olean city), discharge wholly untreated sewage into their streams. More than half the population is served by privies, cesspools and septic tanks. No special effort has been made to secure fly- proofing of privies or to estimate the magnitude of the problem involved and this subject should receive serious attention. Mr. Fuller has prepared a design for a model domestic septic tank and is beginning to codperate actively with school authorities in the field of rural school sanitation. It is our impression, that a rather large proportion of houses are provided with satisfactory cess- pools or septic tanks, as compared with other rural areas. In certain villages, however, leaching cesspools constitute a menace to ground water supplies. The county appraisal score for sewer- age is, of course, very low. Disposal of Garbage and Refuse. The garbage and refuse of Olean is regularly collected, the garbage being fed to hogs and the refuse used for filling. The process is reasonably successful and the cost to the community $21,750 a year. At Salamanca, col- lection is by private parties, but the City rents a dumping ground. So far as general sanitary conditions are concerned, our surveyors have been impressed with the general tidiness of the County. As compared with similar areas in certain other states, Cattaraugus is notably free from offensive deposits of garbage and refuse. Camp Sanitation. The sanitation of camps is a problem which, like privy sanitation, has been left undeveloped—and wisely so, Quality of Basic Health Activities 111 in view of staff limitations and the more urgent need of water and milk control. It must, however, demand attention in the future. This problem is most acute in the Allegany State Park which is under the jurisdiction of a special board of health created by State statute and composed of the Allegany Park Commission and the State Commissioner of Health. In the past there has been no routine system of camp inspection, Mr. Fuller, the county sanitary engineer, functioning only in emergencies or by request for advice. We understand that a trained sanitary engineer has very recently been appointed by the State Park Commission to deal with this problem. The need for marked improvement is clearly indicated by the following facts: Inspection of several camps by Mr. H. H. Walker of our survey staff revealed distinct deficiencies in general sanitary control. Analyses made at the County Laboratory in 1928 of water supplies, provided at camps and other places in the Park under the official auspices of the Park Commissioner, gave a Phelps Index of 15 for 27 well supplies and an index of 70 for 20 spring supplies. (The maximum index corresponding to the Treasury Department standard for safe water is 1.) At least three outbreaks of diarrheal disease are known to have occurred in Cattaraugus camps during 1929, one at a religious camp outside the Park and two at Boy and Girl Scout camps within the Park. Milk Supply. The problem of milk supply would seem to be of very special importance in a county where the human and bovine populations are approximately equal and where 50,000 of the 70,000 cattle are classed as dairy cows. Yet the County Depart- ment of Health began dairy inspection only in 1928, the in- spector being assigned to the new Bureau of Sanitation in 1929. Olean has had an inspector devoting part of his time to dairy inspection for many years and, since Dr. Johnson was appointed health officer in 1928, milk control has been pushed with great vigor in that City. The new State Milk Code which became 112 Health on the Farm and in the Village effective July 1, 1928, is the basis of the County program, but Olean has an even more stringent code of its own. Most of the milk produced in Cattaraugus is shipped out of the County and only 94 farms supplying Olean and 87 supplying other county areas are actually subject to local inspection. Milk from one-cow dairies and, of course, all milk produced for home consumption, is without any supervision, although a beginning has been made in the control of one-cow dairies in the Cat- taraugus village area. The Olean inspector made just one scoring inspection per farm in 1929, while the county inspector made 105 total inspections but only some 20 scoring inspections. Con- siderable confusion results from the conflicting requirements of the various large cities whose inspectors visit the County, New York City, Buffalo, Rochester, Baltimore and Jersey City being among the number. If human beings were rational animals, these cities would certainly agree on a common code and contract with the County Department of Health to enforce it. Mr. Fuller has at present a sound program in force, including scoring, regular bacteriological control and special consultation service when high counts are recorded. It is believed that in every village at least one dairyman has spent $1,000 to $3,000 in complying with the new regulations. The dairy scores reported by the Olean and county inspectors are low, 26 per cent of the Olean dairies and 39 per cent of the county dairies falling below 60 per cent. The score card used by the City and County is, however, an unusually severe one, in- cluding 10 points for medical examination of milk handlers and 10 points for testing for undulant fever, so that most producers would score 20 points lower on this form than on the forms used in many areas. Our impression from the dairies visited is that they are of average quality. Washing and sterilizing methods are often defective and refrigeration facilities poor, but real progress is being made throughout the County in the installation of essential equipment. There are six pasteurizing plants serving the County which meet existing standards. Several ice cream establishments are known to be in distinctly poor condition. PROGRESSIVE IMPROVEMENT OLEAN CITY MILK SUPPLY 5 I= ae 40 or “WBACTERIAL COUNT, 240 .* \\GRADE B RAW a » 30 ’ vy v 2004 & Tasty [& | 0 N TR |= : v | reo] Geos d SS Seen. Vo 3 ° 3 Sen 3 3 =n “ (p [% |x N PERCENT PASTEURIZED + 3, ¢ [Ea n 20{ XT |< \ 3.6le®1% [3 ITA oi 3 I5v Rand . INTS PER _CARITA —ue— : IERIE MILK CONSUMED: FINES 8 3 RO aie. "Ei 3 § |4—-— , $d seis SN 3%: 13 If PERCENT GRADE B RAW SIE (3. WY 220 sh N » ard ss 0 0 0 ° —~ a 1925 1926 1927 1928 1929 FG. § sa1710170Y GpaH d1svg fo Laypnd ¢II 114 Health on the Farm and in the Village Pasteurization of milk, as in other rural areas, is very incom- plete. Gowanda leads with 67 per cent of its supply pasteurized, and Olean and Salamanca, with 39 per cent and 37 per cent, respectively, follow next. The ratio for the County as a whole is only 29 per cent. The most important step which could be taken for the elimination of milk-borne disease would be a vigorous campaign for more general pasteurization. The success of the Olean city milk program is so notable as to deserve special comment. Fig. § indicates its salient features. It will be noted that there has been (4) a steady gain in milk pro- duction per cow, (b) a steady gain in per capita milk consumption, (¢) a recent increase in dairies meeting scoring requirements, (d) a complete elimination of Grade B can milk, and (¢) a recent in- crease in pasteurized milk. . The results of bacterial analyses of milk made in the County Laboratory during the past six months are tabulated in Table 24. These results seem to the writer highly satisfactory, and particularly creditable to the county inspection service which has been functioning for only two years and yet has obtained results closely comparable to those following ten years work at Olean. Table 24. Bacterial content of milk samples tested in the Cattaraugus County Laboratory during the first six months of 1930. Mik Sorp Raw Mik Sop PASTEURIZED Before Pasteurization After Pasteurization oan | Bert Olean | EOF | Olean | Sestof No. Samples . 124 290 1 193 15 24 Under 10,000 . 31 35 24 32 100 60 10,000-24,999 33 29 32 21 20 25,000-49,999 21 19 20 20 20 50,000-99,999 11 9 11 12 100,000-249,999 3 4 5 8 250,000-999,999 1 4 3 8 1,000,000 and over . . . 0 1 2 4 Quality of Basic Health Activities 115 The campaign for the eradication of bovine tuberculosis, which has been carried on since the early days of the demonstration, deserves special mention and commendation. Prior to 1923, little or nothing had been done in this direction, but in that year 58,928 head of cattle were tested with 7.1 per cent reactors. Since that time, progress has been continuous. Altogether 14,366 reactors have been destroyed. During 1929, 41,356 cattle were tested and only 0.8 per cent reacted. It seems probable that, in the present year, the positive tests will fall under 0.5 per cent and make possible the admission of the County to the status of a modified accredited area. The appraisal score for milk and food sanitation suffers chiefly on account of infrequent farm inspection, low proportion of milk pasteurized and lack of systematic instruction of food handlers. Food Inspection. Inspection of food-handling establish- ments outside of the dairy industry has been carried on only in Olean by the inspector of the local health department. The conditions found are fair, but there is no attempt at systematic instruction in the principles of food sanitation, and the lack of facilities for personal cleanliness, inadequate provision for cleansing dishes and utensils and careless dis- posal of garbage were frequently noted. In Salamanca, where there has been no food-store inspection, conditions are worse. There is no local meat inspection in the County and no control of roadside stands. Incidentally, it may be noted that the labelling of wayside boarding places as “Approved Tourist Resorts” by certain commercial agencies is highly misleading, as there is no adequate inspection of such places. A problem of special sanitary importance is the condition of the cheese factories, of which there are a dozen or more in operation in the County during certain seasons of the year. These establishments are in grave need of reform. Several of them, when visited by our survey staff, displayed conditions which might be highly prej- udicial to the public health. 116 Health on the Farm and in the Village Epidemiology. The control of acute communicable diseases 2 is at present chiefly in the hands of Dr. T. P. Burroughs who serves as deputy commissioner and director of the Bureau of Communicable Diseases—an officer of excellent qualifications and capacity. It would seem desirable in the future to delegate his duties with respect to communicable disease control in a con- siderable degree to the part-time local deputies and this will no doubt be done as the program develops. Reporting of communicable diseases is reasonably satisfactory and record keeping adequate. Professor Hiscock finds the routine procedures of the Bureau well above usual standards and “in many respects model for a county health department.” Spot maps are well kept and an ingenious chronological case chart has been devised for displaying daily incidence in each town and village. The actual prevalence of communicable diseases in the County has been normal for the past six years, with the exception of the Olean typhoid epidemic of 1928. Both measles and whooping cough were somewhat high in 1928 and 1929. The consulting diagnostic service is an active one and is worthy of special commendation. Nursing visits are adequate, although it is unfortunate that the county nurses do not keep their records so classified as to indicate the number of visits paid on account of each communicable disease. So far as procedures with regard to the individual diseases of major importance are concerned, typhoid fever, smallpox and scarlet fever are excellently handled. Special attention has been paid to typhoid carriers, of whom 22 were under supervision at the close of 1929. Following the 1929 epidemic of smallpox in Olean, a voluntary vaccination campaign resulted in the pro- tection of 89.5 per cent of the school children of the City—a highly creditable showing. Special mention should also be made of the special study of scarlet fever in Randolph (following an epidemic of 16 cases), which showed about half of the 145 persons subjected to the Dick test to be already immune and led to the active immunization of susceptibles. 2 Venereal disease has been discussed in Chapter VII and tuberculosis will be con- sidered in Chapter X. Quality of Basic Health Activities 117 Diphtheria control is one of the best tests of health department efficiency, since our recently developed methods of control place the complete elimination of this disease well within the range of possibility. Cattaraugus County has made a well-directed effort to deal with this problem and the prospect for success is improved by the very interesting fact which the county studies have brought out, that the age incidence of the disease is higher than in urban communities. About 60 per cent of the last 1,000 cases in the County were in persons over ten years of age. While this late incidence gives greater promise of control, it also makes control more costly, since it means that the child population is relatively less immune than is the case in more crowded areas. It is, there- fore, necessary to continue an immunization campaign up to the age of fifteen years. Toxin-antitoxin is distributed free to all physicians and they are paid a nominal sum (50 cents for three injections) for performing and reporting complete immunization. In addition, immunization clinics were organized very actively for a time. This work was intermitted in 1929 because of the burden placed upon the medical staff by the Olean typhoid and smallpox epidemics; and this intermission seriously affects the 1929 appraisal score for communicable disease control. During the first half of 1930, more than 2,300 children were im- munized. In general, over one quarter of the children of the County between the ages of six months and five years are now protected against diphtheria. Still more striking is an analysis of the data for Olean and for the rest of the County. In Olean, where the County Department has only recently exercised any real authority, only 4 per cent of the children in this age period were protected against diphtheria on January 1, 1929. For the rest of the County, the protected proportion was 35 per cent. This is an admirable demonstration of the value of the county pro- gram. During the present year, Dr. Johnson, the health officer of Olean, has been attacking the problem with vigor. Hospitalization for communicable diseases is accomplished when believed necessary in Buffalo or Jamestown, as there are no facilities within the County. Dr. Atwater believes conditions 118 Health on the Farm and in the Village in this respect to be satisfactory, but one wonders whether 17 cases of diphtheria, 70 cases of scarlet fever, and 53 of smallpox can have been isolated at home (as was the case in 1929) with complete satisfaction. This item (apparently deficient hospitalization) and the small amount of diphtheria immunization in 1929 are the only debits against an otherwise standard appraisal score for communicable disease control. The Laboratory. The County Laboratory has been one of the chief items in the demonstration program from the beginning and it has developed phenomenally since 1928. The Laboratory occupied two rooms in the City Building at Olean which were crowded and inadequate, but this condition was remedied with the removal of the county offices to the new Health Center Building. The staff consists of an experienced full-time director, two technicians and a clerk. During the past two years, the increase in volume of work performed at the Labora- tory has been most gratifying. There were 9,020 examinations made in 1927, 15,753 in 1928 and 18,631 in 1929. ‘This is due in part to the introduction in 1928 of routine water analyses, to a marked increase in milk analyses and to the offering of a num- ber of new services to physicians, including chemical examina- tions of the blood for uric acid, creatin, chlorides, calcium and phosphorus, animal inoculations for tuberculosis, tests for viru- lence of diphtheria bacilli and pneumococcus typing. Some of the more important additions to the routine made during 1929 include: the performance of a Kahn test parallel with Wasser- mann tests on bloods submitted for examination for syphilis; the examination of bloods submitted for syphilis and typhoid fever, for undulant fever, both by agglutination and complement fixation tests; the examination of diagnostic diphtheria cultures for the organisms of Vincent’s angina and for hemolytic strep- tococci; a more intensive study of atypical organisms isolated from intestinal discharges of persons suspected as clinical cases of enteric disease or of being carriers of such diseases; the examina- tion of milk samples for the presence of lactose fermenting organ- Quality of Basic Health Activities 119 isms, the estimation of total solids and the preparation of sedi- ment discs from all samples of market milk. It would be very difficult to find a county laboratory rendering such varied and admirable service. ‘The work is excellently balanced, 83 per cent of all examinations relating to direct control of communicable diseases and environmental sanitation, as compared with an aver- age of 14 per cent for sixteen other county laboratories receiving state aid in 1927. The largest items are syphilis (28 per cent), milk (17 per cent), water (14 per cent), and typhoid (10 per cent). Altogether one specimen was examined in 1929 for every seven persons in the county population and one examination was made for every four persons in the County. Thirty-five specimens were examined for every case of diphtheria and 51 for every case of typhoid. The great value of the laboratory service to the medical profession may be gauged by the fact that, during the first quarter of 1930, 82 per cent of the physicians of the County made use of the Laboratory. Out of 1,247 com- municable disease specimens examined during this period, 1,037 were made for private physicians and of 593 clinical tests, 428 were for private physicians. A particularly commendable phase of Dr. Kline’s activities is the active interest shown by the laboratory staff in research problems. Under severe limitations as to time and equipment, excellent work has been done on the prevalence of undulant fever (which appears to be present, but not to a great extent, in the County), on typhoid carriers, on the bacteriology of swimming pools, on obscure gastro-intestinal infections, and on the part played by salamanders in contributing colon bacilli to spring water supplies and thus resulting in misleading apparent evidence of pollution. The cost of the laboratory service, 15 cents per capita, as has been pointed out in an earlier chapter, is high according to the American Public Health Association standards. These standards are, however, based on 10,000 examinations a year per 100,000 population while Cattaraugus made 18,000 examinations for 120 Health on the Farm and in the Village 72,000 people. ‘The cost per specimen in 1929 was 93 cents and the cost per examination 61 cents, which are entirely reasonable figures, in view of the variety and quality of services rendered. Costs per examination in seventeen New York laboratories (courteously furnished by Dr. Ruth Gilbert of the State De- partment of Health) range from 34 cents to more than two dollars per specimen, depending on type and volume of work performed. In five of these laboratories the cost per capita is lower than in Cattaraugus; in two, the same; in nine, higher. The cost per specimen is lower in nine and higher in seven. The State of Connecticut is very proud of having reduced its cost from $1.29 to $0.49 per examination. The success of Cat- taraugus (a much smaller laboratory) in cutting its cost from $1.05 in 1926-1927 to $0.56 in 1929-1930 is equally notable. The high per capita cost is, therefore, due wholly to the fact that the Cattaraugus Laboratory is providing an unusually fine service. It is an institution of which the County may be proud. Vital Statistics. ‘The vital statistics work of the County De- partment is ably conducted by Miss Frances King and in every respect fulfils the standard of accepted practice. This activity has received a perfect appraisal score for the past three years. The filing of copies of all birth and death records with the County Department of Health under the 1925 law marks an immense step forward as compared with the old plan under which records were available only at Albany or in 41 local registrars’ offices. Cross- checking, tabulation and graphic charting of statistical data are all carried on in the most approved fashion. A particularly valuable feature of Miss King’s bureau, which does not appear on the face of the record, is that she serves not merely as a statistician but as a sort of general intelligence officer for the whole Department. Our survey staff was constantly impressed by the celerity with which she produced or obtained data on all sorts of subjects from inside and outside the department files. Such an official is an invaluable asset to any department. Summary. So far as general sanitation is concerned, the out- standing fact is the recognition (if somewhat tardily) of this Quality of Basic Health Activities 121 problem by the appointment of a qualified sanitarian on the County Health Department staff. He has made an excellent beginning of a very difficult task. Over $400,000 was spent by various local authorities in the County during 1929 for improve- ments in water supply and sewage disposal. The public water supplies of the County, like those of many rural areas, have been in a highly dangerous condition as evidenced by epidemics of typhoid and diarrheal diseases during the past two years. The Sanitary Engineer has attacked this problem with vigor and is making real progress. In our judgment 44 per cent of the population of the County are now provided with thor- oughly good public water supplies, 16 per cent with public water supplies which are still open to danger and 40 per cent with private wells and springs, many of which are seriously pol- luted. The safeguarding of private supplies in a region with the geological structure of Cattaraugus is a difficult task. ‘The writer believes, however, that vigorous efforts should be con- tinued to secure the protection of the public supplies which are open to possible pollution, by the installation of permanent chlorination or by some other means. Conditions with regard to sewerage, sewage disposal and gar- bage and refuse disposal are normal for a Northern rural area. Sanitation of camps, particularly in the State Park, however, is a problem which seriously demands attention. Milk sanitation is making good progress, both in Olean and in the County as a whole, and bacterial results are most encour- aging. The campaign for the eradication of bovine tuberculosis is progressing very favorably. Special stress should, however, be laid on increased pasteurization, which alone can yield a really safe milk supply. ' In the control of food handling in general, Olean has made a beginning, but much remains yet to be done here and elsewhere. The sanitation of cheese factories is a problem demanding serious attention. It seems clear that, in order to do its work most effectively, the Bureau of Sanitation requires one additional inspector, to 122 Health on the Farm and in the Village strengthen the dairy inspection, to develop control of food stores and roadside stands, and to improve water supplies and privies in the rural areas. Communicable disease service is well organized according to the best modern standards; and the consultation service rendered to private physicians is particularly commendable. The small- pox epidemic at Olean in 1929 was well handled and the result- ing voluntary protection of 89 per cent of the school population, most encouraging. The diphtheria immunization program which has led to the protection of a quarter of the children between six months and five years of age of the County (over one-third outside of Olean) has been successful and should be actively prosecuted. The Laboratory is altogether admirable, rendering an unusu- ally large volume of service of high quality and making itself most valuable to the private practitioners of the County. The spirit of research manifested by the staff deserves special praise. The Bureau of Vital Statistics performs all the routine func- tions well above the level of standard practice and renders an unusual and highly valuable service as a sort of general intelli- gence department for the county health service as a whole. It may be noted here that the annual reports of the Commis- sioner of Health do not present the vital statistics for the year in as full detail as would be desirable. Rates are tabulated in his general analysis for only nine principal causes of death. It would seem worth while to add at least some of the standard tables for annual reports outlined in the American Journal of Public Health, Vol. XX, page 34 (January, 1930). CHAPTER X TUBERCULOSIS * The General Program. As in the case of the earlier Framing- ham demonstration, control of tuberculosis has from the begin- ning been a primary objective of the Cattaraugus County health program. Prior to 1923, Cattaraugus had already done more than the average county in dealing with this problem and this fact was one of the reasons which led to its selection as a demonstration area. It had had a sanatorium since 1916, with a nurse who did a modest amount of home bedside care and home follow-up but whose activities were seriously limited by the enormous area to be covered. The sanatorium director held clinics, weekly at Olean and at irregular intervals in various other parts of the County, but in 1920 and 1921 these clinics averaged only 52, with a total attendance of 235. Scarcely any of the cases seen at the clinic were referred by practising physicians and no X-ray facilities were generally available. While in advance of many rural counties, the machinery was, therefore, woefully inade- quate for the task at hand. The following program was outlined at the inception of the demonstration in order to meet the needs of the situation in a comprehensive fashion. (“Experience in Finding Tuberculosis Cases in Cattaraugus County,” S. A. Douglass and W. C. Jensen. Read before the Twenty-second Annual Meeting of the National Tuberculosis Association, Washington, October 7, 1926.) 1 This chapter is in part based upon the special report of Dr. H. R. Edwards on medical aspects of the Cattaraugus County program. 123 124 Health on the Farm and in the Village (1) An intensive case-finding campaign having for its object the medical examination of: (a4) Known cases of tuberculosis. (b) Suspects. (¢) Contacts. (d) Persons suffering from other diseases which are susceptible to control by public health procedures. (e) Persons living under conditions likely to decrease their re- sistance to tuberculosis. (2) Provision for adequate medical and nursing care of positive cases; for home medical care of the tuberculous poor, including visiting nursing, and consultation service to the tuberculous in codperation with their private physicians. (3) Measures including post-graduate training for physicians and nurses and popular health education for the population as a whole, to improve the general knowledge of the prevention of infection. (4) Follow-up service, promotion of medical examinations, and the continuation of medical care for patients having tuberculosis, and for instruction to families of the tuberculous in methods of preventing the spread of the disease. (5) Measures to stimulate the use of available sanatoria and to in- crease their facilities if necessary. (6) Provision for rehabilitation. In order to carry out the above program the following organi- zation was projected: (1) An administrative service for the general direction of the tuberculosis program and for the coérdination of various measures and facilities for the control of the disease. (2) Regularly scheduled diagnostic clinic service directed toward the discovery of all positive cases, periodic reéxamination of such cases, in codperation with the attending physicians, and intensive diagnostic study of all suspects and contacts. (3) Consultation service available to the physicians of the County at all times, either in their offices, at the clinics, or in the patients’ homes. (4) X-ray service available at the clinics or in the patients’ homes. (5) Laboratory service furnished by the County Laboratory. (6) School medical service having for its object the examination of : (@) School children who are more than 10 per cent underweight. Tuberculosis 125 (b) Habitual absentees. (c) Children referred by school physicians or nurses, because of suspicious symptoms or physical findings. (7) Public health nursing service operating from each of the dis- trict stations providing for home visiting for cases undergoing home treatment, educational measures for the family, and thorough follow-up study of contacts and suspects, instruction in nutrition under the super- vision of a nutrition specialist. (8) General popular health education through the means of news- papers, distribution of popular health literature, lectures, moving pic- tures, et cetera, to promote early diagnosis, popularize annual examina- tion, and otherwise educate the public in public health. (9) Social welfare service to insure adequate relief of the tuberculous poor and aid in other social problems. This sound but ambitious program has been carried out with reasonable completeness and with conspicuous success. At its height, the central organization included a medical director and an assistant director, a supervising nurse and a clerk, in addition to the nursing staff of the Sanatorium and the service of the county and local field nurses. It was expected, of course, that a more complete organization would be needed in the initial stages than at a later date, and the assistant medical director and supervising nurse have now dropped out of the picture, Dr. J. H. Korns serv- ing as superintendent of the Sanatorium and also as director of the Bureau of Tuberculosis of the County Department of Health with only one clerical assistant at headquarters. So far as nursing is concerned, it seems to the writer that the generalized county staff —once the program has been outlined and organized by a special- ized supervisor—should be able to carry on and is, as a matter of fact, carrying on with reasonable efficiency and that the perma- nent employment of a specialized supervisor would not be justi- fied. The question whether one physician can, single-handed, conduct the Sanatorium, the routine work of the Bureau, the clinic service and the special studies now being made at Ellicottville is a more serious one. The provision of a medical assistant to Dr. Korns would seem essential, if the work is to be well performed and the director protected from an undue burden. Since the 126 Health on the Farm and in the Village Ellicottville studies are in the nature of fundamental research, outside aid could properly be sought for this purpose. Clinic and Consultation Service. The basic element in tuber- culosis control is prompt case-finding; and excellent machinery for this purpose is provided by Dr. Korns’ clinic and consulta- tion service. Clinics were held in 1929 at eight district stations, with 114 clinic sessions and 1,394 examinations. Clinics are for diagnostic purposes only and are open to all who may present themselves, whether residents of the County or not. Patients under the care of a private physician are not, however, received without his permission. A portable X-ray machine is used. Eight hundred and four visits were for first examination and $90 for reéx.- amination. The volume of work has not fluctuated widely since the first peak of new cases in 1924 and 1925 was passed. During the seven years of the demonstration, 8,528 persons have been examined at these clinics (12 per cent of the total population of the County). The service now rendered is of high quality and it is particularly significant to note that 1,099 X-rays were taken in 1929 for the 1,394 examinations, a proportion far in ex- cess of that recorded for earlier years. It is also very gratifying to find that 50 per cent of the cases positively diagnosed at the clinics were referred by local practitioners. In the earlier days, the nurses and general publicity supplied most of the cases, and the develop- ment of reference by practitioners is an encouraging sign, both of their increasing awareness of the problem of tuberculosis and of their confidence in the county clinics. Dr. Korns also offers to all the physicians of the County a con- sultation service, either in the doctor’s office or in the home of the patient, and, in 1929, 80 such consultations were held for 71 patients at the request of 25 different physicians—another en- couraging indication of medical progress and medical codperation. Results with Regard to Case-finding. The Framingham dem- onstration taught us that in an average community there are actually probably some 9 active and 9 arrested cases of tuberculosis per annual death and the ordinary standards of actual adminis- Tuberculosis 127 trative practice call for the discovery of two new cases per annual death as a reasonable minimum of attainment. The actual ratio in Cattaraugus has averaged 3.5 for the past four years. In 1929, there were 74 new cases of pulmonary tuberculosis re- ported, with 61 cases of other forms (of which 33 were classed as of childhood type). Table 25. Ratio of total cases of tuberculosis on the roster to annual deaths in Cattaraugus County 1922- 1929. AS GISTERED YEAR A a 1922 3 1923 6 1924 9 1925 13 1926 16 1927 19 1928 19 1929 18 The total figures (Table 25) closely approximate those obtained at Framingham, but the division as between active and arrested cases is widely different. Instead of 9 active and 9 arrested cases per annual death, we find, according to the Cattaraugus records, 3 active and 14 arrested cases per death (considering “active”, “quiescent” and “activity undetermined” all as active cases). This ratio seems a fallacious one, as will be indicated by the fol- lowing considerations. In 1929, there were 654 cases carried on the roster of the De- partment, of which 378 were classed as “apparently cured”, “latent” or “apparently well”. Of the remainder, 155 were “ar- rested” or “apparently arrested”, leaving 121 in the “active”, “quiescent” and “undetermined” groups. Prior to 1928, the cases now carried as “apparently cured”, “latent” and “appar- ently well” were all classed as “arrested”—the “arrested” cases in 1926 and 1927 making up between 50 and 60 per cent of the total on the roster. Dr. Korns has very wisely been undertaking a 128 Health on the Farm and in the Village gradual transfer of “minimal arrested” cases from the “arrested” to the “apparently cured” group, so that patients well and at work for two years might be relieved of burdensome supervision and nurses relieved of needless work. Dr. Herbert R. Edwards, director of the Bureau of Tubercu- losis of the City Health Department of New Haven, in a careful analysis of a considerable series of case records, has raised serious doubts as to the accuracy of the diagnosis of many of the cases carried on the Cattaraugus County roster as arrested tuberculosis. The question at issue is essentially the soundness of classing as “minimal arrested” or “cured”, cases in which some tuberculous infection has perhaps existed (as it does in most of us) but which present no clear presumptive evidence of ever having suffered from anatomical or clinical disease. This question is fundamental in many other phases of public health as well as in tuberculosis and is, of course, related to the inevitable tendency of the specialist to emphasize the gravity of the problems with which he deals. It seems clear that the tuberculosis diagnosticians in the earlier years of the Cattaraugus demonstration were far too liberal in their diagnostic interpretations and that the ratio of 14 arrested cases per annual death is too high. Dr. Korns has been wise in gradually purging his roster of doubtful cases, but it seems highly advisable to make a systematic analysis of the entire roster with the purpose of wholly eliminating cases in which there is insuffi- cient basis for a positive diagnosis of biologic or anatomical tuberculosis. From a practical public health standpoint, the great thing is to find the cases which need attention and this has been accom- plished with marked success in Cattaraugus. The registration of cases which are really not cases of tuberculosis at all should, however, be rectified so that the findings of the demonstration may have their full scientific value. Tuberculosis Nursing Service. ‘The search for cases and con- tacts, the follow-up of clinic cases and discharged sanatorium cases, and the supervision and bedside care of cases in the homes is carried on, as we have seen by the generalized county nurses, in Tuberculosis 129 the rural areas, and by a specialized county nurse in Olean. A special nurse cares for the Indians as a part of a generalized program and the local nurse in Gowanda does some tuberculosis work. The amount of tuberculosis nursing performed exceeds the usual standards (2,092 home visits to diagnosed cases in 1929 and 2,353 visits to suspects and contacts, with good control of post-sana- torium cases). On the whole, the nursing service for tubercu- losis seems exceedingly good, particularly in view of travel diffi- culties during the winter and spring months and in view of the discontinuance of specialized supervision. The records made of the work are frequently inadequate, however, although the nurse in charge of a case usually has all necessary facts at her dis- posal. The visiting schedule might be made somewhat more flexible. An interesting advance made last year was the introduction of “contact books” for the nurses. These books were prepared in the central office and placed in the hands of the nurses at each station, containing all household contacts with present or past active cases of tuberculosis known to exist in each nurse’s district. For each contact, name and age and source of exposure are set down and it is hoped to obtain from the nurses a record for each individual of all follow-up procedures, including date, nature and result of reéxamination or reason for failure to secure such examination. There were listed 1,225 such household contacts (excluding Indians and residents of Gowanda village) and of these, 575 had been brought to clinics for examination up to December 31, 1929. This seems an admirable procedure. In the past the search for contacts has not been as active as would seem desirable. The home-treatment plan, which was announced in 1925, was apparently never really launched and when Dr. Korns became director of the Bureau of Tuberculosis in 1928 he definitely abandoned it as essentially impractical. The fact that by this time the pressure on facilities for sanatorium care had been re- laxed (occupancy at Rocky Crest fell from 92 per cent in 1927 130 Health on the Farm and in the Village to 77 per cent in 1929) made any unusual emphasis on home treatment unnecessary. At present, home care is given under about the same conditions and to about the same extent as would obtain in any other well-ordered tuberculosis program. On De- cember 31, 1929, there were 49 cases in the Sanatorium against a total of 121 active or quiescent cases in the County. Dr. Korns has been good enough to prepare for us a fairly complete record of the 85 active and quiescent cases on the roster June 30, 1930, not at the moment under sanatorium care. Thirty of them have had previous sanatorium care. They seem to the writer to divide themselves approximately as follows: Cases living under good home conditions and doing well. Do not need sanatorium care at present 44 Cases under good home care but in which sanatorium care might be advisable 12 Cases which should be under sanatorium care 29 Total 85 The 29 patients who are clearly not receiving adequate care may be further classified as to the reason for failure to enter the sanatorium as follows: Psychological block on part of patient 19 Opposition of private physician + Economic factors 3 Home responsibilities 3 ‘Total 29 Sanatorium Care. Rocky Crest, the County Sanatorium, has been developed to a capacity of 50 beds, well in excess of the usual standard of one bed per annual death. Long antedating the demonstration period, the building is, of course, not a modern one and its physical facilities are by no means ideal. Its location in one corner of the County makes it less generally convenient of access than if it were placed more centrally, but the fact that it is Tuberculosis 131 within five miles of Olean, the largest unit of population, is of ad- vantage. Indeed, if it were not near Olean the present close cor- relation with the work of the County Board of Health would be difficult of attainment. The discontinuance of a once-existing trolley service makes it accessible only by automobile. The de- velopment of bus service along this highway is, however, a possi- bility of the future. The medical service given at the Sanatorium is of high quality although the appointment of a resident medical assistant to Dr. Korns would be highly desirable. The services of seven well- qualified medical consultants are freely utilized. Excellent use is being made of pneumo-thorax and other routine surgical pro- cedures, but in the past there has been difficulty in securing cer- tain types of specialized surgery. The county authorities have recently made available a sum of $1,500 for 1930 for advanced surgery and other corrective measures needed by county residents at Rocky Crest—an admirable step which will go far to meet this need. The nursing personnel consists of a superintendent and three assistants. There is a department of occupational therapy and a school teacher for the children. The hospital reached its present capacity of 50 beds in 1926 and the utilization of bed capacity has been as follows: 1926, 89 per cent; 1927, 92 per cent; 1928, 83 per cent; 1929, 77 per cent. The facilities seem, therefore, quantitatively fully ade- quate in view of the apparently decreasing incidence of tubercu- losis in Cattaraugus; and during the past year the Sanatorium has been opened to patients from outside the County. There were 72 admissions to the institution in 1929, 30 per cent of the persons admitted being under 16 years of age. The percentage of cases at Rocky Crest classed as minimal has for the past five years varied between 23 and 28 per cent, but of these minimal cases the great majority are of childhood type. On account of the relatively low proportion of minimal adult cases, the appraisal score suffers a loss of four points—the only deviation from a perfect score for tuberculosis control—since the American Public Health Association’s practice is to exclude the 132 Health on the Farm and in the Village childhood type in computing its scores. The writer believes that the present appraisal standard of 25 per cent incipient cases, ex- cluding childhood type, is an unreasonably high one. As Dr. Edwards points out, the percentage of minimal cases in most sanatoria is tending to lessen where an active tuberculosis pro- gram is carried on and the record of Rocky Crest in this respect compares very favorably with the general experience of other sanatoria accepting all classes of tuberculosis from a given area. The average length of stay of 62 patients discharged in 1929 (excluding eight who had been in the Sanatorium for an average of four years apiece) was 138 days. During this year there were 38 out of a total of 70 cases discharged after a period of less than four months and the records of 36 of these 38 cases were analyzed in detail to determine the reasons for this early discharge. It appeared that in 28 of the 36 instances there was an entirely sound reason for discharge (death, 4; transfer to some other hospital for special treatment, 5; diagnosed as non-tuberculous, §; latent childhood disease suitable for home supervision, 4, et cetera), while only 8 cases left against advice. Economic or household needs accounted for 4 of these cases, and in 3 of them the patients are reported as doing well. In the other 4 instances the discharge was due to wilful lack of cooperation on the part of the patient and three of these four have since died. It appears, then, that the number of patients discharged against advice was not ex- cessive (11 per cent of total) and that the reasons for such dis- charge were quite outside the control of the institution. Altogether, it seems that the Sanatorium, with physical facili- ties which are not ideal and with serious limitations of staff, is doing a highly creditable piece of work. Open-air Classroom and Health Camp. There is no preven- torium as such in the County, but an open-air classroom at Olean and the Health Camp maintained by the County Tuberculosis and Public Health Association materially help to meet this need. The open-air classroom at Olean has an attendance of 30 chil- dren for an average period of six months and is provided with all Tuberculosis 133 necessary facilities for midday meals, rest periods and special cur- riculum activities. The Health Camp has now been operated for seven years and is one of the notable contributions of the Tuberculosis and Pub- lic Health Association to the welfare of the County. The Camp is well located in the Allegany State Park. The children are be- tween 6 and 12 years of age. They are given a thorough physi- cal examination before entrance and necessary corrections are made of physical defects. There is a nurse on duty at the Camp and a nutrition program is carefully planned. The children are weighed once a week and special attention is given to postural defects. During the year 1929, 125 children were admitted of whom 86 remained for the full period of 42 days. It is un- fortunate that lack of funds made it necessary to cut the camp period down to 28 days for the year 1930. The Tuberculosis Program as a Whole. The program con- sidered as a whole seems to the writer a remarkable and an ad- mirable achievement. The difficulties inherent in the control of tuberculosis in a rural district, the obstacles presented by geo- graphical factors to case-finding, clinic attendance, the taking of X-rays and the like, the lack of familiarity on the part of many rural physicians with refined methods of diagnosing the disease, and the difficulties in the way of carrying health education to remote farms among the hills, have in most rural areas prevented any serious efforts to deal with this problem. Yet in Cattaraugus a program has been built up at very moderate cost which is in every way comparable with our standard urban programs. The fact that the public clinics are for purely diagnostic purposes is an- other factor limiting intensive control, but the policy under exist- ing local circumstances is no doubt a wise one. The clinic service actually provided is ample in quantity and excellent in quality. The taking of over 1,000 X-rays last year is a remarkable achieve- ment. The training of local physicians by special courses at Saranac and the development of an active consultation service are steps of far-reaching importance. Nursing follow-up and sanatorium care seem to the writer generally adequate and effec- 134 Health on the Farm and in the Village tive. ‘The appraisal score for tuberculosis control is 96 per cent and would be 100 per cent except for a minor technicality. What this accomplishment means may be better understood by comparison with achievements elsewhere. In Chapter VIII we have tabulated appraisal scores for five of those rural counties which have attained the fullest development of public health fa- cilities, and of these five none equals, and only two approach, the Cattaraugus attainment. Los Angeles County scores 88 per cent and Athens and Clarke County, Georgia, 91 per cent, while Monmouth County, New Jersey, has a score of only 80 per cent, Rutherford County, Tennessee, only 72 per cent and Marion County, Oregon, only 57 per cent. It seems probable that Cat- taraugus has attained a more highly developed tuberculosis pro- gram than is to be found in any other strictly rural area of the United States. It is this high degree of perfection attained with respect to com- monly accepted standards which invites the application of more stringent criteria. We progress only by rigorous self-criticism and Dr. Edwards was, therefore, asked to examine the records of the tuberculosis work in Cattaraugus with meticulous care and to criticize the quality of service rendered by more rigorous standards than have perhaps ever been applied. His criticisms must, then, be taken as in large measure applicable to our whole tuberculosis program everywhere. Dr. Edwards finds the plan of centralized tuberculosis control and the general set-up of the program admirable. Clinic service is excellently developed, making service more than usually ade- quate and sanatorium care of average quality. The two major limitations to present efficiency—not inherent in the rural situa- tion in general—are to be found in the location, construction and equipment of the fourteen-year old sanatorium and in the fact that the entire medical work of both sanatorium and county tuberculosis bureau must be carried by one individual. Lack of the fullest possible codperation on the part of the medical profession and the public hampers progress in Cattaraugus, as elsewhere, but, to judge from the proportion of cases referred to Tuberculosis 135 clinics by physicians and the use of Dr. Korn’s consultation service, the local medical profession is more codperative than in most communities. Dr. Edwards finds distinct evidence of haste and lack of thoroughness in the tuberculosis work of the earlier years of the demonstration. The X-ray films were often of poor quality and, according to the evidence in the files, there were distinct deficiencies in clinic reéxamination, in nursing follow-up, in the making of sputum tests, and in pursuit of contacts and tuber- culin testing. In part, these apparent deficiencies are no doubt due to the fact that clinic, sanatorium and nursing records made during the early years were found to be notably deficient in es- sential information. It is difficult, however, to escape the con- clusion that in the first phases of the demonstration there was an undue pressure to perform a large volume of work and that funda- mental details were omitted. It may be argued that this was a wise policy and that, in dealing with so vast a problem, greater net results were obtained at first by extensive rather than by in- tensive methods. In any case, the vast majority of these faults have now been remedied and under Dr. Korns the general standards of work are high. Perhaps the most significant of Dr. Edwards’ findings lies in his criticism of the policy followed in the earlier years of classing as “arrested” tuberculosis cases with latent infection but no pre- sumptive evidence of past or present anatomical or clinical disease. This subject has been discussed in an earlier paragraph, but the lesson involved—that of the fallacy of “over-diagnosis”—is one that public health workers in this and other fields may well take to heart. Results of the Cattaraugus Tuberculosis Program. The actual results of the tuberculosis program may be judged from several distinct angles. A. Mortality. The tuberculosis death rate in Cattaraugus County was unusually low for a New York rural area at the beginning of the demonstration period. From 1915 to 1924, it averaged 69 per 100,000 and varied only from a minimum of 136 Health on the Farm and in the Village 54 to amaximumof 76. In 1925, it took a sharp drop and for the past five years has averaged 49 and varied only from 47 to 51. This drop represents a statistically significant deviation from the previous trend. Furthermore, the list of tuberculosis deaths in recent years has been notably swollen by an unusually large pro- portion of deaths attributed to this cause, but which in all proba- bility were in no way related to it (see later paragraph). B. Later Age Incidence. Comparing the period 1916-1924 with the period 1925-1929, we find the following striking change in age incidence (Table 26), a characteristic phenomenon of all successful programs for the control of this disease: Table 26. Percentage change in the age incidence of deaths from tuberculosis per 100,000 popula- tion in Cattaraugus County, in the period 1925-1929 over the period 1916-1924. CHANGE IN AGE PERIOD MORTALITY RATE (PER CENT) 0-4 + 341 5-9 — 81 10-19 — 69 20-29 — 53 30-39 — 38 40-49 — 14 50-59 -31 60-69 + 13 70 and over + 44 1 Numbers in this group very small. C. Reduction in Active Cases. During the past four years there has been a marked decrease in the number of known cases in the County of the significant types classed as “active”, “quies- cent”, “activity undetermined” and “apparently arrested” as in- dicated below: 1926 252 1927 250 1928 184 1929 132 y 121824 30 36 42 48 4212835424956 1 3 1624 32 4048 56 L 182736455 ° 5 ' Tuberculosis 137 D. Reduced Demand for Hospitalization. We have noted that the occupancy of Rocky Crest has fallen off very definitely during the past three years and Dr. Edwards has brought out the interesting fact that Chautauqua County, with about the same tuberculosis death rate as Cattaraugus, fills nearly twice as many beds per 1,000 population as Cattaraugus County can. From the standpoint of mortality, then, we find a most en- couraging and significant decrease in Cattaraugus County, while from the standpoint of morbidity an even greater improvement is apparent. The Future. The most challenging fact about the whole situa- tion is that the death rate, having dropped sharply in 1925, has maintained its new level without further decrease for the past five years (and the same rate holds for the first six months of 1930). During this same five years, all the evidence available as to case incidence tends to show that morbidity has been steadily decreasing, while the death rate has remained steadily close to 49, with the inexorability of a law of nature. ‘Today we are faced with the phenomenon of a ratio of 3 active cases per annual death when we should expect a ratio of 9, in an area where case-finding has been prosecuted so intensively. Such a condition might be ex- plained as due to failure to find cases actually in existence, but this possibility is negatived by all the information at our disposal. It seems more probable that the present death rate is the result of factors long in operation and that the actual accomplishment in the reduction of morbidity has been greater than in the reduction of mortality. If such be the case, the death rate will inevitably show a corresponding reduction at some later date. At the moment we are confronted with the fact that, even in face of the excellent control machinery of Cattaraugus County, 35 to 40 people each year die of tuberculosis. Each death from tuberculosis means a failure somewhere in our scheme of pro- tection. It is a definite challenge to us to ask ourselves, “How did this happen and what could have been done to prevent it?” Every death in Cattaraugus County is studied by Dr. Korns from this angle and his excellent monthly summaries make it possible to answer this question in a relatively satisfactory way. 138 Health on the Farm and in the Village In the first place, it may be noted that, of the 37 cases dying in 1929, 2 were non-residents who had been in local hospitals for a few weeks, and 2 more, while residents, had lived in the County less than two years. Two more were Indians notoriously dif- ficult to deal with. Four were Poles. Three had been exposed to a serious silicosis hazard, one as a granite cutter and two in a cutlery factory at Franklinville. Ten cases were reported only after death. An analysis of the case histories would lead to the belief that, of the total of 37 cases, 9 were cases in which it is extremely doubtful whether tuberculosis played any significant réle. Four of these were rather sudden deaths in which diagnosis was made just be- fore or after death and 5 were deaths of persons over 70 years of age in which the part played by preéxisting tuberculosis was highly problematical. Incidentally, it may be noted that one other case, probably really dying of tuberculosis, was over 70. The total of 6 deaths out of 37 at ages over 70 is in itself the strongest indication of erroneous diagnosis. In any case, if these deaths—or any large proportion of them—were due to tuber- culosis, there was nothing in their symptoms which could have justified public health action. Of the remaining 28 cases which resulted fatally, 14, or just half, were cases in which it seems clear to the writer that there were no obvious delays in diagnosis and no failure to coéperate on the part of patients. These are the sort of cases which either manifest themselves rather suddenly, without evident warning, in a grave condition or else proceed to a fatal termination in spite of reasonably adequate treatment. With such cases our pres- ent machinery is inadequate to deal and only the systematic examination of school children and the checking of child- hood tuberculosis, with elimination of industrial hazards and mitigation of poverty, will probably give us any real control of them. Of the remaining 14, 4 were cases in which the failure of physicians to make an early diagnosis would seem to be an im- portant contributory cause of death. Finally, there were 10 Tuberculosis 139 fatal cases in which the chief obstacle to cure lay in the patient’s refusal to receive or to continue sanatorium treatment or in failure to observe a proper régime at home. Two of these were Poles and one an Indian. There seems to have been no neglect in any of these instances of the ordinary public health machinery. Clinic and sanatorium service were available and public health nurses made vigorous efforts to secure codperation. ‘The only resource in such instances is an application of the art of mental hygiene in fuller degree than has been possible in Cattaraugus (or anywhere else). Some day in the future, applied psychiatry will perhaps eliminate the word “uncodperative” from nursing and sanatorium records. It would, of course, be unjustifiable to stress this small series of cases, but it seems probable that the three factors listed, failure on the part of physicians to make a possible diagnosis, lack of codperation on the part of patients and development of an in- sidious infection which cannot be controlled at the time of ap- pearance (but which might have been detected and controlled by routine medical examination years before) are the chief factors which limit our success in communities with adequate standard machinery for the control of tuberculosis. The first of these factors, failure of physicians to make an early diagnosis, is perhaps less important in Cattaraugus than in most other communities. ‘That it is still of real importance is indicated by the fact that out of a series of 50 cases reported by physicians, 20 died within a year of report. Of 43 cases studied by Dr. Edwards in which the date of first symptoms could be ap- proximately determined, only 9 were reported to the health authorities within one year of the manifestation of symptoms and in 7 instances the period elapsing was ten years or more. It seems probable, however, that our present standard machinery for case-finding will never result in the reasonably complete con- trol of tuberculosis on account of the type of case referred to above, in which a latent infection suddenly flares up in a degree too serious to be easily checked. We may by the present methods reduce the tuberculosis death rate to 50 or 40, perhaps in fortunate 140 Health on the Farm and in the Village communities to 30, per 100,000. To go much further than this we must probably change our tactics. The standard procedure has centered about the positive case and has limited itself largely to the contacts of that case. It was the logical first step and has yielded admirable results. If we are to go much further, it must probably be along a different line. We must take the enemy in the rear by systematic tuberculin testing and X-raying of school children, according to the Massachusetts plan, and in this way we may hope to find and check the latent infections which manifest themselves in later life. The process will be very costly and very slow, but it is our next task in the control of tuberculosis. Dr. Korns has already begun active work along this line and the furtherance of this work should be the crowning achievement of the Cattaraugus tuberculosis program. A considerable number of rural schools in Ellicottville and vicinity, in Great Valley and Little Valley, South Dayton and Limestone, have already been covered and 510 children examined, representing 30 to 40 per cent of the total enrollment. The only limitation lies in the willingness of parents to permit the making of the tests. The results are encouraging for Cattaraugus County and highly significant in connection with our whole theory of tuberculosis, since the number of reactors is so much lower than that reported in surveys elsewhere. Only 54 of these 510 children reacted to tuberculin, the percentage of positives rising from 0 under § years of age to 8 per cent between 6 and 9 years, 10 per cent between 10 and 14 years, and 17 per cent between 15 and 19 years. As in the case of scarlet fever and diphtheria, infections in this rural area are relatively rare and delayed. For the County as a whole (including clinic cases only) 16 per cent of children under 16 from homes where there was no exposure to open tuberculosis reacted, as compared with 70 per cent for children from homes where there was a known sputum-positive case of the disease. One minor point of interest concerns tuberculosis of non- pulmonary type. The ratio of nonpulmonary to pulmonary tuberculosis deaths is rather high (10 per cent), but of a consider- able series of such deaths studied only 2 per cent proved to be in Tuberculosis 141 children under 15 years of age. The usual expectation would be about one-third of all nonpulmonary deaths at this age period. Finally, a word should be said as to three special factors which complicate the Cattaraugus tuberculosis problem in somewhat peculiar degree. These factors are the presence of some thousand Indians and about the same number of persons of Polish race stock (both groups characterized by poor living conditions and high tuberculosis rates) and the existence in the County of several factories where the danger of tuberculosis is greatly en- hanced by exposure to silica dust. The most hazardous of the latter appears to be the knife factory at Franklinville which con- tributed two deaths out of the county total of 37 last year. The County Department of Health has attempted to secure physical examinations of the workers in this factory, but, so far, without success. CHAPTER XI HYGIENE OF MATERNITY, INFANCY AND CHILDHOOD* Hygiene of Maternity. A modern program for the protection of child health must include provision by public authorities, un- official agencies and private physicians of organized health educa- tion and specific advisory and remedial medical service for the mother from an early period of pregnancy, at the time of delivery and during post-partum convalescence, and for the child through the period of infancy, preschool and school life. The hygiene of the school child was a part of the Cattaraugus demonstration from the beginning, but the hygiene of maternity and infancy was first seriously attacked (aside from its purely nursing aspects) in 1926 by the appointment of a full-time director of maternal, infant and child hygiene, Dr. Doris Murray. Dr. Murray re- signed in August, 1929, and financial limitations have prevented the appointment of a successor, so that the present program falls short of completeness and adequacy. Much machinery in the form of clinics, nursing service and health education has, however, been introduced and certain phases of the work are being prose- cuted with vigor and success. The achievements and short- comings of the program may be conveniently considered in the order in which problems chronologically arise in the course of the prenatal period and in the life of the child itself. Prenatal nursing service, to begin with, is extensively developed through the generalized staff of the local County Department of Health and through the work of the local nursing organizations. In the year 1929, the cases under prenatal supervision by all of 1 This chapter is in part based upon the special report of Dr. H. R. Edwards dealing with the medical aspects of the Cattaraugus County program. 142 Hygiene of Maternity, Infancy and Childhood 143 these groups of nurses amounted to 374 or 27 per cent of the total number of births, an excellent showing; 2,242 prenatal visits were paid by the county nurses and 1,009 by the nurses of the various local groups. The nurses’ schedule calls for monthly visits through the seventh month of pregnancy and fortnightly visits thereafter, as a minimum. The value of this educational service is somewhat minimized by the fact that the medical society has not approved the making of blood pressure tests by the nurses, a service which physicians elsewhere usually welcome and desire. The nurses do, however, collect samples for urine examinations; and their prenatal work is being more and more generally welcomed by physicians and laity as a distinct asset to the county program. Prenatal nursing service should, however, be closely connected with medical conferences for the prospective mother and this problem has so far remained unsolved. A prenatal clinic was con- ducted in 1927 for several months in Ellicottville, but the attend- ance was so small that the experiment was abandoned. Difficulty of transportation and the tendency of rural mothers to conceal the fact of pregnancy as long as possible appeared to be the chief obstacles. In 1929, nine lectures were given to pregnant women, and the district centers are provided with complete model layettes. The scheme of community protection must, however, remain seriously deficient until medical counsel during pregnancy is more generally assured. We have noted in an earlier chapter that hospital delivery service is provided in Olean and Salamanca and also by several small maternity homes in various parts of the County. The latter are inspected by the medical staff of the County Department of Health. Altogether, 34 per cent of all births in the County oc- curred in hospitals in 1929 (as compared with 26 per cent in 1925), but itis in the cities alone that hospital delivery is common. The Olean district shows the excellent rate of §3 per cent and the Salamanca district 43 per cent, while the rate for the rest of the County is only 6 per cent. There are § midwives in the County, but they attended only 15 births in 1929, while physicians at- 144 Health on the Farm and in the Village tended 1,275, leaving but 11 unattended (figures exclusive of Indians). The county nurses provided home delivery service and attended 46 cases in 1929, while the Olean nurses have recently in- augurated a similar service. Postpartum care is relatively un- developed, only 42 cases being cared for by the county nurses or under their supervision in 1929. All in all, prenatal service in the County scores 75 per cent on the appraisal score, the deficiency coming entirely under the head of medical conferences. The need for improvement is greater than such figures would suggest, however, as indicated by the following county statistics: A maternal death rate of 7.5 per 1,000 total births for 1920-1929 as compared with 5.7 for New York State, exclusive of New York City. A stillbirth rate of 35 per 1,000 total births for 1920-1929 (about the same as the state rate, 36, but far too high). A total of 8 puerperal deaths during the year 1929. The fact that, out of 70 deaths of infants under one year of age, 46 occurred during the first month of life, 42 during the first week and 23 during the first day. It may be noted, as a basis for the interpretation of these figures, that there were 1,328 live births and 43 stillbirths in the County in1929, Hygiene of Infancy. The program for the hygiene of the in- fant is better organized in principle than that relating to the pre- natal period, since medical conferences as well as nursing service are provided. These conferences have been maintained at the district stations and at other points in the County since 1926. During 1929 they were held at 11 centers, with periodic con- ferences in other villages and rural sections, making a total of 115 such conferences during the year. The conferences are staffed largely by local physicians and have recently been conducted on an appointment basis, which is an admirably progressive step. In 1929, there were 1,409 visits to these conferences, and 521 new cases registered, giving a rate of 2.7 visits per new case. The Hygiene of Maternity, Infancy and Childhood 145 work of the conferences is wholly advisory, no sick babies being received. Excellent educational exhibits are installed at the centers, showing suitable clothing and shoes for infants and pre- school children and good types of toothbrushes, illustrating how food should be selected for tooth-building, indicating how milk should be cared for in the home, and emphasizing the value of cod-liver oil and of sun baths. The medical work of these con- ferences impressed Dr. Edwards as of high order. The total attendance, however, is woefully small, only 434 visits of infants to conferences being registered in 1929, about one-eighth of the Appraisal Form standard (2,500 visits per 1,000 births). There were only 549 visits of infants to these conferences even in 1927 and the work has shown a marked falling off since Dr. Murray’s departure. Those clinics which are held are well attended and the only way to increase total attendance would be to hold more clinics. In Olean there are no medical conferences for infants, §7 con- ferences being held in 1929 by the nurses alone. This seems a fundamentally unsound procedure. Public health nursing service for infants has been carried to a very high level of excellence, the number of visits paid (5,160 visits to 500 infants) reaching more than double the Appraisal Form standard. ‘This is the most highly developed feature of the child health work in Cattaraugus County and it is chiefly to the educational work of the nurses that the excellent results attained must be credited. In one particular period, when a special effort was made in the rural section of Cattaraugus district, 57 out of 103 infants born were visited. The infant hygiene work only scored 72 per cent in 1929 (as against 77 per cent in 1928), the deficiency being due to the low volume of attendance at medical conferences. Nevertheless, chiefly we believe as a result of the excellent nursing service, the results attained in the reduction of infant mortality during the demonstration period have been most en- couraging. The infant mortality rate has dropped from an average of 81 for 1920-1924 to 61 for 1925-1929. Even more 146 Health on the Farm and in the Village striking is the decrease in deaths from gastro-intestinal diseases which averaged 21 a year for 1921-1923 and dropped to 11 for 1924-1926 and to 4 for 1927-1929. There is a clean saving here of 18 lives a year for each thousand live births. Hygiene of the Child of Preschool Age. Children of the pre- school age are wisely handled with their younger brothers and sisters at the infant welfare conferences which have been dis- cussed above. Attendance is relatively somewhat better than for the infants, including 733 visits in 1929. The volume of home nursing visits is very high (6,333), about 10 times the Appraisal Form standard. Altogether, the appraisal score for preschool health work is 100 per cent, but this item of the Ap- praisal Form is known to be based on rather low standards. Special mention should be made of the “summer round-up” which was organized in 1928 and which is carried out each year through the medium of the parent-teachers associations in order to secure corrections of the physical defects of children preparing to enter school in the fall and of the success in diphtheria immuni- zation of the preschool children discussed in an earlier chapter. Summary with Respect to Maternal and Infant Hygiene. In general, it appears that the public health nursing service for maternity and infancy is admirably developed and is yielding excellent results, particularly in reduction of diarrheal diseases. It seems to the writer that Dr. Edwards’ study of 44 families (in the County outside Olean) in which an infant death occurred during 1929 offers significant evidence of the value of public health nursing service. Of these 44 families, 28 had had no con- tact with the county nurses at any time. Nine had had con- tacts previously, but not during the pregnancy or infancy of the child in question. Six cases had had prenatal care and one, only, nursing supervision after birth. Thus, only 14 per cent of the mothers of the children who died had prenatal care, as compared with 27 per cent of the mothers of the County as a whole. The medical conference work for infants is well organized, but fails to reach an adequate proportion of the children of the County. When financial resources permit, it should be sub- Hygiene of Maternity, Infancy and Childhood 147 stantially extended. Additional clinics would be relatively more costly than those now held because they would probably not be so fully attended, but additional clinic work is greatly needed. It seems very clear that child hygiene in Cattaraugus is suffer- ing, and will increasingly suffer, from the lack of a medical director to supervise this essential work. We believe that one of the most urgent steps in the health program of the County is the reéstablishment of this bureau on a full-time basis. The most vital problem is, of course, the development of pre- natal medical service as the accompanying Table 27 indicates. Table 27. Causes of deaths of infants in Cattaraugus County, 1929. CAUSE NUMBER TOTAL: nats ile 3 reel sai 70 Acute communicable diseases 7 Respiratory diseases . . . . 10 Diarrhea. «+ vw 0 + is 3 Congenital malformations and debility = + « +» o » 05s 11 Prematurity’ . . os uss 21 Birthinjurdes , . + « jv eo» 10 Other causes associated with earlyinfoncy . . . . . . 4 Othericauses i. von x vn 4 Fig. 6 shows how the causes of death associated with early in- fancy have remained high while those of communicable, respira- tory and digestive type have decreased. Forty-six of the seventy deaths in 1929 were due to causes as- sociated with childbirth or early infancy and can be dealt with only by an adequate program of prenatal care. We fully realize the difficulty of a prenatal program in a rural area and know of no such area in which such a program is effectively carried out. Yet this is precisely the sort of a difficult problem which can only be solved in a demonstration county like Cattaraugus. The first logical step would seem to be the development of prenatal clinics at the hospitals in Olean and Salamanca, staffed either by the health department or by local physicians. In the rural areas, 148 Health on the Farm and in the Village INFANT MORTALITY IN CATTARAUGUS COUNTY 1916-1929 BY TWO GROUPS OF CAUSES n 60, + - « mo w so aX / NN g 2 JN ™ 40 # : Ava x y 8 A a ’ v oar’ \ ’ \ p-" \ « 7 \ 7 \ > 30h” Praeiast \ w ) \ 3 , ~o e \ a > 8 20 ne pr ny 5 ad Ne 2 ——— CONGENITAL & OTHER CONDITIONS PECULIAR E 0 TO EARLY INFANCY < w =-=-- RESPIRATORY, GASTRO-INTESTINAL. COMMUNICABLE DISEASES AND OTHER CAUSES 0 | | | YEARS 18 ‘18 ‘20 22 24 ‘26 28 Fic. 6 Hygiene of Maternity, Infancy and Childhood 149 prenatal service can probably be rendered most effectively only by physicians in their own offices; and a determined effort should be made to develop such service through the educational efforts of the nursing staff. School Hygiene, General Organization. The program for “School Health Work in Cattaraugus County’ has been admirably outlined by Dr. C. A. Greenleaf, director of the County School Health Service, in a pamphlet published under that title by the Milbank Memorial Fund, and its results have been carefully studied by Professor Ira V. Hiscock and Dr. Edwards. The problem of school hygiene in the rural districts is an exceedingly difficult one, involving in this case the supervision of 293 public schools, of which 266 are rural and 228 one-room schools, with a total school population of 14,000. The Cattaraugus demonstra- tion represents the first serious attempt to attack this problem made in New York State. The program of the demonstration, so far as school hygiene was concerned, included the following objectives: A. Routine examination of all school children, made in accordance with a uniform system for the County as a whole and with records filed and analyzed in the central office. B. Special examinations of children selected by teachers and nurses as requiring physical and medical care. C. Regular and systematic classroom inspection of children by nurses under specialized supervision. D. Home visiting by nurses for follow-up of children show- ing physical defects. E. Dental prophylatic service for children in all country schools. F. Expert diagnosis and medical care for certain groups, such as crippled children and tuberculosis suspects. The realization of this plan has, as we have seen in earlier chapters, been made possible by the creation of a County School Health District with a coérdinating committee at its head and a county director, Dr. Greenleaf, in actual charge of the work. Under the central committee there have now been organized 150 Health on the Farm and in the Village health committees for four of the five rural areas which, together with the school systems of Olean and Salamanca, make up the county district as a whole. The participation of Salamanca city in the program is still a nominal one, and even in the rural areas Dr. Greenleaf’s time does not permit quite as close a per- sonal contact as would be desirable. Up to the present year, Dr. Greenleaf has had a full-time supervising nurse on the staff as well as a clerk, but the services of the nurse have now un- fortunately been discontinued. The educational authorities of the County have given hearty support to the work and in the fall in each district the teachers are called together to discuss the program, so that new teachers may understand it and all may be freshly impressed with its importance. The nursing work is performed by the county nurses in rural areas and by local nurses in Olean, Salamanca, Gowanda and Portville, the nurses in the first two communities devoting their entire time to school work. There are dental hygienists em- ployed in Olean city and in rural districts Numbers 2 and 3 (Olean and Salamanca rural areas). The teachers in 227 out of 266 rural schools made daily class- room inspections of the children in 1928-1929, a decrease from 241 in the previous year. The nurses make sanitary inspections of school buildings and plants and periodic health inspections of the pupils. During the year 1928-1929, 15,500 inspections of the latter type were made. Furthermore, the nurses make all arrangements for the annual medical examinations of the children and write the parents to attend when their children are examined. This is an important element in rural school health practice and it is unfortunate that only 163 parents last year availed them- selves of this opportunity. Finally, the nurses pay the usual follow-up home visits, the number made in the County as a whole being 3,265 for 1928-1929. There has been a steady yearly decrease in these visits since a maximum of 5,892 was reached in 1924-1925. The highly intensive work of this first campaign could not, of course, be permanently continued and the work now done fully meets the appraisal standards but should Hygiene of Maternity, Infancy and Childhood 151 not be allowed to decrease further. The standards for the Cat- taraugus school nursing program have been outlined in a valuable pamphlet by Miss B. B. Randle, supervisor of school nursing, published by the County School Health Service two years ago. The medical examinations of the school children are conducted by part-time physicians employed by the local city, town or village board or trustees. ‘This is the most unsatisfactory feature of the program, since these local authorities usually make a contract with the lowest bidder, at rates varying from ten cents to one dollar per child. The examinations are made at a rate of 6 to 10 children an hour (which causes a loss on the appraisal score). In some localities the work is well done, while in others there are evidences of haste and carelessness. It was originally planned to make these medical examinations at entrance and then every three years thereafter (as has been the practice in Olean city since 1920, and in the Olean rural district between 1921 and 1929) and this would be the sound plan to follow in general. Since the state law still unfortunately requires an annual examination, the attempt is now generally made throughout the County to examine every child each year and this almost necessarily results in slipshod work. It would be far better to secure the consent of the state and local authorities to an examination on entrance and every three years thereafter, with a financial return to the physician which would make a real examination possible. The results of the medical examinations are reported to Dr. Greenleaf on standard forms, and letters notifying parents of needed corrections (with covering letters to enlist the aid of the teachers) are sent out from his office. The records on file in the county office are admirably handled, a visible file being maintained for each school, and Dr. Greenleaf has also a splendid set of graphic charts to illustrate the various phases of the work which are used in popular health instruction throughout the County. In Olean city, where Dr. Greenleaf serves as local medical in- spector of schools, the service rendered is admirable, and includes the holding of a clinic open every morning for children whom the teachers send to it as requiring attention. This clinic is held 152 Health on the Farm and in the Village in a separate frame building in the high school grounds and the fact that the Truant Officer has his office in the same building facilitates checking up on illness absenteeism. The teachers of Olean are well instructed in the signs of incipient disease and all children in the city schools are weighed monthly. Complete medical examinations are made of all kindergarten and first grade children and every three years thereafter. Pupils taking part in competitive athletics are examined several times a year, particularly for heart conditions. The medical work is of high grade and adequate funds are available for the correction of all defects found. Correction of Physical Defects. There are perhaps three primary objectives in any school hygiene program: the correction of physical defects which handicap the individual child and limit his health and efficiency, the provision of a safe and sanitary en- vironment with such facilities as are essential for exercise and recreation, and the development of health knowledge, inclina- tions and habits which are basic in the practice of healthy living. The first of these objectives has rightly been considered as primary in Cattaraugus County and one of the first steps in the demon- stration was an intensive medical examination of school children which had covered 258 of the rural schools by January, 1924. This study indicated that 40 per cent of the children of the County had defective teeth, that 22 per cent were under weight, and that 9 per cent were hampered by defective vision. Heart con- ditions and thyroid abnormalities were found in 2 per cent and orthopedic defects and lung conditions in between 1 and 2 per cent. Two years ago the results of the school medical examinations for 1924-1925 and 1925-1926 were analyzed and 50 per cent of the defects were found to have been corrected. It was somewhat embarrassing to find that later studies show a much lower rate of correction. On analysis of the data, however, it appears that these figures are somewhat misleading, since the lower ratio of defects corrected in recent years proves to be due chiefly to the fact that more defects are now being found—in other words, the Hygiene of Maternity, Infancy and Childhood 153 examinations are more thorough or standards more exacting. The actual situation is presented in the accompanying Table 28. Table 28. Defects of Cattaraugus County school children found and corrected. PER CENT | CORRECTIONS HILDREN DEFECTS DEFECTS AREA ~ SCHOOLS Founp CORRECTED Drsscrs 100 i Olean, 1928-1929 . 4,001 1,587 1,006 65 25 Salamanca, 1928- 1920.4, , . 1,900 893 200 22 11 Rural area, 1928- 1920, .. 8,496 17,114 3,039 18 36 Rural area, 1924- 1926 . . . .| 17,8071 | 13,109 6,500 50 41 1 Two-year population. The percentage of defects corrected is always fallacious as an index, since it is chiefly determined by the subjective judgment of the physician as to what constitutes a “defect.” The really significant index is that found in the last column of the table, which indicates that the County Health Service was actually securing the correction of nearly as many defects in a given school population in 1928-1929 as in 1924-1926, and was doing even better than Olean city. For Salamanca, the ratio is very low and the desirability of a more effective control of Salamanca school health work by the county organization is clearly in- dicated. The nature of the defects found in the rural schools in 1928- 1929 and the success attained in the correction of each type is indicated in Table 29. There is still, as always, room for improvement. Dr. Edwards’ analysis shows that, while the correction of the more serious defects (classed as 2x and 3x) is better than for all defects re- corded, it is still only 26 per cent and for 3x defects only 30 per cent. For teeth and eyes the results are fairly good (43 per cent and 24 per cent, respectively). For tonsils (8 per cent) and adenoids (6 per cent) they are low, and for heart and lung con- ditions the corrections are under 1 per cent. 154 Health on the Farm and in the Village Table 29. Correction of defects among school children in the rural areas of Cattaraugus County, 1928-1929. TypE oF DEFECT NumBer Founp PER CENT CORRECTED TorAaL ed Se ko le 17,114 18 Meath... ial. 4,443 43 Monsils .". ",'. Lua 3,426 8 Cervicalglands . . . . . 2,209 0.5 Weight oo a ri lee 1,872 29 Eyes... bode ila m, 1,816 24 Thyroid, ts Lt 984 8 Adenoids Lita nh al go 811 6 Heart i. oo. ol iin 395 0.8 Skinandscalp co. Lu. 303 5 Bars: oN Dene 181 9 Lungesat bi ie vr lies 11 09 Allothers .0. =.F “i oo. 563 3 Dr. Edwards has made an exceedingly interesting analysis of 1,367 apparently uncorrected defects of a serious nature, obtained from a search of Dr. Greenleaf’s files, in order to discover the reason for failure in each instance. It was found that in 114 cases the defect had been corrected but not yet recorded, while in 21 instances the family had moved away. The results for the remaining 1,232 cases as tabulated (Table 30) are of much signifi- cance. Table 30. Reasons for failure to secure correction in 1,232 cases of serious defect among the school chil- dren of Cattaraugus County. REASON Per CENT Lack of follow- up by nurses . 34 Inability of fam- ily to pay cost of correction . 34 Indifference of family .. 21 Other family reasons . . 1 Hygiene of Maternity, Infancy and Childhood 155 In over one-third of the cases there was no evidence of nursing follow-up to secure the correction of the defect in question. It is quite possible that in some cases such attempts had been made without record, by nurses not now in the field, but, so far as possible, all data were checked by conferences with the nurses at present assigned to the district in question. It would seem clear that more intensive work along this line is needed. Another third of the failures are due to poverty and lack of provision for medical aid to the self-respecting family of a low economic standing. In Olean such facilities are provided and in Portville, where the economic level is high, Dr. Edwards found the factor of minor importance. In such a district as Lime- stone, on the other hand, where the population is poor, the problem was a very serious one. Bradford would be a natural medical center for the area and the fee for a tonsillectomy in Bradford is $50 plus hospital expenses. Valuable service has been rendered by public-spirited physicians and dentists codperat- ing with the County Department of Health in the temporary provision of clinic service for defects of eyes and teeth, but the County sorely needs better permanent facilities for the medical treatment of the self-respecting family of limited means. It is encouraging to note that active progress has recently been made along this line. Eighty-two tonsillectomies were performed at a three-day clinic held in July at Randolph. School Sanitation. The school buildings and grounds are, as we have seen, subject to periodic inspection by the county nurses and Dr. Greenleaf mails out to each teacher every year a question- naire with regard to sanitary needs. The schools in Olean and Salamanca are in fairly good condition, but the rural schools are often seriously lacking in the basic essentials of sanitation. It is our estimate that not over half these small schools have adequate and safe water supplies, and arrangements for handwashing and toilet facilities are often seriously deficient. There has been little or no improvement during the last two years and the appraisal score suffers under this item. It is highly significant that, of 227 teachers replying to Dr. Greenleaf’s last questionnaire, 62 156 Health on the Farm and in the Village reported the lack of sanitary toilets; 29, the lack of any water supply on the school grounds; 26, the absence of drinking foun- tains. Only 66 of these 227 teachers had no specific sanitary need to report. A special problem of the rural schools—that of heating and ventilation—has been somewhat intensively studied in Cat- taraugus County by the New York Commission on Ventilation, with a special appropriation from the Milbank Memorial Fund. Outstanding variations in temperatures were recorded, ranging from gross overheating near the stove to serious chilling in outside seats and it was found that an excess of minor respiratory diseases was definitely present in those schools where the temperature deviated most widely below 70° and above 73°F. Experiments were made in certain schools along the line of reconstruction, which it was hoped might mitigate these evils, and the better insulation of walls and floors proved helpful. The only real remedy for this and other insanitary conditions lies in the develop- ment of consolidated schools to replace the one-room units. While on the subject of material provision for the health of school children, mention should be made of the excellent physical education program of Olean, with its fine swimming pool and supervised summer playgrounds. The County Department of Health staff has been of material assistance in getting this swimming pool into first-class sanitary condition. Health Education. The systematic training of the school child in the fundamental knowledges and practices which underlie healthy living is the third basic element in a school health program. The only way to bring about such training is by a sound plan of instruction throughout the grades, carried out under the direction of a trained supervisor who has specialized in the field of health education. This need was fully realized by the Tech- nical Board of the Milbank Memorial Fund and by the authorities of the State Charities Aid Association. At an Albany con- ference in April, 1924, at which Dr. F. P. Graves, state commis- sioner of education, was present, this item was specifically in- cluded in the program and in June, 1925, Mr. Homer Folks, secretary of the State Charities Aid Association, wrote to Dr. Hygiene of Maternity, Infancy and Childhood 157 Graves calling his attention to the importance of the subject. At a conference held in October, 1925, with Dr. George W. Wiley, deputy state commissioner of education, it was agreed that it would be desirable to appoint a special supervisor of health education (supported by Milbank funds). Dr. Wiley, however, naturally desired to take the matter up with the local school superintendents of the County, and on December 3, 1925, he wrote to the State Charities Aid Association that the sentiment of the local superintendents was adverse to the proposed arrange- ment. In view of this failure to secure provision for a real health education program, the problem has been attacked to a limited degree through lectures delivered by the nurses to student teachers and a general attempt has, of course, been made to enlist the in- terest of all the teachers, their own physical examination being utilized as a point of contact. With no county supervising teacher of health instruction, real progress has, however, been impossible; and the local superintendents recognize that no more is being done than is usual throughout New York State. When only 107 out of 266 rural schools weigh the children more than once a year, and only 104 serve hot lunches, it is obvious that a modern health program is not in operation. Furthermore, in both these respects, as well as in daily inspection and daily health instruction, there was a decrease in 1928-1929 as compared with 1927-1928. In order to evaluate the actual results obtained, a survey of great interest has been made by Dr. F. K. Shuttleworth of the Yale Department of Education. A total of 760 children in Cat- taraugus rural schools were given special tests of health knowledge, preferences, attitudes and habits, and the same tests were given to 923 children in the rural schools of Steuben County, a county, in social and economic conditions highly comparable to Cat- taraugus. In total population, in population per square mile, in proportion of urban and rural and farm population, in population per farm, in average acreage of farms, in proportion of farms operated by owners, in value of farm lands and buildings and of live stock, dairy products and crops, in ratio of mortgage debt, 158 Health on the Farm and in the Village in income from farm sales, in average yearly wages, in value added by manufacturing per wage earner, in per cent of families with telephones, in domestic electric consumers, in passenger auto- mobiles, in postal receipts, in circulation of magazines, in bank deposits and savings deposits per capita—the two counties are practically identical. The only difference between them lies in the fact that Steuben had, in 1920, 79 per cent native whites of native parentage against 65 per cent for Cattaraugus, 15 per cent native whites of foreign and mixed parentage against 23 per cent for Cattaraugus, and 6 per cent of foreign-born whites against 10 per cent for Cattaraugus. The rural school systems of the two counties (in which Dr. Shuttleworth’s testing was done) are also closely alike. Of ten indices available from the annual reports of the State Department of Education, eight are practically the same in the two counties. Essential identity was recorded for such basic factors as the per cent of children of school age enrolled and in daily attendance, length of school year, per cent of male teachers, training of teachers, ratio of pupils per teacher and dollars of current re- ceipts and dollars for instructional service per pupil. Cat- taraugus has, however, one distinct advantage. The value of all school property in this county is $228 per pupil enrolled as against only $176 in Steuben, which means that the school buildings in Cattaraugus are of more recent construction and contain more costly equipment. The testing program in both counties was confined to children of Grades V to XII in the larger village schools. In Grades IX to XII an excellent sample was obtained from both village and strictly rural areas, while in the lower grades only village children are represented, the younger children in the more rural areas being in one-room schools. Six villages were included in each county. The test material included six items: a personal data sheet, reports of health habits, health preferences, health attitudes, a revised Monroe standardized silent reading test and the Gates- Strang health knowledge test. The time occupied was 60-80 minutes. The pupils were assured that only the results of the Hygiene of Maternity, Infancy and Childhood 159 reading and health knowledge tests would be communicated to their teachers. The personal data sheet and the reading tests were designed to measure the comparability of the groups with respect to age, sex, school grade, socio-economic-educational home background (father’s occupation, ownership of farm, automobile, victrola or radio, papers and magazines taken in home, presence of telephone in home, work by mother outside of home, education of parents, et cetera), nationality of parents and general reading ability. On the basis of the personal data sheets and reading tests, the groups in the two counties were balanced after careful statistical analysis by excluding extreme cases, so that groups of 701 children in Cattaraugus and 837 in Steuben were finally obtained which were fully comparable with respect to age, sex, social and economic background and educational level as measured by reading tests. All analyses quoted will refer to these balanced groups. It is of some interest to note that both counties make a very high showing on the reading tests, well above commonly accepted national norms. In the high schools, the superiority of the Cat- taraugus and Steuben children is equivalent to three or four full grades. ‘The norms referred to, however, were established nearly ten years ago. Turning now to results, we may consider first the Gates-Strang test of health knowledge. This is a generally accepted standard- ized procedure and, in special tests by the split-form method for samples of random series of 100 comparable children in our own material, it showed adequate reliability. The average scores ob- tained were as follows: Table 31. Average scores in the Gates- Strang test of health knowledge attained by school children in Cattaraugus County and in Steuben County. GRADES CATTARAUGUS STEUBEN Grades V-VIII 45.19 46.86 Grades IX-XII 54.07 54.01 All grades 49.95 50.39 160 Health on the Farm and in the Village In the lower grades and in all grades, the difference, in favor of Steuben, is more than four times as large as would occur by chance, while the apparent superiority of Cattaraugus in the higher grades is not statistically significant. In health knowledge, then, the Cattaraugus children are behind in the lower grades and about on a level with those of Steuben in the higher grades. Through the courtesy of Professor Gates and Dr. Strang, the results of extensive unpublished data obtained in Duluth, Minnesota, have been made available for comparison, and both the Cattaraugus and Steuben children excel the Duluth children in health knowledge by one or two whole grades. The test of health attitudes yielded essentially similar results. This test included 15 items covering miscellaneous attitudes towards health as indicated by a series of problems. The results were as follows (Table 32): Table 32. Average score in health attitudes attained by school children in Cattaraugus County and in Steuben County. GRADES CATTARAUGUS STEUBEN Grades V-VIII 9.31 9.88 Grades IX-XII 10.13 10.21 All grades 9.74 10.04 The superiority of Steuben in the lower grades is nearly six times and in all grades, over four times, what would be expected by chance, while the difference in the higher grades is not signifi- cant. The test for health preferences included 26 questions relating to choice between two things to eat or drink or two activities to pursue; and the average scores were as follows (Table 33). The only significant difference here is the superiority of Cat- taraugus in the higher grades, which is four times what would be expected by chance. Finally, we come to the test of health habits which included 22 questions covering sleeping and eating, care of the teeth, recre- Hygiene of Maternity, Infancy and Childhood 161 Table 33. Average score in health preferences attained by school children in Cattaraugus County and in Steuben County. GRADES CATTARAUGUS STEUBEN Grades V-VIII 21.07 21.35 Grades IX-XII 21.28 20.58 All grades 21.18 20.97 ation, recent illness, vaccination, e# cetera. ‘This test, of course, involves a considerable subjective factor, but the results seem concordant and reasonably reliable. Analyses of random samples of 100 comparable children check well, and a special comparison of 52 pairs of children in the same families, and of about the same age, for various items, such as sleeping hours, and coffee- and milk- drinking, give correlations varying between .40 and .60. The average scores for this test were as follows (Table 34): Table 34. Average score in health habits attained by school children in Cattaraugus County and in Steuben County. GRADES CATTARAUGUS STEUBEN Grades V-VIII 12.53 12.36 Grades IX-XII 12.32 11.73 All grades 12.42 12.05 The superiority of Cattaraugus in the lower grades is not significant, but in the higher grades and in all grades it is between four and five times what would occur by chance. When Dr. Shuttleworth analyzed the health habit scores in further detail by individual items, he found that in none of the 22 items did Steuben have a clear advantage, while in two items the superiority of Cattaraugus was very high. Fifty-eight per cent of the Cat- taraugus children reported vaccination for smallpox as against 14 per cent of the Steuben children; while the average number of hours spent in bed was 9 hours and 18 minutes for the Cat- 162 Health on the Farm and in the Village taraugus children as compared with 8 hours and 55 minutes for the Steuben children. Comparison of both counties with other areas is here, again, possible, because 11 of our questions as to health habits were identical with questions used by the American Child Health Association in its “Health Survey of 86 Cities”, published in 1925. The American Child Health Association study covered 35,000 fifth grade children in cities of 30,000 to 70,000 popula- tion and Dr. Shuttleworth has made a detailed analysis of the comparative scores of 187 fifth grade children in his two rural counties. The important question, “Write down each thing you ate for breakfast this morning,” shows many suggestive differences. As compared with city children, these rural children record more milk, fresh fruit, more cereals, more pancakes and waffles; Jess coffee and tea, less meat, less cake and pastries, less sweets, and less butter. Cereals are mentioned twice as often as in the cities. Only 10 per cent of our rural children report no milk drunk on the previous day, as compared with 22 per cent of the city children, while 57 per cent of the rural and only 35 per cent of the city children report three or more glasses. Only 20 per cent of the rural children, as against 39 per cent of the city children, re- port coffee drinking. In hours of sleep, the city children are slightly superior and twice as many of them have been vac- cinated. In bathing and care of the teeth, no significant differ- ences appear. All in all, except for low butter consumption, the children of Cattaraugus and Steuben appear to be markedly superior in food habits, as they are in reading ability and health knowledge. On the whole, the comparison of the two counties themselves seems distinctly favorable to Cattaraugus. The general results may be summarized as shown in Table 35. The four types of tests used seem to measure quite distinct things, for, though checks show each to be highly reliable, the in- tercorrelation between the four types is low (.23). It seems highly significant that the health knowledge and health attitudes Hygiene of Maternity, Infancy and Childhood 163 Table 35. Relation of Cattaraugus County children to Steuben County children as revealed by four tests. Grapes V-VIII Grapes IX-XII Knowledge... oe Inferior Equal Attitndes «o.oo. ee Inferior Equal Preferences . . . . . « Equal Superior Habits: i... ii iin Equal Superior tests, which correspond more or less closely to theoretical concepts developed in the classroom, show Cattaraugus inferior to Steuben in the lower grades and equal to it in the higher grades. This is precisely what might be expected, in view of the fact that the plan of the Technical Board of the Milbank Memorial Fund to develop an organized program of health instruction was thwarted. On the other hand, in the more practical health preferences and health habits, the Cattaraugus children equal those of Steuben in the lower grades and surpass them in the higher grades. These are precisely the fields in which an intensive program of medical service would be expected to produce results; and it has ap- parently done so. Nutrition Programs. A nutrition program which was carried on as a special part of the demonstration for several years may be considered here, although it does not, of course, relate exclusively to children. This enterprise has been interestingly described in a pamphlet by Miss Ruby M. Odell (who carried out the program) entitled “Improving the Dietary Habits of a Rural Community” and published by the Milbank Memorial Fund. This pamphlet has an introduction by Dr. Haven Emerson which contains the following pregnant sentences with respect to the fundamental importance of the problem involved. He says, “Probably at no previous time in the experience of our people have we recognized so many defects, diseases and disabili- ties due directly or indirectly to errors in nutrition; to lack of adjustment of food intake to growth and energy needs; to un- familiarity with the values and properties of a great variety of manufactured, stored and sophisticated edibles. Is it not true, 164 Health on the Farm and in the Village therefore, that practiced teaching of the science of nutrition is at the foundation of good public health work?” Miss Odell’s work as county nutritionist, associated with the nursing staff of the County Department of Health, lasted for a considerable portion of the five years, 1924 to 1928. It was recognized that the cost of this service ($3,500 a year) could not be permanently carried by the County and it was believed that, after a preliminary demonstration period, the work could be maintained at a reasonable level by the teachers and nurses, with the supervision of various state nutrition workers, and with occasional consultation service which it was estimated would cost the County $500 a year. This latter service is, unfortunately, not now provided. Miss Odell’s program was carried on in coépera- tion with Cornell University and with the counsel of a special advisory committee of the Milbank Memorial Fund. It began in 1924 with an intensive study of the actual nutrition practice of 100 county families, conducted by voluntary Home Bureau work- ers. The families studied, as a whole, represented the more pros- perous levels of the population. In 14 of them the housewife had received special training in home economics and these families showed a fully adequate diet, although higher than necessary in calories and protein values, and hence costly (63 cents per man per day). In the other 86 more typical families, the cost ranged from 28 to 81 cents and averaged 51 cents per man per day. Only 11 family diets were low in calories and 22 were excessively high, but 4 were lacking in protein against 53 with more than the standard amount. On the other hand, 24 were poor in vita- min-yielding foods, 18 in iron, 11 in calcium and § in phos- phorus. In 63 families there was a shortage of green vegetables, in 29 of other vegetables, in 28 of milk, in 26 of eggs. Miss Odell estimated that, with proper selection of foods, an ade- "quate dietary could have been obtained for 45 cents per man per day. The improvement of dietary standards was attempted in three ways. First, individual consultation service was provided for the patients of physicians who desired such assistance. Twenty Hygiene of Maternity, Infancy and Childhood 165 to thirty cases of this kind were carried each month at the height of the program, the nurses codperating actively in supplementing the nutritionist’s instructions. Under the same general heading may be mentioned aid in planning dietaries at Rocky Crest and the Health Camp. Second, a systematic attempt was made at wider adult education through addresses to granges, parent- teacher associations and other local groups. The Home Bureau workers, under Miss Odell’s supervision, also held group meetings to spread the gospel. During the year 1926, there were 106 such meetings, with an attendance of 1,820 persons. Finally, special emphasis was laid on work in the schools. About ten days each month were spent by the nutritionist on this phase of the problem, in conference with the teachers, in groups or individually, and in giving health talks to the children themselves. The school authorities and teachers responded rather readily and, by 1928, 136 of the rural schools were serving hot lunches for their pupils (the number has now dropped to 104). Practical results of this program were evidenced in 1927 by a resurvey of the original 100 families studied in 1924. There was revealed a most encouraging improvement in dietary habits. Forty-eight families were consuming more fruit; 38, more green vegetables; 47, more tomatoes; 50, more whole grain bread; 33, more eggs; 28, more milk; while 41 were consuming less meat. There was a marked increase in the home cultivation of green vegetables and in home canning and preserving. Still more striking evidence of the success of the movement was the increased market for fruit, green vegetables and whole cereals, as felt by store-keepers throughout the County. Miss Odell says: “Some of the proprietors of these stores tell interesting stories to illustrate why it is necessary for them to increase or add to their stock of essential food supplies. For example, as the result of a talk the nutritionist made to a group of Home Bureau women on the nutritive value of cabbage, a merchant in one community sold a carload of this vegetable in a week, whereas it had pre- viously required a month for him to dispose of this amount. 166 Health on the Farm and in the Village “In 1927, the nutrition worker endeavored, by means of a questionnaire sent to all the grocers in the County, to discover the extent to which the demand for certain food commodities es- sential to good health had influenced the local grocers in increas- ing or adding to their regular stock. Fifty-six grocers and pro- prietors of stores dealing in general merchandise from various parts of the County answered the questionnaires, and the tab- ulated findings show the widespread effects of the nutrition in- struction. The majority of the fifty-six stores were carrying all the food commodities listed on the questionnaire and a large number of them reported increased sales, since 1924, of whole grain cereals, whole wheat and graham bread, graham flour, fresh fruits and vegetables. In some instances, the grocers reported that the sale of one or another of these commodities had doubled or tripled since 1924. With only a few exceptions, the stores reporting supplied both fresh fruits and fresh vegetables to their customers daily or at least semi-weekly, whereas before the advent of the nutrition service a bare handful of country stores kept these supplies in stock regularly.” Review of General Program for the Promotion of the Health of Children of School Age. The first outstanding fact in this field is the general success with which the difficulties inherent in the rural school problem of such a state as New York have been over- come. To weld the scattered responsibilities of 370 local school trustees into a coherent program and to correlate this program in- timately and effectively with the general health organization of the County, was a task of no mean magnitude. It had never been accomplished before in any of the Northeastern states so far as the writer is aware. It has been accomplished in Cat- taraugus, and its initiation here led to the present state law pro- viding for school health districts and to the development of similar plans in other counties. The general administrative program for school hygiene seems to the writer in the main soundly conceived and well adminis- tered; and the major objectives outlined in 1923 have been attained with two exceptions—the lack at present of a supervising school nurse and the lack of an effective dental program in three of the Hygiene of Maternity, Infancy and Childhood 167 five areas. How serious a handicap the loss of the supervising nurse may prove, only future experience will reveal, but the fact that, in a random series of children with uncorrected physical defects, one-third had no recorded nursing follow-up, indicates that no efforts should be spared to keep this work up to the mark. A dental hygienist in each school district is an ideal highly to be desired. The most serious defect in the present program, from a purely public health standpoint, is the uneven character of the medical examination service in the rural areas. It would be most desir- able to carry out the original plan of making really thorough ex- aminations once in three years instead of superficial ones every year. Except in Olean, and except in the case of cripples, facilities for the treatment of physical defects of children of self-respecting families of limited means are distinctly inadequate. It seems urgently necessary that means should be found, either with public or private funds, for maintaining clinics for dental care, for correction of defects of vision and for tonsil and adenoid work under conditions which do not savor of pauperism. The most serious lack in this whole field is the absence of a modern coherent program of health education in the schools. This seems to the writer one of the very few defects in the Cat- taraugus demonstration as a whole. A county supervisor of health education is as essential as a county medical director, and until this gap is filled, the Cattaraugus program as a whole will lack the most important driving force which can be relied upon to maintain its support in the coming years. The existence of a model community health program might have formed the basis and inspiration for unique achievement in the field of health education. A golden opportunity has so far been missed through lack of local support for this part of the Milbank program, but it may not be too late to seize the opportunity. Our personal contacts with local school authorities suggest that their attitude toward the demonstration is a highly favorable one, and perhaps a renewal of the efforts of 1925 might meet with a different result. The total appraisal score for school health work is reasonably 168 Health on the Farm and in the Village high, 82 per cent, having risen steadily to this point from 35 per cent in 1923. ‘The chief debits are due to the absence of parents from medical examinations, too hasty and incomplete medical examinations and sanitary deficiencies in school buildings. The last mentioned point, of course, raises the all-important problem of consolidation. The New York Commission on Ven- tilation studies of school heating and ventilation in Cattaraugus rural schools made it clear that the problem of the one-room school is scarcely susceptible of completely satisfactory solution. The development of consolidated schools would make it far easier to deal with this and other sanitary questions, as well as to accomplish the direct objectives of education. The special work in nutrition which has been carried on in the County is deserving of the highest praise and the very eco- nomical nutrition program projected for the future should certainly be carried out. Care of Crippled Children. A special enterprise stimulated by the demonstration, and one of peculiar appeal and substantial value, is the work carried out for the relief of crippled children, described in detail in a pamphlet entitled “Rebuilding Crippled Children” and published by the County Tuberculosis and Public Health Association in 1929. The first effort along this line (made at the suggestion of Mr. Homer Folks) was a comprehensive survey to determine the extent of the problem, begun by Mrs. E. M. Finch, field secretary of the Association, in 1923. In the report of the New York State Commission for Survey of Crippled Children issued in March, 1925, is given a table showing the number, distribution, ratio to population, ef cetera, of crippled children reported in the counties of the State. These figures were compiled in 1924 when the special survey of crippled children in Cattaraugus County was just getting under way. Reference to this table shows that 151 crippled children had by this time been discovered in Cattaraugus County, giving a ratio of 3.63 children per 1,000 general population, and 10.65 as the ratio of crippled children per 1,000 population under 18 years of age. This was the highest ratio in the State. The county as listed which shows Hygiene of Maternity, Infancy and Childhood 169 the next highest ratio of cripples found is Chenango County, which gave a ratio of 2.95 per 1,000 general population and a ratio of 10.26 crippled children per 1,000 population under 18 years of age. Representatives of the Commission had made an intensive survey in Chenango preliminary to this report. After this report was published, the Cattaraugus County survey discovered 82 additional cripples. The report, “Rebuilding Crippled Children in Cattaraugus County”, shows a total of 233 cripples located, 193 of whom were under 18 years of age. Responsibility for locating cripples from birth to 18 years of age was placed in the Department of Education by the law en- acted in 1925. The school census takers were instructed to reg- ister all such children. In 1929, the State Charities Aid Association assisted the De- partment of Education in an endeavor to secure as complete a census as possible of crippled children between birth and 18 years of age, through the school census takers in two selected counties, Saratoga and Otsego. The results were encouraging, as nine times as many crippled children were recorded in these counties on the census of 1929 as had been recorded on the school census of 1928. However, a much smaller ratio of crippled children was discovered in these two counties than was discovered in Cattaraugus County. The comparative results are shown in the following Table 36: There is no reason to think that Cattaraugus County had any greater relative number of crippled children than were living elsewhere in the State. Had an equal ratio been discovered in all the counties at the time of the 1925 report of the State Com- Table 36. Proportion of crippled children in three New York Counties, 1929. NUMBER OF CRIPPLED CHILDREN | NUMBER OF CRIPPLED CHILDREN County PER 1,000 ToTAL PopuratioN | PER 1,000 POPULATION UNDER : 18 YEARS Saratoga County 1.3 4.3 Otsego County . 1.3 50 Cattaraugus County . 4.6 13.6 170 Health on the Farm and in the Village mission, this report would have recorded over 20,000 instead of its bare total for the State of 2,000 children. The chief causes of crippling in the Cattaraugus County series of cases were infant paralysis (94 cases), congenital defects and birth injuries (52), accidents (20) and tuberculosis (15), with rickets, arthritis and other factors playing a minor role. The problem of diagnosis and reparative treatment was dealt with primarily through the orthopedic clinic and nursing service of the State Department of Health. Four or five clinics were held each year, with an average attendance of 18. ‘The need for financial aid in the treatment of serious conditions was soon manifest, however. A Committee on Crippled Children was organized in 1924 under the Tuberculosis and Public Health Association, with Mr. John Walrath as chairman, to raise money for this purpose. This Committee has been notably successful, obtaining through voluntary subscription in the neighborhood of $1,000 a year for the rehabilitation of cripples. Since 1927, an equal sum has been secured in the form of state aid by the simple device of having the County Supervisors make a $1,000 appropriation on which state aid can be obtained, the county appropriation being later repaid by the Committee on Crippled Children. The results have been most encouraging, as indicated by the following data for 191 cases on the roster recorded as having disabilities discovered for a sufficiently long time to make results possible. Of this group, 39 per cent were reported as practically recovered and 24 per cent as improved. ‘Thirteen per cent were considered as essentially unimprovable and the same proportion as not improved, generally on account of lack of cooperation. The remaining 10 per cent had moved away or died. This singularly appealing and important problem seems to have been handled with remarkable soundness and success. CHAPTER XII NURSING * Development of the County Nursing Staff. At the beginning of the demonstration there were, as we have seen, eight public health nurses in Cattaraugus County, four in Olean (two em- ployed by the Board of Health, one by the schools and one by the Red Cross), a school nurse in Salamanca, Red Cross nurses in Portville and Gowanda and a county tuberculosis nurse attached to the tuberculosis sanatorium. This gave a ratio of one nurse to 9,000 persons in the population. During the year 1923, a new county-wide generalized nursing staff was organized under the County Department of Health (the county tuberculosis nurse being included in this staff), which has been developed as one of the most significant features of the Cattaraugus demonstration. The changes in this staff, year by year, are as indicated below, in Table 37. Table 37. Staff changes in the Bureau of Public Health Nursing of the Cattaraugus County Department of Health, 1923-1929. SPECIALIZED SUPERVISORS v o Epuca- Soca SE T EAR IRECTOR | TIONAL v _ |Maternity ASE- STAFF OTAL DIRECTOR peal, Tube 3, WORK | NyurSES 1923 | Acting 6 7 1924 5 12 13 19252 co l= gh 12 15 1926 2 + + + + 4 14 18 19272 -+ -+ + + 15 19 1928 + + + 14 17 1929 + + 14 16 1 The Educational Director served also as supervisor of maternity and infancy during 1926 and 1927 2 During these years Miss Odell also served as special nutrition supervisor to the nursing staff. 1 This chapter is based upon the special report on the nursing problems of Cat- taraugus County presented by Miss Katharine Tucker and Miss Alma C. Haupt of the National Organization for Public Health Nursing. 171 172 Health on the Farm and in the Village In addition to the staff listed above there was, from 1923 to 1929, a specialized county nursing supervisor of school hygiene, attached to the county school organization but correlating her work closely with that of the Health Department nurses. It will be noted that there was an increase in the county staff to 19 in 1927. Meanwhile, an additional nurse had been employed by the Olean Red Cross and a nurse had been appointed by the State Department of Health for the Indian Reservation. At its maximum in 1927, the total public health nursing staff of the County reached 28, or one to 2,500 population. It has now fallen to 25 with the discontinuance of the school supervisor and reduction of the County Health Department staff to 16, giving a ratio of one nurse to 2,900 population. The policy of developing various special lines of work, such as tuberculosis and venereal disease control by the temporary ap- pointment of specialized supervisors, is of particular interest and importance. The Present Nursing Organization. At present, in June, 1930, the organization may be summarized as follows: The general county nursing service is organized as a separate bureau of the County Department of Health, with Miss Laura A. Gamble as director. Her staff consists of an educational di- rector, two senior nurses and twelve staff nurses. One staff nurse is assigned to Olean city for specialized tuberculosis service and the other staff and senior nurses are assigned to generalized serv- ice in the six district stations throughout the County. In addition we have the local services shown in Table 38. The ratio of nurses to population, even with recent reductions, is excellent for a rural area. The importance given to the nurs- ing aspects of the health program is illustrated by the fact that 42 per cent of the County Health Department budget and 41 per cent of the total county health budget (including school and local health authorities) is allotted to public health nursing. ‘The fact that 9 nurses out of the 25 in the County are still outside of the generalized county service (6 of them doing strictly spe- cialized work) seems distinctly unfortunate. Nursing 173 Table 38. Local nursing services, exclusive of that furnished by the Department of Health, in Cattaraugus County, 1929. AREA NUMBER OF NURSES TYPE Olean. . . . . . .|2healthdepartmentnurses | Specialized 1 school nurse Specialized 2 Red Cross nurses Specialized — bedside Salamanca . . . . .|1 school nurse Specialized Portville. . . . . .]|1 Red Cross nurse School and bedside work Gowanda . . . . .|1local nurse Generalized, chiefly bed- side Indian Reservation . .|1 nurse Generalized The county nursing program benefits by the counsel of a special Nursing Advisory Committee of nationally known ex- perts appointed by the Milbank Memorial Fund; and excellent service is rendered by 17 local nursing committees, widely dis- tributed throughout the County, whose members aid in the equip- ment of stations and in preparing supplies, assist in transportation, and help to raise funds for special purposes. A “Guide to Nurses for their Nursing Committees” is issued by the Bureau of Public Health Nursing, which gives a general outline of the organiza- tion and functions of such committees. The purpose of the public health nursing service is threefold: to assist in carrying out the health program of the bureaus of the County Health Department and the County School Health Service; to give instruction in the homes in personal hygiene, prevention of disease and sanitation, and to offer bedside care in case of sickness as a demonstration or in emergency; and to provide an inclusive maternity service when no other adequate nursing care is available. Staff Personnel and Working Conditions. Members of the nursing staff are in theory supposed to be high school graduates and registered nurses, and to have completed an approved course in public health nursing. The first and third of these require- ments have not been always enforced and certain members of the staff fall short, in training and previous experience, of a de- sirable ideal. Salaries and general conditions of services are in accord with 174 Health on the Farm and in the Village general practice. Clerical facilities are ample, automobiles and service equipment excellent and central and station headquarters adequate. The tan checked gingham uniforms are attractive and practical and Miss Katharine Tucker says, “When the nurses are seen in a group at a meeting, they give the effect of brownies stepping out of a wood.” The hours of duty are from nine to five on week days (with one hour off for lunch) and from nine to twelve on Saturdays, only emergency service being required on Sundays and at night. Miss Tucker, who had charge of the survey of public health nurs- ing activities, points out that the average hours of employment per year per nurse for the Cattaraugus County staff were 1,769 in 1929 as compared with figures ranging from 1,930 to 2,007 for the four demonstration areas of the Commonwealth Fund (Marion County, Oregon; Clarke County, Georgia; Rutherford County, Tennessee; and Fargo, North Dakota). She believes that the working day might properly be begun at 8.30 instead of 9, that further efforts should be made to reduce time spent in the office (24 per cent of the total in 1929 as compared with 29 per cent in 1924) and that nurses might profitably eat their noon meal in their districts and remain in their districts till § o’clock instead of taking half an hour to return to the district office. General staff meetings are held every four to six weeks which is all that can be reasonably expected; but it would be of value to develop more frequent district conferences. At the general conferences, each staff nurse reads a narrative report of her work for the month. All of the local nurses of the County are in- vited to the staff meetings and, with the exception of the Olean and Salamanca school nurses, respond very readily to this invitation. New nurses have been given a 10 to 14 day introduction to the service under the Educational Director and continuing staff education is carried on by lectures, circulation of books and maga- zines, with allowance of time (but no expenses) for attending state and national meetings. The excellent extension course Nursing 175 sponsored by the New York State Department of Health has proved of special value. Records. Prior to February 1, 1930, a record system was in use essentially like that recommended by the National Organiza- tion for Public Health Nursing, consisting of a family folder, a special form for medical social history and individual records for general home visiting, infant hygiene, children, maternity and tuberculosis cases. Clinic and school records were kept separate. ‘The new system introduced last February centralizes all information in a single manila folder of letter size and omits many items on the earlier forms. The folder includes a family sheet for social history, records of visits (classified by service), records of all clinic examinations, laboratory reports and cor- respondence. ‘The family sheet seems to us to omit many im- portant headings which should be called to the attention of the nurse, although there is ample room to write them in. The records for home visits also seem to lack vitally essential items, particularly the maternity record. The general plan of the new records is an admirable one, but their content might well be given careful consideration with a view to securing data, both by visits and cases, which are comparable with those in use else- where. This could best be done in conference with the Bureau of Public Health Nursing of the State Department of Health and with the Records Committee of the National Organization for Public Health Nursing. In considering the function of records, Miss Tucker cites an illuminating analysis from the nursing manual of the Visiting Nurse Society of Philadelphia. It states that nursing records are of value: “A. To the Nurse, making her services to the family more complete— “1. By helping her to be observant of all the factors that might affect the health of the family. “2. By revealing the need of health work in each family and giving evidence of what is being accomplished. 176 Health on the Farm and in the Village “3. By constituting a summary of conditions found and of action taken. “4. By improving the quality of the nurse’s work, since the records also show what is being left undone. “S. By saving duplication and waste effort, since they enable one nurse to begin where another has left off in work with any family. “B. To the Organization— “1. By helping in the supervision of work, thus making it doubly possible to do thorough and complete family health work. “2. By helping to show how far the organization is meet- ing the needs of the community and where further development is desirable. “C. To the Public— “1. By providing valuable material for morbidity and mortality statistics. “2. By showing what are the greatest health needs of the community. “3. By showing the social as well as the medical causes of sickness. “4. Through such statistical material it may be possible to get community or legislative action to remedy con- ditions.” The nursing records of field visits are analyzed by the Bureau of Records and Statistics in a very complete fashion by age period (under 1 year, preschool, school, adult and maternity) and by problem (health and hygiene, tuberculosis positive, tuber- culosis suspect and contact, and communicable disease). “Health and hygiene” seems too indefinite a term, failing to distinguish between bedside care and health education, and clearer definitions of “cases carried over”, “new cases”, “readmitted cases” and “dismissed cases” are recommended by Miss Tucker. Volume of Work Performed. An idea of the total volume of work performed may be gained from Table 39. Nursing 177 Table 39. Total volume of nursing service (actual visits with patients) by public health nurses in Cattaraugus County, 1929. VISITS PER VISITS PER AREA PoPULATION| NURSES Visits Nosy Vb 900 Pope TOTAL Le va io i: 73,640 25 36,100 1,444 500 Olean, ovis vw) 20,752 62 9,160 1,527 420 Salamanca. . . . + 9,570 213 2,597 1,039 270 Gowanda . . . . . 3,040 1 i 1,262 1,262 420 Portville. ..-. .. . . . 975 14 2,159 2,159 220 Indians... Laur. 972 1 1,176 1,176 120 Restof County. sv) 35,295 13% 19,746 1,463 560 1 Only about 2,026 are residents of Cattaraugus County, but all cared for by nurse. 2 focaing tuberculosis nurse from county staff. 3 Local school nurse plus time of county nurses equal to 1} nurses. 4 Tuberculosis nursing done by county staff not estimated. It will be noted that in the County as a whole, particularly in Olean and the rural areas, the volume of service performed is high, and it is particularly significant to note that it is highest of all in the rural areas, the ratio indicating more than one visit to each two persons in the population. Another measure of quantitative adequacy is found in the ac- companying Table 40, which shows Cattaraugus County far ex- ceeding all Appraisal Form nursing standards, particularly in work for preschool children where the volume of visits is ten times the standard. Table 40. Nursing visits by public health nurses in connection with certain special public health problems. NuMBER OF NURSING VISITS PROFLEM APPRAISAL County Olean [Salamanca Portville | Indian Total Quora Staff Nurses Nurse Nurse Nurse Communicable disease . . .| 2,045 | 2,136 4,181 —1 Tuberculosis . .| 2,092 2,092 740 Prenatal . . .i 1,000 845 164 2,069 | 1,028 Infant . . . .{| 3914 579 217 178 4,908 1,992 Preschool . . .| 6,333 309 228 198 7,068 605 School . . . .[ 1,060 1,204 397 1,094 3,761 2,800 1 No appraisal standard for total of all communicable diseases. 178 Health on the Farm and in the Village An interesting quantitative comparison is to be found in Miss Tucker’s report showing that the specialized school nurses in Olean and Salamanca care for 4,000 and 1,900 school children, respectively, while in Portville, Gowanda and the rural areas, where the nurses have a generalized program to carry, the ratios of school children per nurse vary from 354 in Portville to 482 in the rural areas. Cost of Service. No very recent cost data have been worked out in the county health office, but Miss King has data for 1925 and 1927 which show a cost per visit of $1.75 in the former and $1.62 in the latter year. These are wholly reasonable figures in view of the very high cost of transportation in a rural area. One of the most interesting tables furnished to us by Miss King (and quoted in full by Miss Tucker) gives data for visits per day per nurse which are illuminating in this connection. The grand total of visits to homes and on behalf of home cases has varied in individual years from 6.4 to 8.1 per nurse per day and has averaged for the seven years 7.2. This is a really remarkable record of efficiency as compared with the usual ratio of about 8 visits per nurse per day for an urban service (in spite of the fact that the nurses have only a seven-hour day). The average num- ber of families visited per nurse per day has varied for the past four years from 3.4 to 3.8, indicating that about two individuals are given some sort of service on each visit to a home. Types of Service Rendered. The distribution of work along various special lines may be stated—for the County Health De- partment staff alone—as follows (Table 41), with comparable figures for the four Commonwealth Fund demonstration areas. The Cattaraugus figures check fairly well with those for the Commonwealth Fund areas and indicate a reasonably sound and well-balanced program. They appear to differ from com- mon urban practice in a somewhat low ratio of maternity, school and communicable disease work, a somewhat high ratio of tuber- culosis work and an enormously high ratio of preschool work. This represents a definite and praiseworthy effort made several years ago to moderate an excessive preoccupation with school Nursing 179 Table 41. Percentage distribution of time spent in actual field visits by the staff nurses in the health demonstration areas of the Commonwealth Fund and by County Health Department nurses in Cattaraugus County. Sever 22 | vg rome ape Jomnes TOTAL MATERNITY 1 17 18 24 18 Prenatal. . . . 6 7 10 5 7 Delivery. . . . 5 2 Postnatal . . . 5 10 8 14 9 TOTAL CHILDREN 1. 59 34 50 38 45 Infant... . 5% 19 11 17 17 19 Preschool . . . 21 S 23 5 15 School. . . . 19 18 10 16 11 Tuberculosis . . 6 18 10 6 14 Other communi- cable diseases . 6 11 14 10 6 Othert .. . . . 18 19 12 21 17 1 Bedside care of children under “Children” in Commonwealth Fund areas, under “Others” in Cattaraugus. work. It seems possible, however, that the pendulum has swung a little too far and that it might now be well to shift emphasis somewhat from preschool to prenatal and postpartum service. In addition to their home visiting, the county nurses in 1929 made over 15,000 classroom inspections of school children and made sanitary inspections of all the schools of the County. The county nurses also plan and assist at all the medical school inspections throughout the rural areas. They prepare for and assist at the tuberculosis clinics (1-9 per month), the child health conferences (10-12 per month), and a large number of diphtheria and smallpox immunization clinics. They also codperate in the work of the mental and orthopedic clinics held under the auspices of state authorities. Finally, they conduct three separate series of classes, on child care, on home nursing and on first aid, respectively. Over 200 individual lessons were given in 1929, with an average attendance of about 9 persons. Quality of Service. The problem of supervision in a rural area is an exceedingly difficult one. This is perhaps the major nursing 180 Health on the Farm and in the Village problem which has not yet been fully solved in Cattaraugus, al- though in interpreting this fact it must be borne in mind that, in most rural nursing services, there is no supervision at all in any effective sense. Both Miss Tucker and Dr. Edwards in their intensive analysis of case-performance find clear evidence that, while some of the actual public health nursing work performed is admirable, the accomplishments of other staff nurses are by no means up to an ideal standard. Actual bedside technique was wholly adequate, but there was, in some instances, notable failure to note and deal with contingent health problems and, in general, to perceive the full and beneficent possibilities of a modern generalized health program. Dr. Edwards found an appreciable number of cases of physical defects of school children not followed up, and cites other instances of failure in effective family contact. The only real field supervision has been performed by the Edu- cational Director, her schedule calling for one day a month with each staff nurse (in 1929 only 37 per cent of her time was actu- ally spent in field supervision), and office supervision is seriously limited by the incompleteness of the records. The record forms used up to February, 1930, were not effectively used and the new ones omit certain essential elements, as pointed out above. The two “senior nurses” on the staff act as administrators of their respective local offices, but do not serve in any proper sense as supervisors, since they do not do any regular home visiting with the staff nurses and one of them carries a district of her own. Such deficiencies are all too common in most public health nursing organizations and the cause of nursing would be ma- terially advanced if public health administrators and board mem- bers, as well as nurses, would read and ponder the admirable dis- cussion of the part played by records in supervision quoted on a previous page. It is a grave mistake to conceive of nursing records as solely, or primarily, collected for statistical purposes. They form the most essential instrument ot sound nursing admin- istration and the only means of ensuring continuous care tor the patient. Nursing 181 All in all, it seems clear that supervision in the Cattaraugus nursing service needs “tightening up”. Miss Tucker suggests in this connection that, in place of the so-called “senior nurses”, there should be appointed two district supervisors, prepared for their position by a postgraduate course in public health nursing if possible and by experience in an organization offering good supervision. The County and staff should be divided equitably between these two supervisors, who should have definite responsi- bility for supervision both of records and home visiting. They should meet for regular conference, both with the director of the Bureau on the one hand and with the staff nurses assigned to them on the other. The Problem of Bedside Care. The question as to the pro- portion of time which a generalized nursing service under public auspices should devote to bedside care is a somewhat vexed one. Actual practice in Cattaraugus County has been fairly liberal, since Miss King estimates that 26 per cent of nursing time in the homes for all types of cases is devoted to bedside care. A charge of 75 cents a visit is made in theory to those who can pay, but collections are few. ; We were interested to determine how far this bedside service was adequate for rural needs. With this end in view, Miss Mar- garet Pierce, of the National Organization for Public Health Nursing, was asked to make an intensive study of 120 cases of serious illness which had occurred in villages and rural areas of the County within the past year. Fifty of these cases were found through schools and 61 through the nurses (not limited, of course, to cases they had cared for), the rest in other ways. Half the cases were among adults and one-third among children of school age. Seventy of the diseases were of a communicable nature, 33 of other acute types and 17 chronic. Of these 120 cases, 113 were under medical care and 33 at- tended a hospital or clinic. Thirty-two of the 120 had the service of the public health nurse. (This figure is no doubt too high for a general average, since half the total cases were obtained from nurses and they naturally knew of all the cases they cared for 182 Health on the Farm and in the Village and not of all the others.) These patients received an average of 10 visits per case. Thirteen cases had the care of a private duty nurse and 22 of a “practical” nurse, while 53 cases were cared for only by the family or a neighbor. In 76 of the total of 120 cases it seemed that the actual home nursing care given to the patient was reasonably adequate and that in 44 cases it was inadequate. Pride in family self-reliance was a barrier to the use of nursing service and 33 out of 85 families did not know that the county nurses were available for bedside care. In general, this picture seems to the writer more satisfactory than might have been expected; and it would be interesting to have comparative information for other communities. It is, in any case, clear that at least a third of these cases of serious illness did not receive the nursing care they needed; and this suggests the question whether effort should be made to develop bedside nursing service to a greater extent in Cattaraugus County—or other rural areas. Against any such attempt at radically extensive development, there are two good arguments. It was clear to Miss Pierce that there was distinctly no strong demand for such expansion on the part of the rural population. The tradition of the farm is one of independence and self-sufficiency. It is also clear that any great expansion of bedside care would seriously cripple the pre- ventive services rendered by the nurses, which are, after all, the primary interest of a health department. The writer believes, however, that it would be an irreparable blow to sound nursing policy if such a nursing staff as that of Cat- taraugus County did not stand ready to meet emergent needs for bedside care. Any such course would make essential some other organization for providing visiting nurse service and thus involve a serious loss of the great values of a generalized district program. Furthermore, it should always be borne in mind that the real reason why we have turned to the nurse as a messenger of health is that she is also a minister of healing, and her value as a hygienic advisor suffers seriously when she ceases to be a nurse. Nursing 183 In general, then, the policy pursued in Cattaraugus, of pro- viding bedside care when called for, but not stressing it as a major element in the program, seems essentially sound and should be continued in the future. It might well be remembered, also, that the rural nurse plays a most important role in supervising the home care rendered by family and neighbors. In the continuance of bedside service, which we deem so de- sirable, it seems important to emphasize and insist upon payment by those in position to pay the whole or a part of the cost of the service. Fundamental health protective measures and health education are the birthright of every citizen, but special service such as bedside nursing should be paid for by those able to do so, just as the same class of persons pay for institutional care in many tax-supported hospitals. Social Service Problems. It has been made clear in many sec- tions of this survey that the problems of social relief in Cattarau- gus (as in other rural areas) are exceedingly acute and have, in the past, been relatively unrecognized and uncared for. The de- velopment of an adequate nursing service has the effect of un- covering these problems, with an enormous resulting burden of responsibility upon the nursing staff—a responsibility which they can scarcely evade but which they have neither the time nor the professional equipment to meet. There is an illuminating discussion of this general problem by Miss K. D. Hardwick in the Public Health Nurse for March, 1930. The importance of this situation was recognized early in the demonstration and a social worker was employed under the auspices of the Tuberculosis and Public Health Association in 1924, two others being later added to the staff. The general problem of social service will be discussed in Chapter XIII and we are here only concerned with the impact of this problem upon the work of the nursing staff. The first phase of the attempt to meet the social situation was characterized by the setting up of a special staff of social case workers under the Tuberculosis and Public Health Association and, valuable as it was in meeting emergent social needs, this plan 184 Health on the Farm and in the Village by no means gave the nurses the help which they needed. The emphasis of the case work program was on problems of mental defect, on neglected and dependent children and on cases re- quiring court action. This was probably a wise policy from the case work standpoint, but the general family situations and the problems of medical relief with which the nurses were spe- cially concerned were not cared for. In 1926, a special effort was made to secure better working relationships. A new schedule was drawn up of the type of service to be rendered by the case workers and provision made for case conferences and an advisory relationship of the director of social service to the nursing staff. Conditions improved somewhat, but really effective codperation was not brought about and the social service staff was quite unable to meet with adequacy the needs for medical social work. In 1928, on the recommendation of the Nursing Advisory Committee, a new plan was put in force, by the employment on the county nursing staff of a special social service consultant. This experiment was of very real value in developing a sense of social case work on the part of the staff nurses, but this value was not so great as it might have been if the worker in question had had a background involving wider knowledge of medical social work. Furthermore, the closer cooperation between the nurses and the social case workers, which the establishment of such a liaison officer might have brought about, was notably lacking. After fourteen months, this experiment was discontinued and there is still no wholly satisfactory contact between the nurses and the social case workers, who are now two in number, attached to the County Welfare Department and no longer to the Tuber- culosis and Public Health Association. The details of these two, only partially successful, attempts to solve the problem of medical social service have been considered in detail by Miss Tucker and Miss Margaret Byington of the New York School of Social Work. It seems probable that either the plan of two independent but codperating staffs or the plan of a social case work consultant on the Health Department staff, might have worked with other personalities. Logically, how- Nursing 185 ever, the writer is inclined to feel that in a rural nursing program, such as that of Cattaraugus, the permanent employment of a social case work nursing supervisor would scarcely be justified and would be likely in the long run to produce the same conflict of interests which developed in 1928 and 1929. He is much im- pressed with Miss Byington’s suggestion that correlation could most effectively be attained by decentralization of social service and the establishment of close and intimate local district contacts. Definite procedure should be formulated for reporting and re- ferring cases, so that each service may keep the other informed of the facts at hand and the progress made with a given case. Sys- tematic case conferences are needed, in which staff nurses and perhaps members of the local nursing committees should be in- cluded. Ideal results cannot, of course, be attained without a sufficient social service staff to permit broadening the program to include general family case work and without adequate finan- cial resources for relief. In any case, it seems clear that the staff nurses greatly need special aid in the handling of the case work problems with which they must necessarily deal and it seems possible that the whole problem could be best solved by the appointment on the nursing staff of a special consultant on psychiatric social work, rather than on social case work in general. This experiment also was tried in Cattaraugus in 1926, but only for six weeks and under conditions of personnel not conducive to success. Miss Tucker has suggested that such a psychiatric worker might well serve as an official consultant to both the nursing and social service staffs of the County. She says in discussing the matter, “If the nursing staff could have the benefit of the guidance of a psychiatric social worker who would increase their knowledge and awareness through group and individual teaching, who could advise on specific cases and act as general consultant, the sound- ness and effectiveness of the public health nursing program itself would be materially increased. Such a development has passed beyond the experimental state in many public health nursing organizations in cities. There would seem to be even more need 186 Health on the Farm and in the Village for it in a rural area where the public health nurse necessarily carries more responsibilities. It should be pointed out, however, that such a development is not to make psychiatric workers of public health nurses but to make them better public health nurses, better able to handle intelligently the responsibilities they have already accepted and to put to their use the knowledge that is at hand in the field of mental hygiene.” . The plan suggested would kill three birds with one stone. It would give to the nurses the type of leadership, education and supervision needed in dealing with the social problems which every public health nurse—and, particularly, every rural nurse— must, in some measure, be prepared to meet. It would, if the right personality were involved, and if the individual were offi- cially related to both nurses and case workers, promote an effective liaison between the nursing staff and the social service staff. And it would lay a foundation for the beginning of a county mental hygiene program. The Nursing Service as a Training Center. Finally, a word should be said as to the special service rendered by the nursing program of Cattaraugus County to the general cause of nursing education. ‘There are few greater needs in this field than adequate facilities for rural experience in the training of undergraduate and graduate nurses. Since 1926, Cattaraugus has been used as a training center for four graduate nurses from a local training school (now discontinued) and for fifteen advanced students from Teachers College, Columbia University, New York, who have spent from two to four months in the County working under the supervision of the Educational Director. This program has been of great value to the students concerned and their presence has proved a stimulus and inspiration to the local staff. Summary. The place which the nurse occupies in the public health program of Cattaraugus County has been admirably stated by Dr. Atwater in the following paragraphs. “A separate statement of the work in public health nursing is of necessity largely concerned with quantitative measures of the work accomplished. The real report of the public health Nursing 187 nurses, however, deserves a place on every page of the entire departmental record, for these nurses are, indeed, the machinery through which most of the results are now accomplished. Home visits by the nurses are the essence of successful clinic work, school hygiene and communicable disease control. Any numeri- cal statement of work done must, therefore, be interpreted in the light of the whole service rendered by the nursing staff. “The cost of the nursing service rendered during the year represents 42 per cent of total expenditures. This is one ap- proach to the significant position which the public health nurse bears in relation to the whole enterprise. The public health ad- ministrator realizes that scarcely a wheel can turn in the public health program without the public health nurse. To say that she is indispensable to the program does not cover the fact. Her work is the program to a great extent.” The Cattaraugus nursing program is almost unique in three respects. In the first place, there are not more than two or three rural counties in the United States where the problem of an adequate volume of nursing service has been satisfactorily solved as it has been solved in Cattaraugus. We have seen that less than 10 per cent of those rural counties which have any county health service at all provide service in a ratio better than 1 nurse to 10,000 population. Only 4 of the 442 rural counties analyzed in Chap- ter VIII have a ratio better than 1 nurse to 5,000 people. Among the larger counties of over 100,000 population, with full-time service, Chatham County, Georgia, is the only one fully com- parable to Cattaraugus and the only county without full-time health service but with an adequate nursing staff with which the writer is familiar is Monmouth County, New Jersey. In the second place, the Cattaraugus program is a model in the development of a completely generalized county-wide service covering all forms of educational and bedside nursing. In its decentralized district service and in the balance of work per- formed, it is entirely sound and points the way along which other counties should seek to develop. 188 Health on the Farm and in the Village In the third place, the Cattaraugus program is almost unique in the perfection with which the whole nursing service is in- tegrated with the rest of the public health program. Even in urban areas, public health nursing under official auspices is often either starved and undeveloped and is poor in quality or is set up as a more or less separate imperium in imperio. In rural areas we find almost universally, either scattered isolated nursing units, doing individual jobs for local authorities or unofficial agencies without supervision or correlation, or a general service by state or county nurses which, on account of limitations of personnel, can amount to little more than occasional inspection and stimulation. Only in San Joaquin County, California, so far as the writer is aware, is there a county-wide organization rendering full home service and also knit into the whole county health program in an ideal fashion. It is a cause for surprise and regret that this admirable example of a model type of organization should not have been developed in Cattaraugus to include more of the local services in existence when the county plan was introduced. It has been pointed out that there are still nine local nurses in the County outside the generalized scheme. The Gowanda and Indian situations must probably remain as they are for administrative reasons. It would be of great advantage, however, if the Olean, Salamanca and Portville nurses could be brought more definitely into the county scheme. Particularly in the case of Salamanca and Portville, there is evidence that the present program is neither economical nor efficient. The plan adopted in Cattaraugus County of employing special- ized supervisors for a temporary period to develop techniques and carry on staff education along their special lines is an inter- esting and a sound one. Such an organization as that of Cat- taraugus cannot be expected to maintain a permanent staff of specialized supervisors, but the specialists employed temporarily in the fields of tuberculosis, infant welfare, social case work and nutrition seem to have been notably successful in leaving a perma- nent impress upon the staff program. The social hygiene influ- Nursing 189 ence appears to have been less lasting, probably because the special supervisor in this field was used chiefly to handle cases directly and did not really function as a supervisor. This problem needs reémphasis in the supervisory and staff education program. It is impossible yet to determine the effect of the discontinuance of special supervision in school hygiene. As Miss Tucker points out, there is, now that specialized supervision has been discontinued, an opportunity to profit by the supervisory and consultant services offered along various lines by the State Department of Health, the State Departments of Education and Mental Hygiene and the American Red Cross—an opportunity which should be utilized to the full. When funds can be obtained it would be highly desirable to add to the staff a special consultant on psychiatric social work for the purposes outlined in an earlier paragraph. Taken as a whole, the Cattaraugus nursing program, in its quantitative adequacy, its generalized district service and its integration with the health program as a whole, is an inspiring example of what may be done in carrying health to the farm dweller. - CHAPTER XIII SOCIAL SERVICE"* The Need. Perhaps the most significant by-product of the Cattaraugus demonstration has been its revelation of the gravity of the social problems which confront the worker in a rural area. Originally conceived as a health demonstration, the availability of facilities for material relief and social reconstruction was tacitly assumed in the drafting of the program; but in no way at first were such facilities specifically provided for. It is usually the case, however, that a serious attempt to solve one problem reveals other problems in a new light. Just as soon as reasonably adequate nursing service was provided for Cattaraugus County, the need for social service which had been unnoted and ignored was made obvious and glaring. Within a few months this need was so clearly apparent that efforts were made to meet it; and such efforts, along several different lines, have been repeated during the past six years. The lessons to be drawn from the varied experi- ence obtained are highly instructive. They have been analyzed in detail by Miss Margaret Byington and will be briefly reviewed in the present chapter. First of all, however, it seems desirable to note the major funda- mental fact which the whole of this experience most strongly emphasizes—the appalling extent of the social problems which present themselves in a rural area. This fact is no novelty to the trained social worker; but its significance is rarely fully visual- ized by the public health administrator, and to the layman, the countryside is a symbol of peace and plenty, while poverty and suffering are considered as attributes of the city tenements. 1 This chapter is based upon the special report presented by Miss Margaret Byington on the social problems of Cattaraugus County. 190 Social Service 191 The visitor driving along the main motor-roads of Cattaraugus County sees, for the most part, only prosperous, well-painted farms and residences with spacious barns and gardens aflame with roses and hollyhocks. The picture obtained is scarcely more typical than a view of New York City obtained on Fifth Avenue or Riverside Drive. In the hamlets, up in the re- mote valleys, among the hills, lies the gravest problem. Here, the tenant farmer struggles with poor and unproductive land and uses every spare cent to pay for fodder for his dairy! cattle. It is not only in the more ill-kempt and dilapidated farms, however, that social problems are presented. Even where there is a fair exterior, living conditions may be arduous; and the net total of the problem revealed during the past six years in Cattarau- gus County is staggering. In a single month, the first social worker to attack this heavy task reported 38 new cases repre- senting “dependency, inadequate relief, desertion, delinquency, mental defect, neglect, improper guardianship, poverty, rape, in- cest, immorality, transportation for tuberculosis cases, venereal disease, placement of dependent children and supervision of board- ing homes.” Let us review half a dozen cases, taken from the records of the social case workers and nurses at work in the county. A. A family of eight, father, mother and six children be- tween 8 and 23 years of age. The mother is epileptic. The children are all said to have had fits”. The oldest daughter, 23, has had two children by her father, one an idiot of 3 years, one a girl of 1 year. No one in the neighborhood has ever seen the second child. ‘The door of the house is always kept locked and when anyone calls, the door is not opened until this child has been hidden in the barn or hen house, or until the visitor leaves. The father is known as the “bad character of the neighborhood”. B. Family, town charges. Man, syphilitic with open lesions. Mother, low grade mentality. Living conditions horrible. Three children, half starved. 192 Health on the Farm and in the Village C. Father, white, mother, Indian, eleven children between 13 months and 20 years of age and two unmarried uncles living in a crude two-room shack in very isolated section. Heaps of ragged bedclothing on floor of one small dark room where entire family slept. Oldest girl reported to be mother of two illegiti- mate children by her uncle or father. Children attend school very irregularly, are undernourished and suffer from many physical defects, including running ears, scabies, bad tonsils, cross eyes and speech defects. Entire family mentally defective, with possible exception of father. Some of the children wear only outside garments which only partially cover their naked- ness and are without shoes or stockings or underwear even in coldest winter weather. D. Father earning $5 to $8 a day. Mother of mental age of 6.6 years, with three neglected children and an old sick grand- mother in a filthy home. “Whenever interest in their welfare became too intense, the family moved. Then presently the new neighbors became excited about the filthy home, the rags in which the children were clothed and reported the case again.” In February, 1930, this family settled in a chicken coop on a neighbor’s farm, the children sleeping on straw in the corner. Eldest girl, 15, married and has a baby. E. Tiny house on low, damp ground with water for drinking carried from an adjacent lot. Eight rooms and eleven people. Rooms very dark and dirty. Feeble-minded child with webbed fingers and toes and cleft palate. Daughter of 14 with mental age of 8.4 years, pregnant either by brother or grandfather. F. Home on mountains with dark kitchen, uneven rough board floor, apparently not swept for months, dirty rags in corner, streaks of half-cooked dough and burned pancakes on stove, living-room with pile of filthy bedding on floor and similar piles on two beds along one side. Four little children huddled in one corner, apparently mentally defective, two of them children of daughter of family by her own father. The last three of these situations have been materially relieved by social service. Such conditions are by no means peculiar to Cattaraugus County. On the contrary, it is a very real achievement that Cattaraugus County has brought out into the light problems which are usually forgotten or ignored. Social Service 193 The essential deduction is stated with great moderation by Miss Byington as follows: “All the evidence brought out in this study points to the conclusion that individuals and families living in small towns and rural communities suffer from social maladjustments as complex and varied as do city dwellers; in fact, conditions apparently exist in isolated hamlets that would hardly be tolerated in more congested neighborhoods. “The rural community should, therefore, ideally, place at the disposal of its disadvantaged members social service as ade- quate and as skilled as exists in urban areas.” Social Resources of the County Prior to 1923. At the be- ginning of the demonstration period, Cattaraugus had only the usual meager resources of the ordinary rural county. There was a superintendent of the poor at Machias and each of the thirty-three cities and townships had its local poormaster. The system was administered along the conventional lines of granting relief at home only under urgent pressure. As a matter of fact, in 1923, only $11,665.71 of public funds were actually expended for outdoor relief by all public authorities throughout the County. A representative of the State Board of Charities reported in 1921, “Preventive family relief is given no consideration by poor law officials, and apparently the treatment of children’s cases, in- cluding the mentally defective, is entirely inadequate.” There was a Board of Child Welfare administering widows’ aid, but with no expert advice and wholly inadequate grants. The customary allowance was, and is, $5 a month per child and sometimes an additional $4 for the mother herself. The county branch of the Society for the Prevention of Cruelty to Children has one worker (not technically trained), who also serves as attendance officer for the city of Olean and as unofficial pro- bation officer for its juvenile court. The cities of Olean and Salamanca also carry on certain relief and service programs on a private basis. Olean has a com- munity chest with a budget of $29,330 in 1928 including support 194 Health on the Farm and in the Village for a city relief society ($2,000), the Salvation Army ($1,500), the Anti-Tuberculosis Society ($5,850), the School Nutritional Fund ($1,500), the Olean General Hospital ($5,000), and the Red Cross ($2,800)—the remainder being for Boy and Girl Scouts, Campfire Girls, Society for the Prevention of Cruelty to * Animals, and administrative overhead and emergencies. The Catholic Charities of the Diocese of Buffalo have for two years had an office in Olean, and the King’s Daughters, Queen’s Daughters and various benefit organizations do more or less informal chari- table work. The County had but one outstanding piece of social machinery, in the form of the Randolph Home, established in 1850 and since supported with praiseworthy generosity by a group of public- spirited citizens. It houses 100 children, many of them from outside the limits of Cattaraugus, only 38 being county charges in 1929. Admirable as it is in many ways, the Home has no social case worker and no follow-up after discharge and cannot, there- fore, serve one of the most important objectives of a modern children’s institution—that of a center for home placement. The outstanding fact of the whole situation was that, in the whole County, prior to 1923, there was not a single technically trained social worker, so that intelligent social reconstruction was impossible; while no agency, either official or voluntary, had funds for even adequate emergency relief. ‘The condition with respect to dependent children was recognized as particularly acute because it was particularly obvious. Indenture was in force. There was often no supervision of adoption. There were no records, even, by which the history of a given child could be intelligently followed, if there had been anyone to follow it. There was no provision for medical care in other than acute cases. The problem of mental deficiency was scarcely recognized. Socially, the situation corresponded to that which would exist medically, in an area with no doctors and no nurses and no board of health, but with a single layman in each town who might, or might not, have taken a short course in first aid. Again, it must be emphasized that Cattaraugus County was Social Service 195 in no respect singular in this respect. It was probably typical of most of the rural areas of the United States today. Development of the Social Service Program of the Demon- stration. It took only a few months of intensive public health nursing in Cattaraugus County to reveal the urgency of social needs and the lack of facilities for meeting them; and in March, 1924, the Technical Board of the Milbank Memorial Fund de- cided that a social worker must be added to the demonstration staff. It was decided to develop this phase of the work through the medium of the County Tuberculosis and Public Health As- sociation, and in April the first social case worker was appointed to serve with this organization. Through 1926, with a short interregnum following a resignation, one worker attempted to carry this heavy load. In January, 1927, a second case worker was appointed and in October, 1927, a third. In June, 1929, a fourth worker was added, her salary to be paid from the funds provided by the Olean Community Chest and the Olean Hospital. All in all, during the six years from April, 1924 to April, 1930, the staff was as follows (allowing for temporary vacancies) : No worker for 6 months 1 worker for 18 months 2 workers for 28 months 3 workers for 14 months 4 workers for 6 months The financial burden of social service was borne up to No- vember, 1929, entirely by the Milbank Memorial Fund, aside from the fourth worker employed in Olean, to whom reference has been made above. The annual budget from the Fund for this purpose, mounted from $2,348.00 in 1924 (nine months) to $10,364.00 in 1929. The general results of the work will be considered in a succeed- ing paragraph, but the historical development of the program cannot be understood without pointing out certain essential limiting conditions. Foremost among these is the fact that the 196 Health on the Farm and in the Village first social workers were sent into the County without any clear definition of their rdle in the program as a whole. Since the demonstration was essentially a health demonstration, the health workers not unnaturally visualized social service as primarily an aid in the solution of health problems; while the social workers, finding other conditions, such as those relating to dependent and neglected children, most pressing, naturally, devoted their at- tention largely to them. Here was a fundamental source of dissatisfaction as between the two groups. Furthermore, the members of the social service staff had not, for the most part, enjoyed very wide experience before coming to the County, and only one of them had had any experience at all in the more specifically medical phases of social work. The case workers under the County Tuberculosis and Pub- lic Health Association showed a fine spirit in attacking a task of great difficulty. To one who knows the roads of Cattaraugus County in winter, the fact that the social workers recorded auto travel amounting to 1,800 miles in January, 1926, and 2,088 miles in April, 1926, is, of itself, eloquent of achieve- ment. When the second of the workers, Miss Roble, took office, in February, 1925, she found 104 cases already on the records, need- ing further and continued care. She made 105 visits during the month of April to these and to new cases—a good record but obviously a volume of work wholly inadequate to meet the need. The number of new cases taken under care rose from 129 in 1924 t0 208 in 1929, the total being 1,048 for the six years. In the latter part of the period, the case load per worker seems by no means heavy (about six new and reopened cases per worker per month) ; but it is difficult to evaluate social case work in quan- titative terms. ‘The content of a public health nursing case of a given type is more or less standardized, but a problem of family readjustment may take days and days to solve. In any case it is evident that the social service staff, even at its maximum, was almost wholly preoccupied with emergent and critical problems of a remedial nature, such as those involving Social Service 197 court action and institutionalization, and at no period had ade- quate time for real family reconstruction. The work was largely emergency relief rather than preventive case work. Miss Bying- ton suggests that in a demonstration program the social workers might well have been asked to close their eyes to some of the urgent but essentially hopeless problems and to concentrate on the ultimately more fruitful task of constructive prevention; but this policy was not adopted. The actual work of the social service staff was, then, largely devoted to acute situations demanding drastic legal or institutional remedies and chiefly to those concerned with child care. In about half the cases handled, problems of child dependency or neglect of children were predominant, as against only 10 per cent and 8 per cent, respectively, in which health and mental problems formed the predominant issue. Add to this the fact that the work of the staff came more and more to be concentrated in Olean (9 per cent of all cases in Olean in 1923 and 48 per cent in 1929), where the county nurses were not working, and the fact that conferences between the two groups were too infrequent for either to understand the problems of the other, and it will be clear why the nursing staff, as pointed out in Chapter XII, came to feel that its demands in the field of social service were not be- ing met. In 1926, an attempt was made to relieve the needs of the nurses by the appointment of a psychiatric social worker on the Health Department staff. This experiment lasted only a few weeks and failed for purely personal reasons. In 1927, Miss Susan M. Boyd was appointed director of the social service staff, with two assistants. In 1928, a social service consultant was added to the county nursing staff and this second experiment was con- tinued up to October, 1929. In 1928, too, for the first time a serious attempt was made to visualize the social problems of the County as a whole and to define their relation to its health problems. Even the valuable joint program which was drawn up at this time, however, was concerned chiefly with emergency relief and laid little or no stress upon fundamental measures of 198 Health on the Farm and in the Village family reconstruction. To draw an analogy from the health field, the program was concerned rather with the care of social sickness than with the prevention of social maladjustments. The preoccupation of the social staff with problems involving urgent legal and institutional problems had, however, its practically helpful aspects. It made the service intimately and favorably known to the public authorities of the County, so that when the Milbank appropriations were withdrawn this year, the County, in April, 1930, took over two of the demonstration social workers as assistants to the County Commissioner of Public Welfare. Results of the Social Service Demonstration Program. Miss Byington’s report, based upon first hand study of the work per- formed and on a study of over 200 of a total of 946 available case records, reveals three fundamental shortcomings in the social program of the past six years, which may be summarized as follows. In the first place, it is clear that the social service staff, as set up in Cattaraugus County, fell far short of the need felt by the health workers for aid in solving the social factors complicating their health problems. Of a total of 73 cases referred to the social service staff in 1924-1926 from all sources, 33 were never visited at all; while of 41 cases referred by the nurses during this same period, 16 were never visited. Out of 87 families in which tuberculosis was present, 23 presented definite social problems; but only § were known to the Social Service Department. Furthermore, Miss Byington analyzes 9 cases actually handled by the social service staff in which tuberculosis was a predominant problem and concludes that in no instance in which a plan for the family was asked for, was adequate financial relief actually provided. Nor was the situation greatly ameliorated by the appointment of the social service consultant on the County Health Depart- ment staff. This worker did accomplish much in developing the social consciousness of the staff nurses; but Miss Byington cites striking instances of wasted effort on the part of nurses in dealing Social Service 199 with superficial health problems without regard to their funda- mental social causes. One is impressed again and again by records of endless counselling of mothers in regard to sunbaths, sleeping arrangements or correction of physical defects, when it should have been obvious that the mental status of the mother or the economic condition of the home made such advice futile. Even after the appointment of the social service consultant, the two staffs failed to work together effectively. Mutual contacts were inadequate, joint planning rare and the records of the two services are barren of reference on the part of one to the activities of the other. It is an eloquent fact that between October, 1929, and April, 1930, only 12 cases were referred by nurses to the Social Service Department. For the four years 1926-1929, however, 31 per cent of the social service cases were referred by the nurses, 23 per cent by other social agencies, schools and churches, 20 per cent by public officials and courts, 19 per cent by relatives and interested in- dividuals and 7 per cent came in as personal applications. The second, and more fundamental, defect in the social service program was its preoccupation with emergent problems demand- ing immediate radical action rather than with those involving the more fruitful tasks of social reconstruction. There are few instances in which it was possible to deal with a family problem in its incipient stages and to effect the sort of readjustment which will prevent the breaking up of a home five years later. There were many cases in which institutional care and protection was secured for girls and young women and institutional training for defective children, but few in which the far more rewarding task of personality adjustment could be attacked. The reasons for these limitations of the program were threefold: lack of adequate funds for rehabilitation (the success of the county program for the care of crippled children shows how much can be done when such funds are available) ; the deficient back- ground of certain members of the staff; and, most important of all, the quantitative inadequacy of the staff to meet the task in hand. The Cattaraugus program provided a much more nearly 200 Health on the Farm and in the Village adequate staff than is available in most rural counties, but (except perhaps for 1929) it was sufficient only for critical emergency needs, not for fundamental social reconstruction. In 1929, there were 3 workers for half the year on the social service staff and 4 for the other half year, plus the social case work supervisor on the nursing staff. In this year the case load of the social workers was 28 cases per worker per month, which is not high. Finally, there is a third respect in which the social service program seems to have fallen short of its largest potentialities. This is the failure to enlist in its favor a general enlightened local public support. A general Committee on Social Service for the County was created, but it was never active and there were no local groups formed comparable to those which have been so help- ful in the nursing program. The fact that funds for social service and the direction for social service came largely from New York perhaps militated against local initiative; but, from what- ever cause, it is clear that no general unofficial support was ever developed for the program as a whole. On the other side of the account, the demonstration has sub- stantial and inspiring accomplishments to its credit. A vast volume of unsuspected social maladjustments was revealed and, in its more acute phases, ameliorated. Miss Byington makes the following brief summary of the major achievements of the social service staff: “During the six years, 1,048 different families received help in solving their social and economic problems from the staff of the Department. “Nearly half of these families were outside the towns of Salamanca and Olean. Such problems arose in all but one of the 33 townships, the proportion from each following very closely the general distribution of the population. “These families presented social problems of every type and of every form of human need. The largest group were those of children suffering from neglect and in desperate need of pro- tection. “By the close of 1929, 95 children were under the supervision + or, frat ed a © 5 og Oat st Social Service 201 of the Department, of whom 7 were in free homes and §1 in boarding homes, the remainder in hospitals or institutions. For each of these children a careful plan was made involving physical and mental examinations, correction of physical defects with the assistance of public officials, and current supervision of foster homes. There is every evidence of radical improve- ment in the physical and mental condition of many of these children. “A new standard was created for the investigation and super- vision of foster homes. It proved possible to find in the County families of good standard who were willing to give kindly and intelligent care to these neglected children. The 28 homes in use in January, 1930, showed a good standard, 27 of the families being American born, 26 owning their own homes, all of them people who are respected in their own communities. “The Department played a very large part in the carrying on of the mental hygiene work of the County. They arranged for the schedule of examinations for the clinic and secured most of the social histories. In 1925, 146 individuals were examined in the clinic. As a result of this work it was possible to break up homes of low mental and moral standard and to secure in- stitutional care, especially for girls in danger because of their mental inadequacies. “Special service was also given to 49 unmarried mothers, practically all of the cases which arose in the County during the period. Care and supervision was secured for both mothers and children. “Assistance was given to the nurses in difficult cases, arrange- ments being made for relief from public funds and for court action in cases of neglect. “A steadily increasing use was made by public officials of the skill of the social workers, thus helping to create a better standard of work in the community. “Some coordination of the work of private agencies was also achieved with the development of a confidential exchange and of codperative service for individual families. There is un- doubtedly a better understanding in the County of the pos- sibilities of constructive work than there was prior to the dem- onstration.” 202 Health on the Farm and in the Village In spite of the pressure of work, many individual cases were handled with technical skill and success, of which a single case cited by Miss Byington may be reviewed as illustrative. An Italian widow (not a citizen), with six children under twelve years of age, was being spasmodically aided by poormasters and local organizations in two townships (one a legal, the other an actual residence). The mother had been advised to give up the two older boys, who presented behavior problems, and to find work outside her home. The social worker found that the behavior problems were not serious, that the mother was un- fitted for outside work and that her absence from home would seriously prejudice the welfare of the younger children. A con- ference was called, including the County Superintendent, the overseers of the two towns involved, the local nurse, a repre- sentative from a local charity organizatior and a friend of the family. A budget for the family was worked out and approved by the official and unofficial agencies and the social worker agreed to supervise the family and secure mental hygiene guidance for the two boys. This is real social case work; and many such in- stances could be cited if space limitation would permit. The major achievement of the social service staff from a practi- cal standpoint has been the development of a comprehensive program for the supervision of boarding homes. In most New York counties, such homes are licensed by local boards of health, and in a highly casual manner. In Cattaraugus, for example, there was found under the old system a boy who had been placed in the family of an Italian bootlegger where he was taught only Italian and frequently given liquor, so that he would “act up” to amuse the family. Now, however, the licensing is central - ized in the hands of the County Board of Health. According to a plan worked out in June, 1928, the social service staff in- vestigates prospective homes, makes financial and legal arrange- ments in cooperation with public authorities (including provision for correction of physical defects), and supervises the social con- ditions in the homes after placement. The Health Department issues licenses, reports the results of physical examinations to the Social Service 203 Social Service Department and supervises health conditions in the homes through its local nurses. The plan seems a model one and is operating with substantial success. In general, the work of the Social Service Department has been highly fruitful in dealing with such problems as are likely to be referred by public officials—such as securing commitment of juvenile delinquents and sex offenders presenting mental problems, placement of the children of parents committed to jail, mental examinations of school children presenting behavior problems and the like. Thus, while the social service program has failed to develop an organized body of volunteer aid, it has notably succeeded in winning the confidence and support of public officials. The fact that appropriations from county and local sources for outdoor relief have risen from $11,666 in 1923 to $40,320 in 1929, is eloquent of success along this line, and even more signifi- cant is the fact that, on the withdrawal of the Milbank Memorial Fund, the authorities have taken over two social workers as a part of the regular county budget. In general, then, while the demonstration social service pro- gram has proved inadequate to provide a complete program of social prophylaxis and to meet fully the needs of a highly de- veloped health organization, it has revealed unsuspected social problems in their full magnitude, it has dealt with the more critical of these problems (particularly in the field of child care) with notable success, and it has convinced the public authorities of the need of permanent social service as a governmental function. Surely, such results have more than justified the experiment to date. The Future. The outstanding result of this whole experience is the demonstration of the fact that the need for skilled social service in rural districts is far more serious than the lay public, or even the public health worker, has begun to realize. The situation in New York counties should be vastly improved by the new law taking effect this year and providing a coérdinated county organization, animated by the new concept of “Public 204 Health on the Farm and in the Village Welfare” rather than by the older one of “Poor Relief” (see Chapter VII). In Cattaraugus County the fact that two social case workers are now on the county staff and that a third case worker will soon be added, serving as a member of this staff but paid by the Olean Tuberculosis Association and the Olean General Hospital, is highly encouraging. The experience of the demonstration has made it clear, how- ever, that three social workers cannot deal adequately with the needs of a rural county of 70,000 population. In the health field we have come to realize that a definite ratio of public health nursing service to population is essential for good service and that this ratio is approximately one nurse to 2,000 people. Cat- taraugus has approximated this latter ratio, but has attempted to attack its social problems with only one-seventh as many social workers as nurses. Just what the desirable proportion of case workers in a rural population should be, no one can now say. Cattaraugus experience clearly shows that a ratio of one case worker to 20,000 or 25,000 people is too low. The writer would venture to suggest that one to 10,000 is perhaps an ideal toward which we should work for the present. With respect to administrative set-up—viewed particularly from the health angle—neither a separate staff of social workers nor such a staff plus a social service consultant in the health de- partment, has proved wholly satisfactory. The writer is inclined to believe that in a county of the size of Cattaraugus, the employ- ment of a social service consultant as such, on the nursing staff, is scarcely justifiable economically, and is likely to create division of responsibilty. The situation is quite different from that which exists in a large city with ample social service facilities and a nursing staff of 50 or 60. On the other hand, it seems possible, as pointed out in Chapter XII, that a psychiatric social worker serving both the nursing staff and the social service staff would be highly desirable and that such an appointment would sub- stantially contribute to coordination of health and social work. In the main, effective coérdination of these two programs would seem, as Miss Byington has suggested, to be best attained by de- Social Service 205 centralization of the social service, as the health service is now decentralized, and by provision for intimate contact between the two types of local workers in their districts. Through such contact the nurse could be aided in dealing with such social problems as she can properly handle and those which require the service of the trained case worker can be passed over toher. Full exchange of information should be provided for and summaries of each agency’s work made a part of the other agency’s record of a given case. Difficult cases should be planned for in joint conference and such conferences would gradually develop sound general policies of codperation. Finally, it would be most important in the future to develop a wider base of popular understanding and support. Miss Byington states the case admirably in the following paragraph: “What are the essential factors in organizing to take over a genuine community responsibility? A study of the local situa- tion as the basis for the program; a local group responsible for the development of the work; community recognition of this responsibility; stable financing; some means for drawing into its activities individuals and groups in the community who are con- cerned with the task; cooperation with other organizations both public and private, working in the same field; some means of keep- ing the public aware of the nature and volume of its service.” In the future development of social work in Cattaraugus County (and in other counties), this sound statement might well be borne in mind. It would seem clearly of advantage to organize a volunteer, county-wide association to furnish stimulus and support for the official authorities who will be fundamentally responsible for the program, and case committees should be formed in local communities, similar to, and perhaps identical with, the local nursing groups. The part to be played by unofficial agencies in actual financing must be determined as the program evolves; but the codperation of the Olean Tuberculosis Association and the Olean Hospital, as well as the notable success of the Crippled Children’s Committee, augur well for such joint effort. CHAPTER XIV STATISTICAL RESULTS OF THE DEMONSTRATION Statistical Criteria of Accomplishment. 1f our public health programs are justified, they should show tangible results which can be measured in terms of vital statistics. The dictum of Dr. Biggs, “Public Health is purchasable—within natural limitations a community may determine its own death rate” must be our ultimate standard of achievement. The application of this standard is, however, fraught with many and grave dangers. It takes time to produce results. Chance variations so affect mortality rates that, for a short term, in a small community, such rates may have no significance. Finally, even when a variation has statistical validity, it may be influenced by many factors other than those involved in our organized public health program. The Milbank Memorial Fund has wisely placed its analysis of results obtained in the demonstration areas in the hands of one of the ablest and most critical experts in the field of vital statis- tics, Mr. Edgar Sydenstricker, and his contributions to this analysis are of fundamental value to the whole science of public health. His introductory monograph on “The Measurement of Results of Public Health Work” (Annual Report of the Milbank Memorial Fund for 1926) should be read and pondered by all students of this subject. Comparison with Control Communities. Our first need in any scientific experiment (and a health demonstration, if properly conducted, should be such an experiment) is a satis- factory control. It was natural, then, that one of the first thoughts of those who planned the Cattaraugus demonstration 206 Statistical Results of the Demonstration 207 should be the selection of certain similar counties which should serve as control areas for comparison with Cattaraugus. The essential feature of a control area is that it should be in all respects comparable with the experimental area, except in regard to the demonstration program. In laboratory work we do not use “a guinea-pig” as a control. We use a guinea-pig of the same age and weight and in careful work we use one which has been bred from identical stock and subjected during its whole life to identical conditions. When we attempt to apply such criteria to population areas, we find serious difficulties. No two areas are identical in racial composition, in social and economic conditions, in history and psychology; and the more carefully we study this question the more serious do these differences appear. The problem may be most clearly indicated by a typical case. After careful consideration of known facts as to racial and social status, the counties of Chautauqua, Jefferson and Steuben were selected as those counties in New York State most nearly com- parable to Cattaraugus. In Fig. 7 are presented the graphs of the tuberculosis death rates in these counties as prepared by Mr. Sydenstricker two years ago (Quarterly Bulletin, Milbank Me- morial Fund, April, 1928). Evidently we have here no satisfactory control guinea-pigs. If we were studying the effect of a new vitamin, we should use animals which, prior to the experimental period, had the same weight and were gaining at the same rate. On the other hand the “control counties” had tuberculosis rates in 1900 which were from 49 per cent to 86 per cent higher than those of Cattaraugus. We cannot explain why these differences existed, but they did exist. We should clearly be in error if we concluded that the Cat- taraugus demonstration had succeeded because this county had in 1927 a tuberculosis death rate lower then than of Chautauqua or Steuben, since its death rate was lower than that of these counties long before the demonstration started. It would be equally fallacious to draw the opposite conclusion, that the Cattaraugus demonstration had failed because the rate of decline in the death rate in this county since 1923 has been 208 Health on the Farm and in the Village 1900 1905 1910 1915 1920 1925 156 TUBERCULOSIS MORTALITY 5% 1900-1927 DEATHS PER 100000 POPULATION Tr YT ~ CATTARAUGUS COUNTY Fic. 7 Statistical Results of the Demonstration 209 substantially the same as that in Jefferson where no special pro- gram has been in force. The graphs show, as has been demon- strated in many other studies of this subject, that wherever we find an initially high mortality from tuberculosis we find also a relatively rapid rate of decline. The reasons for this phenomenon are not clearly understood but the fact remains. Each of the counties on the graph has not only its characteristic initial mortality, but its characteristic rate of decline. For each, there is a definite trend line, determined by uncontrollable and un- known factors, and these trend lines are so widely different that the idea of using even counties, so apparently similar in demo- graphic and social characteristics, as scientific “controls” is manifestly absurd. There is, however, one striking and significant fact revealed by Fig. 7. In the other three counties, and in Cattaraugus up to 1924, the annual death rates fluctuated up and down about the definite trend line characteristic of the community in question. Since 1924, however, the Cattaraugus rate has deviated sharply and significantly from this trend. Here, as it seems to the writer, lies the key to the problem. We must frankly abandon the idea of using control areas for the measurement of public health achievements in any strict and literal sense; for there are no control areas which we may affirm with any certainty to be comparable. We must use our experi- mental area, and its various subdivisions, at various periods of time as its own control. Here, we can say with certainty that the material studied is truly comparable and that no factors have entered in other than those variables whose influence we seek to measure. We must compare other areas only for the purpose of seeing that no general cyclical or economic influences are at work, but our main criterion must be what has happened in the area where a change in health procedure has occurred, before and after that change. It is this method which seems to be the only valid one and which will be used in our subsequent discussion. Vital Statistics of Cattaraugus County in 1920. First of all, 210 Health on the Farm and in the Village it seems desirable to present a picture of the health situation in Cattaraugus County prior to the demonstration period in order to visualize the essential health problems to be met. For this purpose, the accompanying Table 42 has been prepared indicat- ing the average death rates from the more important causes in Cattaraugus County and in the United States Registration Area (as of 1919) for the three-year period 1919-1921. It will be noted that Cattaraugus had, in 1919-1921, low death rates from typhoid fever, measles, scarlet fever, influenza, Table 42. Deaths per 100,000 population by principal causes, in Catta- raugus County and in the United States Registration Area of 1919, Average 1919-1921. CATTA- |REGISTRA-| CATTA- |REGISTRA- CAUSE RAUGUS TION CAUSE RAUGUS TION County AREA County AREA Typhoid fever . . 5.6 8.7 || Heart diseases . .| 261.4 | 155.1 Other diseases of the Smallpox. . . . . 0.0 0.6 circulatory system. | 43.3 26.9 Measles, . . . . 4.7 5.7 || Broncho and lobar pneumonia . . .| 116.3 | 116.2 Scarlet fever . . 2.8 4.2 Giher disonees of ros Whooping cough . . 9.8 9.1 spiratory system .| 24.8 224 : : Diarrhea and enteri- Diphtheria . . . . 16.8 16.0 tis under two . . 24.8 43.6 Appendicitis . . . 15.9 132 Influenza . . , , 36.4 60.1 Other dischzcs oi tho Poliomyelitis . . . 0.9 1.2 digestive system . 79.8 37.9 Acute and chronic Tuberculosis, pulmo- nephritis . . .| 96.7 | 88.0 mary . . . , . 63.1 100.0 || Other diseases of the : . genito-urinary sys- Tuberenlosls, main. 2 sel Bn oS ny] eo & ponte : “|| Puerperal diseases .| 21.0 17.7 Tuberculosis, other . 6.5 8.1 Piienser oF the skin 7 3 : and cellular tissues .0 39 Of oiacmie nd ys | any | DRcwcsolthebones eases. : : and organs of loco- Cancer . . . . .| 105.0 83.3 motion sel oti 23 24 Diabetes . . . .| 21.9 | 159 || Congenital debility, prematurity and Other general diseases | 28.9 20.6 diseases of early Cerebral hemorrhage spe Trident 248 na and apoplexy . | 127.8 80.6 Auto accidents 12.6 10.5 Other diseases of nerv- Other external causes | 86.4 79.4 oussystem . . .| 49.5 41.6 || Ill-defined causes 23 174 Statistical Results of the Demonstration 211 tuberculosis, other epidemic diseases and diarrhea and enteritis under 2; high rates from cancer, diabetes, cerebral hemorrhage and apoplexy, diseases of the nervous system, of the heart, and cir- culatory system, appendicitis, diseases of the digestive system and genito-urinary system, diseases of early infancy and automobile accidents. In other words, it exhibited the phenomena of a population in- cluding a large proportion of older people and at a relatively high economic level, since such populations always show relatively low mortality from communicable and environmental diseases and relatively high mortality from organic and degenerative diseases. ‘The actual age distribution of the population at this period is indicated below (Table 43). Table 43. Percentage age distribution of population in Cattaraugus County and in the United States Registration Area (of 1920). AGE Catragiucns Beonymation Under 15.4.5 29 32 1544. © on 44 47 45-64. . . . . 19 16 65andover. . . 8 5 The general picture is, of course, not a favorable one for sensa- tional achievement, since the easily controllable environmental diseases are already at a relatively low level. The death rate for 1919-1921, from all causes was 14.3 per 1,000 for Cattaraugus County and 12.6 for the Registration Area, the excess for Cattaraugus being due to the organic diseases of later life. Indian Mortality Rates. There is one element in the Cat- taraugus population—that composed of the Reservation Indians— which presents a very different situation. This is a separate problem not substantially affected by the demonstration program and, of course the figures are too small to have any significance for a short period. As a matter of general interest, however, it 212 Health on the Farm and in the Village seems worth while to present the following average rates (Table 44) for the decade, 1919 to 1929. Table 44. Mortality of Reservation Indians in Cattaraugus County by principal causes. Deaths per 100,000. Average 1919-1929. CAuse Per CENT Cause Per CENT Measles . 36.8 || Other diseases of the respira- Whooping cough 9.2 tory system lie oy 27.6 Influenza . as 27.6 || Diarrhea and enteritis under 2 46.1 Pulmonary tuberculosis . 294.6 || Other diseases of the digestive Other forms of tuberculosis . 18.4 system a 3.1 Other epidemic and infec- Acute and chronic nephritis . 92.1 tious diseases 18.4 | Other diseases of the genito- Cancer. Shoat aL, 64.4 urinary system re 9.2 Cerebral hemorrhage and Puerperal diseases . . . . 36.8 apoplexy . . . . . . 18.4 || Congenital debility, prema- Other diseases of the nerv- turity and diseases of early oussystem . . . . . 36.8 infancy Lo UE 1012 Heart disease . . . . .| 156.6 Senility, aii 28 sls VEE 18.4 Other diseases of the circula- Automobile accidents . . . 27.6 tory system . . . . . 36.8 || Other external causes . . .| 119.6 Broncho and lobar pneu- Ill-defined causes . . . . 9.2 mionia Ltn NE 267 The total death rate for the Indians for this decade was 15.5 > not an enormously high one; but the relative importance of the various causes, as compared with the figures previously cited for the County, as a whole, is of interest as indicating the completely different nature of the problem involved. One notes, for example, the enormous death rates from measles, tuberculosis, pneumonia, and puerperal diseases and the low rates for cerebral hemorrhage and apoplexy, cancer and heart disease. Changes in Mortality During the Demonstration Period. We may now proceed to our major problem, the changes which have occurred in the vital statistics of Cattaraugus County during the past ten years. The first crude measure of progress in the reduction of mortality is to be found in an analysis of death rates from all causes and the facts in this regard are presented in Table 45. All rates in this chapter for years since 1920 are computed on populations estimated by the use of preliminary 1930 Census Statistical Results of the Demonstration 213 Table 45. Mortality at different ages in Cattaraugus County, 1920- 1922, 1926-1928 and 1929. DeatsS PER 1,000 Ace Per CENT CHANGE, 1929, COMPARED WITH 1920-1922 1920-1922 1926-1928 1929 ALL AGES . 14.2 13.3 12.9 - 9 Under 1 84.4 65.0 50.0 — 41 14 . 6.4 41 44 -31 59. 2.2 1.7 2.1 - 5 10-14 2.2 17 20 - 10 15-24 3.9 3.0 25 — 36 25-34 52 4.0 3.8 —- 27 35-44 . 6.4 7.0 4.5 — 30 45-54 . 11.2 11.7 9.6 - 14 55-64 21.0 23.8 23.7 +11 65-74 . . 52.9 53.4 56.8 + 7 75 and over 146.4 146.5 154.5 + 3 figures. They do not, therefore, correspond exactly with earlier statistical studies by others. Death rates at all periods up to 54 years have decreased—most markedly under 1 year (41 per cent) and at ages between 15 and 44 years (27-36 per cent), while, at ages over 54, mortality has increased. In general, these phenomena—of decreasing death rates in youth and increasing death rates in later life—are of course more or less universal. The very high rates of decrease in infancy and in the age period of young adult life (when tuberculosis is prevalent) are suggestive; but it is necessary to proceed to an analysis of in- dividual causes of death before drawing any conclusions. Such an analysis is presented in Table 46, p. 24, using the crude figures for the County as a whole, including Indians and non-residents, although the latter inclusion involves serious errors in certain in- stances, which will be discussed below. Inspection of this table brings out the following facts. Twelve causes of death—scarlet fever, diphtheria, whooping cough, pneumonia, diarrheal diseases, diseases of the puerperal state, congenital debility, prematurity and other diseases of early in- fancy, cerebral hemorrhage and apoplexy, “other diseases” of Table 46. Death rates for certain principal causes in Cattaraugus County, by years, 1920-1929. Deaths per 100,000 INTER- NATIORAL CAUSE oF DEATH 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 NUMBERS 1 Typhoid fever . 14 4.2 28 28 14 14 2.8 0.0 31.8 14 7 Measles . 9.8 14 0.0 112 5.6 14 14 0.0 55 9.6 8 Scarlet fever 14 42 5.6 9.7 42 8.3 14 14 0.0 0.0 9 Whooping cough . 19.6 5.6 14 11.2 7.0 0.0 6.9 0.0 41 4.1 10 Diphtheria . : 21.0 84 14.0 8.4 2.8 2.8 2.8 4.2 14 2.8 11 Influenza 42.0 84 23.1 40.4 8.4 11.1 26.3 20.7 13.8 57.8 22 Poliomyelitis » 0.0 2.8 14 0.0 14 0.0 6.9 2.8 14 14 31-37 a | Tuberculosis, pulmonary 60.2 69.8 79.6 73.8 75.1 65.3 73.5 71.5 55.3 67.5 32 Tuberculosis, meningeal 4.2 2.8 7.0 2.8 42 0.0 2.8 14 4.1 2.8 LS Tuberculosis, other . 8.4 8.4 5.6 8.4 9.7 2.8 9.7 2.8 2.8 9.6 3 c 2-5, 12- 21, | Other epidemic and 23-30 38-42 infectious diseases . 7.0 19.6 84 237 18.1 9.7 11.1 9.7 20.7 9.6 43°49 Cancer 92.4 120.2 1274 124.1 103.5 116.8 118.0 110.8 118.8 135.1 37 Diabetes . 12.6 23.8 30.7 13.9 222 26.4 33.3 22.1 27.6 17.9 50-56,58-69| Other general diseases 23.8 294 223 33.4 34.8 29.2 33.3 27.7 373 334 74 Cerebral hemorrhage and apoplexy . . . . . .| 1232 | 1426 | 1408 | 136.6 | 143.3 | 123.7 | 1332 | 117.7 | 1092 | 97.38 70-73, |Other diseases of the 75-86 nervous system . 1 46.3 47.5 40.5 474 32.0 32.0 29.1 45.6 33.1 30.3 87-90 | Heart disease . .| 269.0 | 260.1 | 312.6 | 282.6 | 2449 | 279.2 | 309.0 | 297.3 | 356.3 | 369.3 91-96 | Other circulatory diseases .| 43.4 40.6 30.7 29.2 41.7 44.5 54.1 49.8 42.8 34.5 100-101 | Broncho and lobar pneu- monia . . + 1274 88.2 | 106.2 | 1254 86.2 81.8 | 105.5 82.9 | 105.0 82.6 97-99, | Other respiratory diseases .| 25.2 21.0 15.3 23.7 8.4 33 18.0 4.2 8.3 4.1 102-107 ye IVP A 27 ur pup wav,] ag7 uO GIL] Table 46. Death rates for certain principal causes in Cattaraugus County, by years, 1920-1929. (Continued) Deaths per 100,000 INTER- BaTuonaL CAUSE oF DEATH 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 NUMBERS 113 Diarrhea and enteritis under 2 ea ee Le AS 33.3 25.1 26.5 18.1 16.7 18.0 11.1 6.9 4.1 117 Appendicitis and typhlitis . | 14.0 23.8 14.0 19.5 18.1 16.7 23.6 249 23.3 24.8 an Other digestive diseases 74.3 85.3 72.6 52.9 52.8 62.5 56.8 60.9 44.2 40.0 114-116, 118-129 128-129 | Acute and chronic nephritis | 123.3 76.8 99.1 947 | 121.2 | 105.6 | 131.8 | 143.8 | 102.3 | 1199 130-142 | Other genito-urinary dis- eases . 3 ; 19.6 21.0 21.0 16.7 23.6 13.9 18.0 221 16.6 9.7 143-150 | Puerperal diseases 26.2 23.8 19.6 16.7 5.6 5.6 27.8 12.3 13.8 11.0 151-154 | Diseases of skin and cellular tissue . 42 7.0 14 2.8 28 6.9 2.8 4.2 55 0.0 155-158 | Diseases of bones and organs of locomotion. 4.2 14 14 0.0 0.0 14 14 0.0 2.8 0.0 159-163 | Congenital debility, prema- turity and early Hiascy. 114.7 | 100.6 | 122.6 | 103.1 91.8 97.2 99.8 85.7 96.6 64.7 164 Senility . 7.0 12.6 9.8 11.1 7.0 8.3 8.3 35 111 14 188 ¢ Automobile accidents 9.8 12.6 12.6 22.3 29.2 27.8 222 21.7 35.9 46.6 165-188 b, | Other external causes 88.3 81.2 | 114.6 | 100.3 | 101.6 | 104.3 99.8 | 113.5 92.6 93.7 188 4-203 204-205 | Ill-defined causes . 14 14 2.8 14 28 5.6 0.0 14 2.8 0.0 UOLIPAISUOULI(T 2G] fO SNSY [9217511078 SIC 216 Health on the Farm and in the Village the respiratory system, of the digestive system, of the nervous system and of the genito-urinary system—have diminished; while five causes—cancer, other general diseases, heart disease, appendicitis and automobile accidents—show a significant in- crease. Other causes show only chance variations, with the exception of the rise of typhoid in 1928 due to the Olean epidemic. All of the increases, as well as the decreases in pneumonia, cerebral hemorrhage and apoplexy and general diseases of the respiratory, digestive and genito-urinary system, are in accord with general experience and are due either to changes in diagnosis or to general social and biological conditions over which we have at present no effective control. In the case of whooping cough the decrease is slight. In five causes of death, however, there are reductions which, at first sight, might be assumed to be specifically related to medical and sanitary progress. These diseases are as follows (Table 47), with the number of deaths caused by them in Cattaraugus County in 1920-1922 and 1927-1929, respectively. Table 47. Number of deaths from certain causes in Cattaraugus County, 1920-1922, 1927-1929. ActUuAL DEATHS, THREE-YEAR PERIOD CAUSE ch 1920-1922 1927-1929 Scarlet fever . . . 8 1 Diphtheria . . . . 31 6 Diarrhea under 2 years: .. J... 53 16 Puerperal diseases 49 27 Diseases of early in- fancy ie ss 242 179 In the last three of these instances, the figures are potentially misleading because the causes of death concerned are all more directly related to the birth rate than to the general population and the birth rate in Cattaraugus as elsewhere is falling. These Statistical Results of the Demonstration 217 three causes will be analyzed in a later paragraph in proper re- lation to the birth rate and for a longer period of years. The problem of tuberculosis will also be considered later. The basic table on p. 216 shows no decrease in this disease on ac- count of inclusion of deaths of non-residents occurring in the sanatorium at Perrysburg. The outstanding achievements so far revealed appear to be the marked reductions in scarlet fever and diphtheria, a con- siderable part of which may fairly be credited to the public health program of the County. It seemed of some possible interest to compare the vital statis- tics of the cities of Olean and Salamanca with those of the rural areas, but the figures are too small to be significant except for major causes of death and periods of years. The table (Table 48) below, however, indicates, first, the higher mortality from cancer, cerebral hemorrhage, heart disease and pneumonia in rural areas, due in large measure, to a presumably older population. The tuberculosis rate is also materially higher in the rural areas, while nephritis and diseases of early infancy seem unduly high in Salamanca. Table 48. Mortality from certain causes in urban and rural areas of Cattaraugus County, 1926-1929. DeAtaS PER 100,000 frei CAUSE Olean Salamanca Rural Areas Pulmonary tuberculosis . . . . . 35 40 45 Cancer . . . 89 108 124 Cerebral hemorrhage and apoplexy 2 90 71 129 Heart disease . . Mi : 262 279 348 Pneumonia, all forme. il. . ait 81 82 97 Nephritis 100 184 108 Congenital debility, prematurity and other diseases of early infancy . . 83 92 71 Morbidity from Diphtheria and Scarlet Fever. We have seen that the death rates from diphtheria and scarlet fever have shown marked and definite reductions. There has also, however, been 218 Health on the Farm and in the Village an even more striking reduction in morbidity, as evidenced by the following table (Table 49). Table 49. Morbidity rates per 100,000 population for scarlet fever and diphtheria in urban and rural areas of Cattaraugus County by years, 1922-1929. SCARLET FEVER DIPHTHERIA YEAR Olean Salamanca | Rural Areas Olean Salamanca | Rural Areas 1922 101 171 432 144 182 186 1923 2.112 693 492 129 533 65 1924 722 64 238 19 53 43 1925 387 106 249 113 11 22 1926 193 106 208 24 32 17 1927 210 84 130 23 21 34 1928 107 105 162 9 83 29 1929 78 10 124 23 31 24 In terms of actual cases, this means a reduction for the whole County from an average of 395 cases of scarlet fever a year for 1922-1924 to an average of 92 cases a year for 1927-1929; and for diphtheria, a reduction from an average of 85 cases a year for 1922-1924 to an average of 20 cases a year for 1927-1929. The County has now not only 2 deaths a year less from scarlet fever and 8 less from diphtheria, but also some 300 cases a year less of scarlet fever and 60 less of diphtheria. In the case of diphtheria, a comparison between 1920-1922 and 1927-1929 is not quite fair. As will be noted by reference to Fig. 8, 1918-1921 was a period of unusually high prevalence for this disease. We may, however, quite fairly compare 1927— 1929 (a death rate about 3 per 100,000) with 1915-1917 (death rate about 10 per 100,000) and conclude that the intensive im- munization of recent years has been associated with a saving of five lives a year in the County. Statistics of Tuberculosis. “We may turn next to the problem of tuberculosis which has been a special major objective of the demonstration and which should, therefore, be a critical test of its effectiveness. The crude rates tabulated for the County show no decrease in Statistical Results of the Demonstration 219 tuberculosis mortality but, as indicated above, this is a wholly misleading picture, due to the inclusion in such tabulations of deaths occurring among non-residents in the J. N. Adam Me- morial Hospital at Perrysburg. These have amounted in some years to 25, or nearly half the total deaths in the County. The trend of tuberculosis mortality in Cattaraugus has been analyzed by Mr. Sydenstricker up to 1927 in the Quarterly Bulletin of the Milbank Memorial Fund for April, 1928. He ex- cludes from his tabulation both Perrysburg patients and Indians, but we have preferred to include the latter, as presenting a real part of the county problem. On this basis, excluding only deaths of Perrysburg patients but not other non-residents (and using 1930 census figures for computing populations), the picture is as shown in Table 50 for a period of fifteen years. Table 50. Tuberculos is mortality per 100,000 population, in Cattaraugus County, 1915-1929. YEAR DEATHS DS ee 1915 37 54 1916 48 70 1917 50 72 1918 54 76 1919 44 62 1920 45 63 1921 54 76 1922 5 71 1923 50 70 1924 50 70 1925 35 49 1926 37 51 1927 34 47 1928 335 48 1929 37 51 The general trend line of the County up to 1927 has been already presented in Fig. 7, as prepared by Mr. Sydenstricker, and it will be recalled that tuberculosis mortality followed a very definite trend of slow decrease and then broke sharply in 1925 to a lower level. This low level, as indicated by Table 50 above, has been maintained for the past five years. 220 Health on the Farm and in the Village To smooth out chance variations, we may summarize the situa- tion by five-year periods as follows: Deaths per Year Rate per 100,000 1915-1919 47 67 1920-1924 50 70 1925-1929 36 49 The chance that any five successive years would show consistent deviation from prior trends of this magnitude by chance is con- siderably less than one in a million, according to Mr. Syden- stricker, and there are no other changes in Cattaraugus County, so far as can be determined, which could in any way account for the decrease with the exception of the organized program for the control of tuberculosis which has been introduced. In not one of a series of twelve other rural counties in New York State, studied by Mr. Sydenstricker, has any such significant deviation from trend occurred. It seems reasonable to conclude that a saving of fourteen lives a year has been effected by improved machinery for dealing with this disease. This conclusion is greatly strengthened by a consideration of the changes in age incidence, in the number of known active cases, in the proportion of advanced cases and in the decreased demand for hospitalization which have been reviewed in Chapter X. These data and our analysis of the many deaths classed as tuber- culosis but probably not due to this disease, make it seem certain that a saving of fourteen lives a year from tuberculosis is a very modest estimate of the achievement of this part of the Cattaraugus program. Infant Mortality. A second phase of public health work which has been intensively (though not completely) developed in Cattaraugus County is that of infant hygiene, and here again, we should look for significant results. The crude infant mortality rate for the County is presented in Table 51. Here, as in the case of tuberculosis, we find a very striking Statistical Results of the Demonstration 22 Table 51. Deaths of infants under one year of age per 1,000 live births in Catta- raugus County, by years, 1915-1929. YEAR RATE YEAR RATE 1915 88 1922 95 1916 74 1923 91 1917 82 1924 67 1918 94 1925 72 1919 81 1926 68 1920 84 1927 60 1921 79 1928 70 1929 53 phenomenon. The rate, which had been stationary or rising, drops sharply to a new level in 1924. The averages by five-year periods are as follows: Year Infant Mortality 1915-1919 84 1920-1924 81 1925-1929 65 This tabulation would appear to indicate a saving of nearly twenty infant lives a year (with some 1,200 births as in recent years). The problem of infant mortality is, however, greatly complicated by non-resident births and deaths due to hospitaliza- tion of maternity cases. The statisticians of the Milbank Memo- rial Fund’s Research Division have analyzed this problem in great detail (see articles by Dorothy G. Wiehl in the Quarterly Bulletin of the Fund for January, 1928, and in the American Journal of Public Health for May, 1929; and by Jean Downes in the Journal of the American Statistical Association for March, 1929). If correction be made for these factors, however, the decrease in mortality remains undiminished. Furthermore, analysis of the particular causes of death which have decreased furnishes the strongest evidence that this decrease has been the result of organ- ized effort. The important data are presented in Table 52. 222 Health on the Farm and in the Village Table 52. Deaths of children under one year of age per 1,000 live births (infant mortality) from important groups of causes among resident infants born in Cattaraugus County, 1921-1929. MALFORMATIONS Comuunicans, YEAR AND EARLY ieanney fasmarosy no Arr OTHER CAUSES Arr CAUSES 1921 41 26 8 75 1922 54 26 9 89 1923 50 29 9 88 1924 42 14 6 62 1025 48 17 7 72 1926 49 14 2 65 1927 39 13 3 55 1928 46 13 6 65 1929 33 14 2 49 The average figures for the first four and the last five years are as shown in Table 53. From this table it appears that the group of diseases of early infancy (for which no effective program has been in force) has decreased but slightly, while the major reduction has occurred in the group of communicable, respiratory and diarrheal diseases (which the child health conference and nursing program of Cat- taraugus was specifically planned to meet). Miss Wiehl (Quarterly Bulletin of the Milbank Memorial Fund, January, 1928) has shown that the trend of infant mortality in Cat- taraugus County was, if anything, slightly upward from 1916 to 1923 and that the break in this trend was statistically significant. The trend in rural New York and in the Rural Registration Area in general has been generally downward, but no sharp break such as that manifest in Cattaraugus is apparent Table 53. Infant mortality in Cattaraugus County, 1921-1924 and 1925-1929. YEAR Diseases oF EARLY COMMUNICABLE, RESPIRATORY AND ArL orHER CAUSES Arr Causes Inrancy DIGESTIVE DISEASES] 1921-24 47 24 8 79 1925-29 43 14 4 61 Statistical Results of the Demonstration 223 elsewhere. Furthermore, in reasonably comparable New York counties, such as Chautauqua, Jefferson, Steuben and Washing- ton, while the total rates for 1924-1925 were closely similar to those in Cattaraugus, the rates for communicable, respiratory and digestive diseases were generally higher. It may reasonably be concluded that a definite reduction of infant mortality has been accomplished in Cattaraugus County, amounting to the saving of about eighteen infant lives per 1,000 births or about twenty lives a year. The significant decreases in diphtheria, tuberculosis and infant mortality rates which have been discussed are strikingly shown in the form of three-year moving averages in Fig. 8. Correction of Physical Defects of School Children. The re- sults of a public health program are, of course, much more far- reaching than a mere study of mortality figures would imply. In particular, the correction of the physical defects of school children is of primary significance and in Cattaraugus County we have certain interesting data on this point. The first type of statistical evidence available relates, not to the demonstration as such, but to the accomplishments of the city of Olean. Here, there was an intensive school hygiene program for a number of years before the demonstration started and even now, the work in Olean is far more complete than in rural areas. It is, therefore, of interest to note (see Annual Report of the Milbank Memorial Fund for 1928) that the children in the village schools examined in 1926-1928 showed from 6 to 20 per cent more underweights at various ages than those in the Olean schools and a distinctly higher proportion of uncorrected defects of heart, lungs, posture, skin, tonsils, teeth and eyes. These dif- ferences are made somewhat more significant by the racial homogeneity of urban and rural populations and by the fact that the standard of medical examinations in Olean is certainly more rigorous than in the rural areas. On the other hand, lower economic status and less available medical service in the rural sections may undoubtedly contribute to the differences observed. More significant for our purposes is the measure of performance 224 Health on the Farm and in the Village INFANT MORTALITY MORTALITY FROM TUBERCULOSIS AND DIPHTHERIA CATTARAUGUS COUNTY 1915-1929 3 YR MOVING AVERAGE 100, a3 x2 &S domme, areeitae, aS =r ae ~ INFANT MORTA| © 80 ——— ~.” ~ wo vs, a \ > \, 5 NN 8 ~~ ger] Yeeed 8s TUBERCULOSIS pe m—. e No ad co 60 ag 2 -% 58 SE ar a EE) he 2 Ves te 32 TTT DIPHTHERIA fe — i» emit SN~—e—. 0 \ i : A L 191517 7-19 9-21 21-23 23-25 25-27 27-29 Frc. 8 Statistical Results of the Demonstration 225 presented in the following tabulation (Table 54) by Miss Jean Downes of the actual findings as to corrected defects among rural school children examined at two successive periods. Table 54. Findings with regard to correction of defects among children ? examined in village schools in Cattaraugus County at two successive periods, showing ages of children and percentage of corrections. DATE OF Per CENT DEFECTS CORRECTED DEFECT ExAMINA- To 9 years 10 years 11 years 12 years 13 years Tonsils . . .| 1923-24 8 8 7 8 9 1926-28 15 19 21 22 16 Permanent teeth | 1923-24 2 4 4 3 6 1926-28 8 14 20 20 21 Eyes . . . .[| 1923-24 4 3 6 6 11 1926-28 7 11 12 16 11 1 Between 169 and 392 children in each age group. The progress in the correction of the defects listed is significant and encouraging. The Cash Value of a Public Health Program. Finally, in view of the fact that it costs money to purchase public health, and that a costly program like that of Cattaraugus must justify itself by results, it seems important to consider what some of these achieve- ments really mean in terms of dollars and cents. We shall limit ourselves in this discussion to the definite achievements involved in the saving of § lives a year from diphtheria, 14 from tuber- culosis and 20 from diseases of infancy. It has been the custom to use absurdly low figures for the value of a human life, ranging from $500 in infancy to $5,000 in early adult life. Dr. Louis I. Dublin, in a series of studies (Statistical Bulletin, Metropolitan Life Insurance Company, February, March, April, June and August, 1926; May and June, 1927; August and September, 1928), has shown that the actual investment value of a human life in the United States today is far greater than this. Taking a wage-earner in the $2,500 in- come class (which corresponds to a somewhat lower level than the $874 per capita income of Cattaraugus), he estimates the actual 226 Health on the Farm and in the Village future earning capacity of a man at the age period 18 to 40 years as between $25,000 and $50,000 (Statistical Bulletin, June, 1926). Since this computation is based on wage earnings, it may be held in a rural county, where women are not generally industrially employed but contribute indirectly to the total family income through home labor, that the cash value repre- sented by the family income should be shared between both its adult members. Making this assumption, we may divide Dublin’s figures by half and consider the value of a young adult life as $12,000. For the saving of lives by reduction in tuber- culosis, which takes its toll chiefly at this period, we may estimate a cash value of $12,000 times 14 or approximately $170,000. Dublin estimates the cost of bringing up a child to the age of 18 years (in the $2,500 income class) at $7,200 (Metropolitan Life Insurance Company Statistical Bulletin, April, 1926). If an adult has a value of $12,000 and it costs an investment of $7,200 to produce such an adult, we may fairly estimate the net value of an infant at $5,000. Although deaths from diphtheria do not generally occur as early as the first year, the same allowance may be made for them in order to be conservative. On this basis, the saving of 20 lives from diseases of infancy would involve a net gain in life capital of $100,000 and the saving of § lives from diphtheria a saving of $25,000. In these three groups of diseases where there is very definite evidence of the influence of the demonstration program, we find, then, a saving of life capital worth to the community $300,000 a year—or double the cost of the entire health program of the County. Finally, it should be pointed out that such computations tell only a small part of the story. The greater vigor of infancy, the freedom of school children from hampering physical defects, the decreased loss of time and decreased cost of medical care for non- fatal illnesses, the increased productiveness of the robust adult— these are achievements which far outweigh reductions in mortality. CHAPTER XV THE COST OF THE CATTARAUGUS PROGRAM The Health Budget of Cattaraugus County. The 1929 health budget of the County has been presented in detail in Chapter VII and the main facts may be summarized as follows, classified according to administrative authorities but without reference to ultimate source of funds. A. Basic Public Health Activities 1. County, health and schools $116,989 2. Olean, health and schools 16,691 3. Salamanca, health and schools 3,665 4. Rural areas, health and schools 12,630 5. Local nursing groups 10,467 $160,442 B. Special Activities 1. Rocky Crest Sanatorium $46,000 2. Garbage and plumbing, Olean 22,650 3. Garbage and plumbing, Salamanca 450 4. Tuberculosis and Public Health Association 11,725 5. Olean open air schools, et cetera 4,689 $85,514 If we add these two sums together, we get a grand total of $245,956 or $3.39 per capita. In comparative studies of the cost of health administration it is not, however, the custom to include garbage collection and disposal or sanatorium treatment or such allied activities as the work of the Tuberculosis and Public Health Association in the maintenance of the Health Camp and 227 228 Health on the Farm and in the Village the care of crippled children. We may then take as our basic figure for the fundamental 1929 health program of the County, $160,442 or $2.20 per capita. This figure closely approximates the accepted standard of $2.17 for the health department of a large city. It is far in excess of the expenditure of any rural county with which the writer is familiar. In Chapter VIII we have analyzed the data for full-time county health departments furnished by the Rockefeller Foundation which give a wide basis of comparison. The figures in question deal only with the appropriations for the County Department itself and do not comprise figures for local areas (such as we have included for Olean and Salamanca) and the total for Cattaraugus is given by Dr. Ferrell as $1.44 per capita. On a comparable basis, there are only 14 out of all the nearly 500 county health departments in the United States whose budgets exceed $1.00 per capita and in no other county except Cattaraugus does the figure rise above $1.16 per capita. Cattaraugus is the banner county of the United States in point- ing the way toward an adequate financial provision for the health of a rural population. Growth and Source of Budget. In the table below (Table 55), the health budget for basic health work in Cattaraugus County is Table 55. Annual health budgets of Cattaraugus County, 1922-1930. 1922 1923 1924 1925 1926 1927 1928 1929 1930 ToraLs . | 34,023 86,106 | 135,845 | 135,418 | 174,235 | 176,556 | 166,495 | 160,443 | 140,633 County authorities | 3,1001| 7,884 13,562 8,838 | 27,234 | 27,588 | 27,996 | 33,000 33,000 State aid. . 3,698 8,075 | 27,235 | 28,030 | 28,000 | 33,000 33,000 Local health : authorities | 13,218 14,735 16,496 | 14,986 | 18,672 | 20,019 | 20,628 | 15,757 | 16,000? Local school authorities | 11,397 11,795 15,560 | 14,083 | 16,335 | 16,905 | 17,056 | 17,229 | 17,000? Local nursing groups. .| 6,308 8,388 7,688 7,921 6,758 7,122 8,270 7,967 | 8,000? Milbank Memorial Fund?. . 43,304 78,841 | 81,015 | 76,501 | 74,392 | 62,045| 50,990 31,133 ASHA.. . 500 1,500 1,500 Indian nurse 1,000 2,500 2,500 ( 2,500 1 Includes budget of tuberculosis nurse attached to sanatorium. 2? Does not include appropriations to County Tuberculosis and Public Health Association and other special projects. The Cost of the Cattaraugus Program 229 analyzed for the past eight years (with estimates for 1930) on the basis of administrative authority as in our earlier analysis. In this table the Milbank Memorial Fund grants to the Tuberculosis and Public Health Association and other special activities are not included and the total appropriation from the Fund, from state aid and from the County equals the budget for county health and school work as given on an earlier page. It will be noted that the total budget for basic health work in Cattaraugus County has mounted from $34,023 in 1922 to a maximum of $176,556 in 1927 and has fallen to an estimated figure of $140,633 or $1.94 for 1930. The chief trends are presented in graphic form in Fig. 9, the appropriations of local health and school authorities and nursing groups being combined. County appropriations have increased tenfold and state grants have, of course, matched them. Local expenditures increased from $30,923 in 1922 to $45,954 in 1928, and then decreased to an estimated figure of $41,000 for 1930—the decrease being due to assumption by the County of the cost of rural health services. If one considers the actual financial burden borne by the citizens of the County, the total of county plus local expenditures has in- creased from $34,023 in 1922 to $74,000 in 1930—an actual net increase of 55 cents per capita. The Milbank Memorial Fund appropriation for standard health services rose to $81,015 in 1925 and has fallen to $31,133 in 1930. It should be pointed out that in 1925 the actual expenditure of the Milbank Memorial Fund (including appropriations to the County Tuberculosis and Health Association for social service and other activities and special projects) reached an annual total of $100,681. The Adequacy of the Budget. In scrutinizing the largest budget yet made available anywhere in the United States for rural health service, one must naturally inquire whether the sum provided is unreasonably high. We have given careful con- sideration to this question and are convinced that every dollar which was expended in 1929 was expended economically and for necessary purposes. Cattaraugus, as pointed out in Chapter 230 Health on the Farm and in the Village SOURCES OF FUNDS 0 CATTARAUGUS HEALTH SERVICES iy 4 ~~. 0 : 3 / MILBANK FUND 3 / NN 5 J I: 2 / » 3 l \ 3 / Lam TS \ £ 40 o re NS se Nemes ~~... — LOGAL SOURCES \ ht" 4 <0 rl CETTE YEARS EN 23 24 25 26 27 28 29 "30 Fic. 9 The Cost of the Cattaraugus Program 231 VII, is providing essentially the standard program recognized as requisite in a well-organized urban area and at almost exactly standard costs. This is no mean achievement, in view of the fact that unit costs in a scattered rural area tend necessarily to be substantially higher than in an urban community. We must now consider the alternative question—is the county health budget adequate? It must be recalled that our budgetary and appraisal form analyses are both based on 1929, when the total budget was $160,443. Even in that year the control of venereal disease was quite inadequately provided for, and no effective effort had been made to develop health education in the schools. Provision for these two essential activities and a modest beginning in dealing with the problems of mental hygiene are vital needs which should be provided for in the future. This would involve an increase from $160,000 to approximately $175,000 and this sum we believe would furnish a reasonably complete and adequate basic health program for the County. The 1930 budget will be about $140,000 or $35,000 less than the needed sum and even this $140,000 includes $30,000 of funds supplied by the Milbank Memorial Fund which will be withdrawn with the close of the demonstration. The conclusion that still further financial efforts must be made will no doubt seem highly discouraging in face of the fact that the County has already made so admirable a response to the call of public health. Yet the supreme value of the boldness with which this demonstration has been conceived lies in the fact that it challenges us to face the real facts of the situation. The ex- perience in Cattaraugus has made it clear that something like $2.40 is actually needed for a sound rural health program. The money may not be available, here and now, but we gain nothing by pretending that the inadequate is adequate. The protection of health is not a fad or a luxury. If an effective health organ- ization is justified at all, it saves the citizen far more money than it costs. ‘That such has been the case in Cattaraugus has been 232 Health on the Farm and in the Village indicated in Chapter XIV. The essential question is not, “Can we afford to pay for public health?” but “Can we afford not to pay for public health?” Where Can the Money Come From? If the health budget of Cattaraugus County is to be maintained at its 1929 level, there must somehow be found $50,000 to balance the Milbank Me- morial Fund grant asit stood in that year. If it is to be made fully adequate, there must be found $15,000 more. There are three possible sources of funds, the County Treasury, state aid and grants from outside foundations. It was originally contemplated that the County would by this time have increased its appropriation to balance the withdrawal of Milbank appropria- tions. It has gone far along this road. Even the maintenance of the present appropriation, with an increase for the Sanatorium last year, represented a real achievement in view of high tax rates due to highway financing. Yet it is entirely reasonable that moderate and gradual further increases should be made. An immediate additional county appropriation of $10,000, to be matched by a similar increase in state aid, would go far to balance the withdrawal of appropriations by the Milbank Memorial Fund and at least this measure of support seems demanded to avoid serious demoralization of the entire program as it stands. There are two considerations which make a moderate increase in county appropriations by no means unreasonable. In the first place, it must be remembered that the health budget in any area is, after all, only a small part of the total budget. The total “cost of government” in New York counties ranges from $4.00 to $16.00 per capita, and averages $6.87, while the budget for the same counties for “conservation of health” averages $0.65 or less than 10 per cent. Even in Cattaraugus, the “conserva- tion of health” items come only to 17 per cent of the total. Even a substantial increase in health budget does not greatly increase the burden on the taxpayer. Secondly, it must be remembered that, as pointed out in Chap- 1 This appropriation, as stated in Chapter I, has been made since the survey was completed. The Cost of the Cattaraugus Program 233 ter II, Cattaraugus, while poor by comparison with urban areas, is among the richest 10 per cent of the rural counties of the United States. It has been pointed out that, outside of Cat- taraugus, there are only 13 rural counties which expend over $1.00 per capita for county health work; but it should be noted that not one of the other thirteen counties (all of them outside of New York State) has as high an average income as Cattarau- gus. The Cattaraugus income, as we have seen, is $874. Of the other thirteen counties, three have average incomes under $250; three, incomes between $250 and $499; five, incomes between $500 and $749, and only two (besides Cattaraugus), incomes of $750 or more. Cattaraugus is making a much less substantial financial sacrifice for health than these poorer counties. The next possible source of funds is state aid. It may be assumed that additional direct appropriations from the County Treasury will be automatically balanced in this way, but there seems to be still another possibility worthy of exploration. We have seen that, at present, the County appropriates $33,000 for the County Board of Health and receives an equivalent amount in a state grant. There is another sum of over $40,000 a year spent for health work in the County by the cities of Olean and Salamanca and by local school authorities and local nursing groups. In essence, the work paid for by such sources is just as much a part of the county program as that performed at the county health office. It would seem possible that, if some of these funds could be further centralized by paying them into the County Treasury and then out again, the amount of state aid obtained could be materially increased. It seems to have been assumed in Cattaraugus that state funds could not be made available for the County School Health Service, but there is certainly nothing in the wording of the law to warrant this assumption. Finally, even if outside grants for the demonstration “as such” are soon to be discontinued, there should be no serious difficulties in obtaining grants from some source for certain special projects, such as a rural program for the control of maternal and neonatal 234 Health on the Farm and in the Village mortality and for the control of venereal disease, for health edu- cation in the schools and for research work in tuberculosis con- trol. These are public health research problems of pressing im- portance which have nowhere been solved and could nowhere be better solved than in Cattaraugus.’ Certainly, no effort should be spared, either by County, State or the Milbank Memorial Fund, to see that the Cattaraugus pro- gram is carried forward. If it should be materially reduced, a heavy blow would be struck at the progress of rural health work throughout the country; for the skeptics would at once say, “You see—no county can maintain an adequate health program.” 2 Such grants for specific research projects have been made by the Milbank Memorial Fund since the survey was completed. CHAPTER XVI PSYCHOLOGICAL REACTIONS TO THE HEALTH DEMONSTRATION Psychology of the Demonstration Staff. With our growing knowledge of the elements of mental hygiene, we are beginning to realize that psychological factors are often more important than logical ones in determining the fate of human enterprises. In the conduct of a local health demonstration, financed in part by outside funds, there are many complex and subtle human relationships involved; and it will be profitable to devote some- what careful consideration to the impacts of the Cattaraugus health program upon the various local groups concerned and to the psychological reactions of those groups toward the program, so far as they can be estimated. Obviously the first group of persons to be considered in this regard is that composed of the actual members of the demonstra- tion staff. It is important to know whether they felt a divided loyalty as between Little Valley (the county seat) and New York. Were they harassed by undue interference on the part of various authorities? Were they subject to undue pressure to secure immediate results? The general machinery set up for relating the Milbank Memorial Fund to the County was excellently planned to avoid the dangers suggested by the questions above. The State Chari- ties Aid Association, an existing unofficial state-wide agency with long and successful experience (through its Committee on Tuber- culosis and Public Health) in the stimulation of local health work, was made the operating agency for the demonstration. Its functions were essentially as follows. As stated in the 1923 report of the Milbank Memorial Fund, 235 236 Health on the Farm and in the Village the State Charities Aid Association “advises with the local oper- ating agencies in the selection of subjects for special study, lead- ing to the formulation of definite projects to be undertaken as parts of the demonstration. It advises in the selection and em- ployment of experts when necessary and is the channel through which the codperation and assistance of national health agencies aresecured. . . . Itassists the local operating agencies in formu- lating in terms of budgets by six-month periods the proposed ac- tivities, mutually agreed upon as the result of studies of the char- acter above indicated. It prepares the plan and form of these budgets, considers the budgetary proposals of the different local operating agencies as a total for each locality, and carries into effect plans for securing administrative and financial coéperation by local public authorities and voluntary agencies in financing, as well as administering the demonstrations. . . . It receives from each of the local codperating agencies periodical reports of progress. . . . In general, it exercises primary responsibility for seeing that the recommendations of the Technical Board and the decisions of the Board of Directors of the Milbank Memorial Fund, in regard to objectives, policies, methods, and funds, are actually carried into effect.” As stated here, the powers of the State Charities Aid Association seem perhaps a little broader and more far-reaching than should be necessary. In actual practice, however, they appear to have been exercised with discretion. The writer has talked with many persons con- cerned and has searched the files of the County Health Depart- ment without finding tangible evidence of dictation of any sort on the part of Mr. Homer Folks, the secretary of the State Chari- ties Aid Association. His attitude toward the County Health Officer as the official representative of the County seems to have been scrupulously correct. Personal contacts of the State Chari- ties Aid Association were made by Dr. A. C. Burnham, a man of good public health background and admirable personal quali- ties, whose visits to the County seem to have been uniformly wel- come, until his fatal illness set in. It is the writer’s belief that a primary essential in the relation between a foundation and a Psychological Reactions to the Health Demonstration 237 local health agency is the establishment of contact through a single, well-qualified expert and this essential was admirably provided for by the appointment of Dr. Burnham. There is ample evidence that there was in certain specific in- stances complete deference to local opinion even against the judg- ment of the New York group and, in one or two cases, policies were pursued with regard to appointments which Mr. Folks be- lieved to be unwise but with which he never attempted to inter- fere. A specially severe test of policy is to be found in connection with special attempts, like the nutrition study, carried on with appropriations provided by the Milbank Memorial Fund and more or less outside the regular county health program. In such cases, Mr. Folks’ attitude seems to have been meticulously correct. When a study of occupational therapy at Rocky Crest was in prospect, he wrote to the County Health Officer to ask whether the Director of the Bureau of Tuberculosis would care to extend an invitation. On April 1, 1925, he prepared a special memor- andum to members of the State Charities Aid Association staff in New York which read as follows: “To prevent misunderstanding and to establish clear lines of responsibility and thereby to promote efficiency of operation, I write to point out to you that you or your representatives will be visiting the health demonstration areas from time to time for the purpose of giving advice and assistance in particular lines in which you have expert knowledge and special experience, such as occupational therapy, public health nursing, case work for de- pendent children, mental hygiene activities, ef cetera, et cetera. Please give careful instructions to your assistants and carefully observe yourself that such help from your agents and yourselves in the field must always be of an advisory character; that persons on the staff of the various demonstration agencies are adminis- tratively responsible directly to the heads of those agencies in Cat- taraugus County, the County Health Officer, the Director of the County School Hygiene Supervisory District, and the Secretary of the County Association, and in Syracuse, the Health Com- 238 Health on the Farm and in the Village missioner, Health Director, Division of Health Supervision of School Children, and the Secretary of the local association. Your representative in any special line of work, in visiting Cattarau- gus County, for instance, would naturally confer directly and in detail with the staff member directly concerned in that particular line of work; she should also always confer with the head of the agency in which the staff member may be employed in regard to the progress of that particular line of work and should be especially careful that all instruc- tions must come through and be given by the responsible administrative head of the local agency. Whatever your repre- sentative may say to a subordinate member of the staff must be wholly of an advisory nature and must be understood to be such. I am sure you will find that the local responsible administrative heads will wish to avail themselves to the fullest degree of the special knowledge and experience of members of your staff and of yourselves and will wish your advice and aid in planning for and carrying out those lines of work with which you may have special familiarity. “This is not written in any degree as a criticism of anything that has happened but for the purpose of making sure that local administrative responsibilities are kept clearly in mind. Head- quarters is much too far from Cattaraugus County or Syracuse to permit of any administrative responsibility for work in these areas being carried here. On the other hand, we should take great pains at all times to make the services of our special and expert staff fully available in the planning and in the detailed opera- tions of the various features of the health demonstrations.” That the services of the special and expert staff of the State Charities Aid Association and of the Milbank Memorial Fund should have been welcomed and desired was inevitable, since this staff included some of the ablest public health experts in the United States. In connection with the preparation of annual budgets, it was, of course, necessary and proper to go into the details of pro- jected programs, since the Milbank Memorial Fund must naturally Psychological Reactions to the Health Demonstration 239 determine the soundness of that part of the program which it was asked to support. These budgets were prepared by the County Health Officer in conference with Dr. Burnham and the program was, of course, subject to periodic criticism by the Fund’s Tech- nical Board. Appropriations were made by the Milbank Memorial Fund for very definite and specific purposes and this, the writer believes, to have been an entirely sound policy. It seems, perhaps, unfortunate that checks were for some time sent to members of the Health Department staff direct from the State Charities Aid Association; but this is a small matter, and the system was changed on January 1, 1928. Since that time the Milbank Memorial Fund has made payments to the credit of the Board of Health in an Olean bank and checks have been made out to employees by the proper local authorities. The greater part of the correspondence from the Milbank Me- morial Fund offices was altogether correct, concerning programs of projected public health meetings, visits of distinguished guests to the County and the like. In one letter Mr. Kingsbury urges that the demonstration should never be called the “Milbank Demonstration” but always the “Cattaraugus County Demon- stration.” In another he emphasized that it is more important to “make the demonstration” than to “talk about it.” On the other hand there are on file letters from the Milbank Memorial Fund office dealing with details of administration and personnel which might perhaps better have been handled through the channels of the State Charities Aid Association. Such deviations from es- tablished policy, if they were deviations, occurred only in the earlier phases of the demonstration. During the past two years, the files show an absolutely detached and impersonal attitude on the part of the officers of the Fund. On the whole, the relationship between the Milbank Memorial Fund, the State Charities Aid Association and the county staff seem to have been established and maintained on reasonably sound lines. ‘The county staff seems to have been truly a county staff, appreciative of the opportunities offered by grants of the Milbank Memorial Fund, but primarily loyal to its local responsi- 240 Health on the Farm and in the Village bilities. The generous and intimate team play between the Di- rector of School Hygiene and the County Department of Health is deserving of special praise. Political Relationships. The next group to be considered in- cludes those persons officially responsible for county policies, the County Board of Health, the County Board of Supervisors and the political leaders behind these official representatives. Upon outstanding individuals like the late Senator Fancher (for many years Republican leader of the County), Mr. James Devine (Democratic leader), Mr. Victor Lynde, Mr. John Wal- rath, Mr. W. A. Dusenbury and Miss Lilla C. Wheeler, the suc- cess of the health program has depended and must depend in the future. Here, contacts with the Milbank Memorial Fund had not un- naturally been more direct, since the problem of finances was so intimately concerned. There have been differences of opinion, chiefly relating to the possible rate at which the County could in- crease its appropriations for health work. It was natural that representatives of a Fund which was pouring half a million dol- crease its appropriations for health work. It was natural that they should be anxious that the financial burden of the program should be taken over by the County as promptly as originally planned. Since the large increase of county appropriations to nearly $28,000 in 1926, there has been a further increase of only about $5,000. On the other hand, it was equally natural that the local politi- cal leaders, feeling the financial limitations of the County Treasury and the demands for expenditure along other lines, should be tempted to resist pressure from metropolitan visitors and should have their own very definite concepts of the possible rate of progress and the ways in which such progress could be wisely stimulated. On the whole, in spite of these inherent differences in view- point, the relations between those responsible for the demonstra- tion and the political authorities of the County have been cordial and constructive. The county budget has been increased to Psychological Reactions to the Health Demonstration 241 $33,000 a year with no backward steps and no trace of political interference. When the demonstration was attacked in 1926 and 1927, the Board of Supervisors supported it by an over- whelming vote. Altogether, aside from the question of rate of progress in as- suming financial responsibility, no demonstration could have had more cordial and loyal support than has been given by the officials of Cattaraugus County; and the writer has been particu- larly impressed by the completeness with which the value of the health program has been accepted, not only by the county authori- ties, but also by such local leaders as Mayor Vedder of Olean and Mayor Hunt of Salamanca. The concept of a modern health program has been “sold” to the political leaders of Cattaraugus County. The Demonstration and the Local Medical Profession. It is in its relations to the local medical profession that the chief diffi- culty in psychological adjustment has developed in Cattaraugus County, and this difficulty, while only temporarily acute and less serious locally than its more distant reverberations might imply, deserves full and frank consideration. It has been pointed out in Chapter VI that the Cattaraugus County Medical Society on October 16, 1922, approved the at- tempt to secure aid from the Milbank Memorial Fund for a health demonstration and pledged its full cooperation to make such a demonstration a success. It was provided, when the County Board of Health was created, that one of its members should be a physician nominated by the local Medical Society and, when the Board was enlarged, a second medical member to be nominated in the same way was provided for. These nominations were duly (though informally) made by the Society and confirmed by the Supervisors, in January, 1923, and May, 1925, respectively. On April 17, 1924, the president of the Medical Society took an active part in a conference held at Albany to draw up the demon- stration program. On December 3, 1925, Dr. J. P. Garen, a local physician serving as full-time deputy health officer and di- rector of the County Laboratory and of the Bureau of Com- 242 Health on the Farm and in the Village municable Diseases, was elected president of the county society. No prospects for close cooperation could have seemed fairer. The first break in cordial relations occurred in September, 1926, when, out of a clear sky and with no warning, the Medical Society passed a resolution criticising the work of the demonstration. No specific allegations were made and the gravamen of the charges appeared to be failure to consult the Society sufficiently with re- gard to program and policies. It was apparent that many of the physicians had originally gained the impression that the demon- stration was to deal only with tuberculosis and resented its ex- tension into wider fields. ‘The County Board of Health, on learn- ing of this resolution, promptly invited the Medical Society to meet with the Board and consider its program and policies. In December, 1926, the Medical Society’s Committee on Public Relations, after three months of study and conference, presented a report which the Society adopted. ‘This report went on record as favoring the present day public health movement and the county health unit as its most practical expression in rural areas, expressing its confidence in the County Board of Health and favoring coéperation with the Board by the organized profession of the County. It also expressed its appreciation to the Milbank Memorial Fund for enabling Cattaraugus to try out the county health plan. In the spring of 1927, relations again seemed excel- lent. At that time it appeared probable that Dr. Douglass, then County Health Officer, would shortly resign. ‘The matter of a possible successor was discussed with the Committee on Public Health of the local Medical Society and the Committee urged the appointment of some local man. They were asked to suggest a candidate and did suggest one of the medical members of the Board of Health who was thereupon urged to consider the matter; when he was offered the position in the fall this physician finally felt obliged to decline. On July 7, the officers of the Medical Society were reélected, including Dr. Garen who had been (and at that time was still) director of the County Laboratory. On August 4, 1927, the Society at a largely attended meeting adopted its fourth resolu- Psychological Reactions to the Health Demonstration 243 tion with regard to the demonstration—this time one of con- demnation. The only thing that had happened in the interim was the de- cision by the County Board of Health (on motion of Dr. Fisher) that it could not fully carry the health program by the end of 1927 and that it must ask the Milbank Memorial Fund to continue aid for a further period. The criticism of the county demonstration by the Medical Society, as in 1926, was lacking in any concrete specifications. The actual resolution read as follows: “That the Cattaraugus County Medical Society go on record as desiring the withdrawal of the Milbank demonstration from this County and opposing any request for its continuation after the termination of this year. “That the Society go on record as favoring and supporting a County Board of Health, conducted on a modest and practical scale and without interference from the State Charities Aid As- sociation or other unofficial bodies. “That the Society, while expressing its appreciation to the Milbank Memorial Fund for its Cattaraugus County effort, records its opinion that this experiment has demonstrated the ineptitude of lay bodies to bring about properly the transfer of the theoretical to the practical.” The adoption of these resolutions was followed by the publi- cation, under the name of the Society of a remarkable series of controversial booklets, yellow, blue, pink, and brown, which were widely distributed throughout the medical profession of the country. The first of these booklets summarized a question- naire which had been sent out to the physicians of the County, from which it appeared that a considerable majority recorded themselves as against the development of the county health plan as it had been conducted in Cattaraugus, against its continuance, and against the codperation of lay and unofficial health agencies in county health work. A majority, however, favored the con- tinuation of the County Board of Health, with withdrawal of outside aid. The chief reactions expressed in this and succeed- 244 Health on the Farm and in the Village ing booklets were the costliness of the demonstration, overglorifi- cation of its exponents, lack of deference to the local Medical Society and loss of prestige by its members and, always, inter- ference by lay bodies and failure in the actual conduct of the work—*‘the ineptitude of lay bodies”, to quote the terms of the original resolution. These remarkable charges stirred the County to vigorous response. Miss Lilla C. Wheeler, in an effective letter occupy- ing about a page of the Olean Herald, conclusively answered the charges of “interference” and gave an illuminating outline of what the State Charities Aid Association had accomplished for public health throughout the State. The Salamanca Republican- Press published a series of five smashing editorials, each headed “The Ineptitude of Lay Bodies” and each beginning with an ex- tract from the resolution of the Medical Society and then analyz- ing some one or other of the concrete accomplishments of the demonstration. ‘The County Board of Health, on September 9, adopted a resolution which stated that the services of the State Charities Aid Association had been “invaluable” in furnishing advice as to policies and aid, in securing trained personnel, and in recording and interpreting the work accomplished and added that “all these and many other services have been rendered only at our request and always in a spirit of codperation, friendliness and kindly understanding of our difficulties, which have made our working relationship at all times extremely satisfactory.” On October 3, the County Board issued a vigorously worded “Open Letter to Citizens of County Telling of Health Program and Policy,” declaring “work will continue so long as authorized and answering criticisms of doctors.” Meanwhile, on the other side, Dr. Garen, president of the Medi- cal Society and (until December) director of the County Labora- tory and recipient of a salary derived from appropriations supplied by the Milbank Memorial Fund, was continuing a vigorous speak- ing campaign against the demonstration, inside and outside of the County. The State Charities Aid Association and the officers of the Psychological Reactions to the Health Demonstration 245 State Medical Society were making every effort to ameliorate the situation and on November 3 a conference was held at Olean be- tween representatives of the local and state societies with the State Commissioner of Health and Dr. Linsly R. Williams, repre- senting the Committee on Medical Relations of the State Charities Aid Association. At this conference the local society group presented their alternative plan for a county health program which involved cutting the budget of the County Department from $56,000 to $36,000 and reconstituting the County Board of Health with five medical members out of seven. The State Commissioner of Health replied to this proposition by saying that if a board were so constituted he would refuse to recognize the County as eligible for state aid on the ground that to give control of a public board to a single professional group was contrary to every principle of democratic government and sound public policy. Finally, on November 21, the Board of Supervisors approved the program presented by the County Board of Health, including a county budget of $56,000 with continued aid from the Milbank Memorial Fund. This action essentially closed the matter, so far as Cattaraugus County was concerned. The officers of the local Medical Society, however, now carried the controversy into a wider field. The issue of polychrome booklets was continued and there seems no doubt that bad feeling between public health authorities and the medical profession was stimulated in many localities where the true facts were not known. The subject was brought up at the May, 1928, meeting of the State Medical Society and by appeal to professional esprit de corps and, with no presentation of supporting evidence, the passage of a resolution was secured, endorsing “the protest of the Cattarau- gus County Medical Society in its opposition to the Milbank demonstration as at present conducted by the State Charities Aid Association, because the Milbank Foundation has not governed itself either in spirit or in practice by the principles laid down by this society for the conduct of its members in their relation to public health work conducted by lay organizations.” At 246 Health on the Farm and in the Village the same meeting there were adopted eight general principles “as a basis for the conjoint work of the medical profession and volun- tary public health agencies.” These principles were sound and were consistently observed by the demonstration authorities in Cattaraugus County. Incidentally, it may be mentioned that at the 1927 meetings of the State Medical Society and of the State Charities Aid Association a joint program of principles govern- ing relations between medical organizations and voluntary health agencies had been adopted by both bodies—a program which has ever since been carried out in the most cordial fashion on both sides. The Cattaraugus controversy did not then in any way practi- cally impair the general good relations existing throughout the State; and within the County, it served to strengthen rather than to weaken general public approval of the demonstration. Its more distant echoes were, perhaps, less fortunate and require a brief interpretation of the situation. In the first place, it must be clear to any impartial observer that there was no basis in fact for the actual charges made by the local Medical Society, so far as those charges can be crystallized into any concrete form. A. There was no “dictation” by “lay bodies”. The demon- stration program was conducted by medical men, expert in pub- lic health, acting under the direction of the constituted legal authorities of the County. The initial program was prepared by a group of highly trained health experts whose directing mind was that of Dr. Hermann M. Biggs, the leading medical states- man this country has produced. Each part of this program for which outside aid was desired by the County was adopted in con- ference between representatives of the County and of the outside agencies. Appropriations by the Milbank Memorial Fund were provided only for specific activities which the County Board de- sired and no control was ever exercised over the moneys appro- priated from the public treasury. Even with respect to outside grants there was no dictation as to detailed policies or personnel. B. There was no failure in reasonable deference to the local Psychological Reactions to the Health Demonstration 247 organized medical profession. The program was at the begin- ning submitted to, and twice approved by, the local Society. That Society nominated two members of the County Board of Health and its president was second in command of the county staff. When a vacancy was expected in the position of county health officer, the nominee of the Medical Society was promptly offered the position. Only in the fall of 1927, when the local Medical Society presented a program so unsound that the State Commissioner of Health declared he would withdraw state ap- proval if it were adopted, was the policy of the Society necessarily disavowed by the County Board of Health. C. Finally, the charges of “ineptitude”, “inefficiency”, “chaos”, “extravagance”, and “pauperism”, had equally little justification in fact. As our somewhat rigorous criticism has revealed, the Cattaraugus County program, like other human enterprises, was not perfect. It had, however, been conceived with re- markable soundness and in the main executed with efficiency and economy. It represents one of the most effective and inspiring contributions made to the cause of rural public health anywhere in the world. When we find a position for which there is no logical justice held with passionate vigor by an individual or a group, modern knowledge of the human mind leads us to look for emotional rather than rational motives. Such motives are fundamentally important in human affairs; and we must next ask ourselves— what were the psychological factors which led to this emotional crisis among certain members of the local medical group? Such a diagnosis is, of course, a difficult and largely a subjective one. The writer has endeavored, however, to analyze the situa- tion in full dispassionateness and believes that at least three factors may be detected at work. In the first place, there was involved in this situation a deep and significant psychological “block” which is essentially inherent in any demonstration program and can anywhere be overcome only by great skill and patience. It may be stated as follows: Whenever a medical or health enterprise of any sort is set going 248 Health on the Farm and in the Village in any community—whether it be a new health department pro- gram, a new hospital, a closed medical school, an industrial or a university medical service—the presumption is that it is going to do the thing it sets out to do better than it had been done before. Otherwise, the enterprise would not have been undertaken. Is it not inevitable that physicians who are not on the staff of the new organization should feel that its creation is in some sense a challenge to them, a claim that those within the organization are superior in some respect to those outside (even though the “in- siders” make no such claim)? As Artemus Ward said, “There is a great deal of human nature in man”—even in physicians. Such an emotional reaction is always rationalized in some form, but the real key to the problem is an implied challenge by the “ins” to the prestige of the “outs”. This tendency is, of course, particu- larly acute when a part of the funds involved and a considerable part of the expert medical personnel must be derived from outside the community itself. This basic psychological tendency, in- herent in the situation and involving no reasonable blame on anyone concerned, seems to the writer the first major factor in the problem. This factor was perhaps not fully realized at first. While the relations of the demonstration to the local Medical Society were technically correct, some local members of the staff and some visitors from New York were apparently not always as tactful in personal contact as might have been desirable. ‘There was no quantitative lack of such contacts in the early days, for one of the complaints of the critical physicians is that they were bored to death by presentations of too many papers at their meetings from the demonstration staff. On the other hand, some of these physi- cians who are now most loyal to the demonstration will say in confidence that its exponents at the beginning were “on a high horse” and that they treated the doctors without that degree of deference which they might properly expect. It is easy to criti- cise the technique of the rural practitioner; but it is far less easy to understand the limitations under which he works or to appre- ciate fully the triumphs he often achieves. This factor in the Psychological Reactions to the Health Demonstration 249 situation seems wholly eliminated today; but it was a real one in earlier years. These two elements—instinctive resentment against a new organ- ization in which one does not play a part, and lack of the con- summate tact which might help to overcome such resentment— are in varying degree present in all communities where active advances in public health work are made. The only factors peculiar to the Cattaraugus situation which determined the evolu- tion of latent grumbling into vocal opposition were purely per- sonal ones—for which neither the New York supporters of the demonstration nor those in charge of its work at Olean were in any sense to blame. Finally, it must be very clearly emphasized that all that has been said with regard to this controversy refers to the official representatives of the organized medical profession and not to the members of that profession as a whole. Resolutions and questionnaires, obtained under the pressure of an active group of advocates, are notoriously fallacious records of opinion; it is inherently improbable that the doctors of the County were all in favor of the demonstration on October 16, 1922; all against it on September 26, 1926; all in favor of it on December 16, 1926; and all against it on August 4, 1927. At the height of the 1926 agitation, 36 of the physicians were actually participating actively in the work of the County Department of Health. This question of the actual attitude of individual physicians seemed to the writer so important that he has devoted consider- able time to attempting to evaluate it. By reference to pub- lished records, by first hand interviews and by judicious inquiry, it has been possible to obtain a reasonably clear idea as to how each member of the profession has really reacted to the demon- stration. There have been changes and reversals of attitude, but at present the situation would seem to be about as follows: Of 68 physicians in Cattaraugus County, 17 appear to be more or less antagonistic to the present demonstration program. Of the 17, only 8 have been actively hostile. The nucleus of this opposition is a group of intimate friends of the opposition leader. 250 Health on the Farm and in the Village Of the 9 who are classed as moderately antagonistic, 3 are actually participating to a considerable degree in the work of the demon- stration, serving in child health, or toxin-antitoxin conferences, at venereal or vaccination clinics, and one seems to be considered by the demonstration staff as among the most public spirited and useful physicians of the County, so far as actual participation in the work is concerned. Among the minor factors which might naturally contribute to opposition in individual cases are disagree- ments with nurses, loss of position as local health officers and re- sentment of appointment of fellow-practitioners as child welfare clinic doctors. A second group of 18 physicians can be classed neither as an- tagonists nor as active supporters of the demonstration. This group includes 14 who have apparently taken no stand, including young men who have recently come to the County, older men no longer in active practice and specialists who have had little or no contact with the demonstration work. The other 4 are men whose attitude appears to vary sharply at times from vigor- ous criticism to hearty support. All of these last four are at present actively engaged in some phase of the Health Department work. Finally, there are 33 of the total of 68 physicians in the County who have given ample evidence during recent years of active support of the demonstration program. Here, as in the case of the opposition, the “human nature in man” has played its part. Twenty-two of the 33 men in this group have been so actively connected with the various branches of demonstration work as to feel themselves actually a part of it, and to be actuated by sub- conscious impulses for, rather than against, the whole enter- prise. They have been prominent as members of the County Board, as local health officers, physicians at child welfare, venereal disease or toxin-antitoxin conferences, or in the local tuberculosis program, as school physicians or medical consultants on the Elli- cottville studies. ‘The other 11 have not been directly connected with the demonstration but have been notably friendly, have wel- comed the consultation service and, in two instances, have been Psychological Reactions to the Health Demonstration 251 specially generous in performing free medical service for the poor. Dr. Edwards, in his independent canvass of medical opinion, emphasized the point that present criticisms of clinic and nursing activities are relatively minor and such as would inevitably be made in any community. He finds no criticism of the general concept of a county health program or of the present personnel of the County Department of Health. He concludes that “the inherent good in the principles of public health have been able to thrive apace, and we now see a well established County Depart- ment of Health rendering admirable service with a growing respect and appreciation among private practitioners.” From a practical standpoint, it is apparent that the provision of five scholarships at Trudeau and the development of infant welfare conference work have led certain individual physicians to lay greater emphasis on tuberculosis and child hygiene, benefit- ing these physicians themselves and raising the general level of medical practice. Modest honoraria paid for child hygiene, venereal and immunization clinics have added slightly to the total volume of funds available for medical care, while laboratory service and diagnostic service in tuberculosis and communicable diseases have been of substantial assistance to the general practi- tioner. On the other hand, certain physicians have lost their small fees as local health officers and physicians who were operat- ing X-ray machines prior to 1923 have suffered some competi- tion. All in all, even the most vigorous medical critics make no serious claim of economic damage to the profession. The basis of a sound relation between a health department and the members of the medical profession lies in mutual codperation for a common end. The unique contribution of the County Department Laboratory, and of the consultation services, and the active cooperation of Health Department and practitioners in child welfare conferences, venereal and immunization clinics and school medical examinations are the most heartening aspects of the situation. It is the belief of the writer that the maximum possible utilization of the properly compensated service of private physicians is essential to the sound development of our public 252 Health on the Farm and in the Village health program in the future. Such steps as have been taken by the health officers of New York City and of Detroit are most significant of possibilities along this line. Such possibilities might be further explored with advantage in Cattaraugus, particularly along the lines of prenatal clinic service and the treatment of venereal cases in the rural areas. Reactions of the County Press. We may pass next to a con- sideration of the reactions toward the demonstration of the wider public, upon whose intelligent support the success of our whole public health program must ultimately depend. As a first measure of such reactions we may logically turn to the county press. Intellectuals may fume and fret at the news- papers but, when all is said and done, these organs reflect and react upon public opinion in a fundamental fashion and on the whole represent its higher rather than its lower levels. Par- ticularly in a rural area, the local editor is a personage of im- portance and his attitude is likely to typify that of other leaders of opinion. It, therefore, seemed well worth while to use the county press as a mirror of the impact of the demonstration upon the minds of the County’s more enlightened citizens. It must be recognized, of course, that there are two factors which govern the space devoted to a subject like public health in the newspapers. One factor is the extent of the effort to provide material for publication; the other is the willingness of the editors to accept such materials. From the first standpoint, the demonstration has passed through three general phases which are of significance in interpreting the results which are to follow. At the beginning of the work, in 1923, Mr. John Armstrong, edi- tor of the Olean Times, was made executive secretary of the County Tuberculosis and Public Health Association with the aim of developing newspaper publicity with vigor, so that this objective was clearly in mind from the first. In 1926, Mr. Arm- strong was transferred to the County Department of Health. In 1927, on account of the controversy with the local Medical So- ciety, the educational campaign was intensified with the pur- pose of placing the true facts of the case before the public; but Psychological Reactions to the Health Demonstration 253 after this controversy passed its acute stage, influential members of the County Board of Health felt that the soft-pedaling of general publicity might tend to allay bad feeling; and during the past three years there has been no one in full-time charge of popular health instruction, and systematic press publicity from the Department has been limited. To gauge the effect of the program and to determine the reac- tion of the editors thereto, it was decided to make an intensive survey of the issues of the county press at three successive periods —in 1922 before the demonstration began, in 1927, when the program of popular health instruction was at its height, and in 1929, after it had been reduced to a minimum. A comparable survey was made for 1929 in Steuben County which, as has been pointed out in an earlier chapter, is a generally comparable rural county but lacking any special public health development. The survey was made by Mr. and Mrs. J. H. Watkins of the Department of Public Health of the Yale School of Medicine. It covered the three dailies in Cattaraugus and the two dailies in Steuben, with three representatives for each county of the weekly papers published in the smaller towns. (There are altogether, as it happens, eleven such weeklies in each county.) In Cattarau- gus it was planned to select the three weeklies having the largest circulation, but as certain files in two offices were missing (one stolen and the other burned), those papers having the next largest circulation were taken. This change was relatively unim- portant for, of the eleven weeklies published in the County, six had a circulation between 1,100 and 1,500, the largest being 1,500. The daily papers selected, with their circulations, were: (1) The Olean Evening Times, 8,833; (2) The Olean Herald, 5,230; and (3) The Salamanca Republican-Press, 2,550. The weeklies used were: (1) The Randolph Register, 1,500; (2) The Ellicottville Post, 1,125; and (3) The Cattaraugus Times, 900. Steuben County has two dailies, the Corning Evening Leader, 9,232; and the Hornell Evening Tribune-Times, 8,012. The eleven weeklies range more widely in circulation than those of Cattaraugus County, 4 being in excess of 2,000. In order to 254 Health on the Farm and in the Village compare more closely with Cattaraugus County, only one weekly, having a circulation greater than 2,000, the Bath-Steuben Courier, 2,460, was studied. The other weeklies chosen, the Cobocton Valley Times-Index and the Hammondsport Herald had circula- tions of 1,150 and 1,200, respectively (the latter estimated by the editor) and make a group comparable with the three selected in Cattaraugus. The circulation, except in the two cases noted above, was obtained from Ayer’s American Newspaper Annual and Directory and is always for 1929. Of the dailies, one issue a week was examined for each year studied, distributing the days of the week uniformly by choosing a Monday issue for one week, a Tuesday issue for the next week, and so on. All issues of the weeklies were analyzed. Each issue was carefully examined and the number of edi- torials, news items, articles and advertisements relating to health topics noted. For each item thus listed, the number of column inches were determined. The items of news matter were classi- fied in certain major groups to be listed later and each advertise- ment was classed as, on the whole, of a beneficial or a harmful nature, from the standpoint of the public health. The number of items in our later discussion will be expressed on the basis of articles per issue, the volume of material as a percentage of the total volume of the paper in column inches, the width of columns being generally 2.25 inches. This percentage was computed on the total number and size of pages for the year (or sample of approximately 52 issues in the case of the dailies). In the case of news, the volume percentage is related to the total volume of the paper, in the case of advertising only to the “available possible advertising space” equivalent to the total volume less the front page, which does not carry advertising. In general, the weeklies and the Salamanca daily averaged 8 pages per issue, while the other four dailies rose to between 10 and 18 pages per issue. The general results as regards all health matter, except ad- vertisements, are summarized in Table 56. At first it was in- tended to distinguish between useful and misleading health news, but the latter item proved so small, never reaching 12 per cent Psychological Reactions to the Health Demonstration 255 Table 56. Summary of health material in Cattaraugus and Steuben papers. (Excluding advertising.) ARTICLES PER ISSUE Per CENT OF TOTAL SPACE PAPER 1922 1927 1929 1922 1927 1929 Cattaraugus County Olesn Times... . .| 08 23 21 0.4 0.8 1) Olean Herald . . . 0.9 1.5 2.2 0.4 1.0 0.9 Salamanca Republican Presario 08 1.2 1.9 1.1 1.1 1.3 Average, dailies . .| 0.7 1.7 23 0.6 1.0 i 5 | Randolph Register . .| 0.8 19 0.9 0.6 1.0 0.7 Ellicottville Post. . .| 0.9 4.1 24 0.6 3.9 2.4 Cattaraugus Times . . 1.9 1.3 1.0 2.0 1.3 0.6 Average, weeklies. . 12 2.3 13 Ad 2.2 11 Steuben County Corning Leader . . . 2.2 0.8 Hornell Tribune-Times . 1.9 1.2 Average, dailies 21 1.0 Bath-Steuben Courier . 13 0.8 Hammondsport Herald. 1.8 1.3 Cohocton Valley Times- Index . 0.9 0.9 Average, Weekitios . 1.4 1.0 of the total health news even during the 1927 controversy and generally falling below § per cent, that this distinction has been ignored. It appears evident that the Cattaraugus County dailies have steadily increased their articles dealing with health, the number having trebled since 1922 and the space allotment having ap- proximately doubled. In the weeklies there was a great increase, due to causes mentioned above, in 1927, and then a falling back to approximately the old level in 1929. The conclusion that the demonstration has markedly affected even the dailies is, however, negatived by the figures for Steuben, which in 1929 almost exactly check those for Cattaraugus. We do not know what the situation was in Steuben in 1922, but it seems probable that the increase of health articles in the Cattaraugus papers merely mirrors a generally increased interest in the subject 256 Health on the Farm and in the Village throughout the country. Incidentally, the close check between the average figures is most encouraging with respect to the pos- sibilities of such a study, in view of the many factors which in- fluence an individual paper. Thus, in 1922, the high space al- lotment for the Salamanca Republican-Press was due to the fact that over one-third of a 12-page issue was devoted to publication in full of the city sanitary code. A further analysis of the type of health news published is pre- sented in the accompanying table (Table 57). There appear Table 57. Analysis of type of health articles, number per issue. Darues WEEKLIES TyPES oF NEws Cattaraugus Steuben Cattaraugus Steuben 1922 | 1927 | 1929 | 1929 | 1922 | 1927 | 1929 | 1929 Fditorials, ....... .].-04 0.1 0.2] 0.1 0.1 0.1 0.1 0.1 Local health depart- ment letters . . . 0.1 0.1 0.3 0.2 Other local health news 0.3 06] 07] 07 0.4 1.7 0.7] 04 State Health Depart- ment publicity . .| <0.1 [ <0.1 | <0.1| 0.1 04 | 0.1 [<0.1( 0.2 Other general health news '. o.oo. 0.3 0.3 0.5] 0.5 0.3 0.2 0.3 70.5 Syndicated articles . 0.5 08 | 0.8 0.1 <0.1) 02 TOTAL... il {07 1.7 23] 2.1 12 2.5 13] 14 to be no really significant changes in the Cattaraugus dailies ex- cept a general increase in all items, an increase which, however, only brings the totals up to the same level reached by Steuben in 1929. Among the Cattaraugus weeklies, however, there was a 300 per cent increase in local health news in 1927, as a result of the interest focused on the demonstration at that time and even the 1929 weeklies continued to publish nearly twice as many items of this kind as in 1922 and nearly twice as many as the Steuben weeklies did in 1929. This was balanced, however, by less state and general health news in the Cattaraugus weeklies. On the whole, there was little difference in the type of edi- Psychological Reactions to the Health Demonstration 257 torials printed in the various groups of papers except in 1927. At that time the Cattaraugus papers with scarcely an exception supported the county health program. The Olean Herald, for example, stressed the safeguarding of human health as of funda- mental importance and emphasized the values of the Milbank Memorial Fund’s contribution and the necessity of maintaining the County Health Department. It recognized the seriousness of medical opposition and urged a compromise, but approved the action of the Supervisors in continuing the demonstration. The Olean Times published a long letter from a local physician vigor- ously defending the demonstration and condemning the attitude of the Medical Society and gave editorial approval to the action of the Board of Supervisors. The Salamanca Republican-Press was at all times an active and ardent advocate for the work. The Cattaraugus Times took no stand on the matter. The Randolph Register was at first much impressed by the physicians’ side of the controversy and urged agreement between the parties concerned. The Ellicottville Post was a strong and consistent champion of the demonstration and strongly criticised the attitude of the Medical Society. A word may be added as to the nature of the various types of news items in Table $7. Under the heading “Other Local Health News” have been included articles evidently emanating from the county and local health departments and voluntary agencies, typified by the following headlines: “Typhoid at East Randolph”, “Appointment of a Cattaraugus County Sanitary Engineer”, “Child Guidance Conference”, “Toxin-antitoxin Clinic to be Held”, “Xmas Seal Sale Begins”. The local health department letters, separately tabulated, are the “health letters” issued over the signatures of Dr. Douglass and Dr. Atwater. The State Health Department publicity in- cluded radio talks and special dispatches from Albany. “Other General Health News” includes items, some Associated Press material and some “boiler plate,” dealing with news in the health field from outside the County and not clearly attributable to the State Department of Health. Such articles included As- 258 Health on the Farm and in the Village sociated Press reports on the 1929 epidemic of influenza, a notice of the death of Dr. Goldberger, reports of legislative attempts to control stream pollution, and articles on radium poisoning and on the “No Cold Club” of Syracuse. Syndicated health articles were chiefly by the Gorgas Me- morial Institute Staff, Lulu Hunt Peters, Morris J. Fishbein, J. J. Gaines, Alice Judson Peale—and Bernarr MacFadden. Mr. and Mrs. Watkins next proceeded to a similar analysis of the advertising matter in the papers studied, with the result (so far as advertisements appealing on health grounds are concerned) presented in Table 58. It appears that the Cattaraugus County dailies and both dailies and weeklies in Steuben County have about twice as much ad- vertising space as news space devoted to health topics, but the Cattaraugus County weeklies are relatively less successful in Table 58. Summary of health advertising in Cattaraugus and Steuben newspapers, in 1922, 1927 and 1929. Per CENT oF ToTAL ADVERTISEMENTS PER ISSUE AVAILABLE SPACE PAPERS 1922 1927 1929 1922 1927 1929 Cattaraugus County Olean Times . . . .| 13.6 8.6 9.0 2.7 1.9 24 Olean Herald . . . . 7.6 29 3.4 23 1.0 14 Salamanca Republican- Press , . . . 7.6 9.2 5.9 21 4.1 2.8 Average, dailies . . 9.6 6.9 6.1 24 23 22 Randolph Register . . 33 31 12 1.1 0.8 0.6 Ellicottville Post. . . 34 1.6 34 12 0.5 14 Cattaraugus Times . . 0.9 0.0 0.8 0.3 <0.1 0.2 Average, weeklies. . 25 1.6 1.8 0.9 0.4 0.7 Steuben County Corning Leader . ; 8. Hornell Tribune-Times . 9. Average, dailies 8.7 Bath-Steuben Courier . 0.6 Hammondsport Herald. 3.7 Cohocton Valley Times- Index:.0% 0 3.0 33 Average, weeklies . 1 for IR - WON © ing ° Psychological Reactions to the Health Demonstration 259 securing health advertising. (The calculation of the ratio of advertising on a basis of inside pages only does not affect this relationship seriously.) With this exception, no notable dif- ferences appear. As to type of health advertising, a special analysis was made for two three-month periods. It proved that 71 per cent of the total number of advertisements relating to health were advertise- ments of patent medicines. The other leading advertisers were chiropractors (12 per cent), health baths and other physiothera- peutic treatments (7 per cent), dentists (2 per cent), dairies (2 per cent), other foods advertised on health grounds (2 per cent), standard drugs (2 per cent), nurses’ training schools (1 per cent). Finally, the various advertisements were classified, as in Table 59, on the basis of subjective judgment as to the general influence of each advertisement upon readers who might be influenced by it. The criterion applied was whether response to the advertise- ment would be likely on the whole to benefit or harm the receptive reader; and it will be noted that over four-fifths of the advertising in Cattaraugus County, and a considerably higher proportion in Table 59. Analysis of type of health advertisements. DAILIES WEEKLIES Cattaraugus Steuben Cattaraugus Steuben 1922 1927 1929 1929 1922 1927 1929 1929 Number per Issue Good .| 1.2 0.6 0.5 04 0.1 0.1 03 |<0.1 Bad i. 34 6.3 5.6 8.2 24 15 15 3.2 TorAL.] 9.6 6.9 6.1 8.6 25 1.6 1.8 33 Per cent of Available Space Good .| 04 0.3 0.2 02 <01 j<01 0.1" {5<0.] Bad .| 20 2.0 2.0 27 0.9 0.4 0.6 1.9 ToraL.| 24 23 22 29 1.0 0.5 0.7 2.0 260 Health on the Farm and in the Village Steuben County, was adjudged to be harmful rather than beneficial. Considerable space has been given to analysis of this news- paper study, because of our belief that the type of investigation has considerable general interest and might well be repeated else- where. So far as the reaction to Cattaraugus County’s health program is concerned, it brings out the following points: A. That the amount of space devoted to health news in the Cattaraugus County dailies nearly doubled between 1922 and 1929, while that in the weeklies doubled in 1927 and fell back again in 1929. B. The increased space devoted to health news in 1929 was, however, about the same as that occupied by the same subject in the corresponding papers of Steuben County, in the same year— about 1 per cent. It was somewhat surprising to us to find that the intensive health program of Cattaraugus County (and particularly the public conflict of 1927) produced so little relative effect. The whole picture strongly suggests—what perhaps we should have expected—that the amount of space devoted to a given topic is governed by rather fundamental tendencies of public opinion. It would seem probable that the increase in space devoted to health between 1922 and 1929 reflected a generally increasing interest in this subject which made itself felt without much reference to temporary local pressures. If this be the case, it would seem that our wise course as public health workers would be to strive for the highest quality of newspaper publicity without attempting to enlarge its volume beyond what the instinctive judgments of editorial policy dictate. Vox Populi. Finally, we may pass to what is perhaps the most important and difficult of all the psychological problems involved in our efforts toward social progress—the opinion of “the man in the street” or, in a rural county, “the man in the furrow”. First of all, a word should be said as to the general program of the demonstration with regard to popular health instruction. Psychological Reactions to the Health Demonstration 261 We have seen that rather special efforts were made to secure news- paper publicity in the early days of the demonstration, which proved of real value in obtaining increased appropriations in 1925, and that such publicity has been of late rather definitely “soft-pedaled”, even to the discontinuance of Dr. Atwater’s admirable health letters. Newspapers stories issued by the De- partment dropped from 1,594 in 1927, to 734 in 1929—meetings addressed from 417 to 106. On the whole, the County Health Department has had an average, but by no means an ambitious, program of popular health instruction. It has fulfilled the very modest requirements of the Appraisal Form. It has prepared good annual reports (that of 1928 being a masterpiece). It has prepared modest but excellent exhibits for use at the child welfare conferences and at County Fairs. It has provided a lecture service, but not on any organized basis. It has, on the whole, relied chiefly on the actual service of its nurses and clinics to educate the public as to its values and possibilities, and, since 1927, has had no special individual assigned to the task of popular health instruction. The impression of Dr. F. K. Shuttleworth of the Department of Education at Yale University, a wholly detached observer from the educational field, is of interest with regard to the type of popular health instruction which has been developed. He says: “The author would like to endorse the statement of one superin- tendent that the program has been educational in the best meaning of the word. Too often an educational program on some vital public question places the emphasis on advertising, propaganda, publicity, lectures, and circulation of printed material to the neglect of effort to actually improve conditions. The emphasis of the program on nursing services, clinics, medical examinations and toxin-antitoxin treatments has been in accord with the best educational methods. If anything, it has leaned over backward in neglecting the easier and more popular educational devices which by themselves tend to be impotent in the long run but which in connection with the concrete services might have helped to make the whole work more effective.” 262 Health on the Farm and in the Village In the attempt to estimate the influence, not primarily of popular health instruction, but of the Cattaraugus County pro- gram as a whole, the expert just quoted, Dr. F. K. Shuttleworth, was asked to make a special study of the problem. We have seen that the political leaders and the newspaper editors of the County have responded to the program with general cordiality. Among the school authorities, Dr. Shuttleworth found the same highly favorable reaction. He made contact with all but three of the village principals and rural superintendents in the County and found this group of men and women without exception heartily sympathetic and even enthusiastic about the health program. The reading of Dr. Shuttleworth’s quotations from these school authorities must warm the hearts of all connected with the demon- stration, for they have seen it intimately and at first hand and without prejudices. On the other hand, when Dr. Shuttleworth talked with casual individuals by the roadside, he found that of the small group approached about half had no idea that there was any such thing as a county health program and only about a quarter had any opinion about the program, favorable or unfavorable. It seems rather important to know what the average citizen thinks about the things which the leaders are trying to “sell” him; and for this purpose Dr. Shuttleworth resorted to a questionnaire and used Steuben County for purposes of control. The questionnaire was sent to 287 persons in Cattaraugus and to 330 in Steuben, the names (of men only) being selected at random from local telephone directories (in general, every eighth name was chosen). The letters were written on the stationery of the Yale University Department of Education. Each letter en- closed a stamped and addressed return envolope and a quarter of a dollar in a coin mailing card with the following introductory statement: “A responsible organization has asked me as an impartial out- sider to make a survey of opinion toward public health work in the western counties of New York State. They are anxious to have 100 per cent replies to the questions and accordingly have pro- Psychological Reactions to the Health Demonstration 263 vided funds which make possible the enclosed coin. It is not in payment for your trouble in answering the questions, but rather a small token of appreciation of your codperation.” The separate sheet containing the six inquiries was given the following heading: “HOW DO YOU VOTE? “In explanation: An intensive survey is being made of opinion in certain areas of New York to determine what people think of public health work. You are asked to help by answering the following questions. You do not need to sign your name. “Note: Public health work is concerned primarily with the health of the entire community instead of primarily with the health of a particular person. It may supervise water and milk supplies and sewage disposal; it may provide vaccination and toxin-antitoxin treatment; it may watch contagious diseases such as tuberculosis, smallpox, and typhoid; it may provide medical examinations for school children; it may hold dental, prenatal and tuberculosis clinics; it may provide free nursing services; it may work for a cleaner village, etc., etc.” The enclosure of the coin is a device which will be of some interest to those who have occasion to use similar questionnaires. It was believed that it would increase response and to test this assumption a similar questionnaire was sent out (without a coin) in counties adjacent to Cattaraugus County and Steuben County. Without the coin, only 19 per cent of replies were received; with the coin, 53 per cent in Cattaraugus and 51 per cent in Steuben. The questionnaire contained five questions carefully framed to test knowledge of, and attitude toward, the public health pro- gram, to which we shall return very shortly. It also contained a sixth question framed as follows: “In order to evaluate your replies to the above questions we need to know one more thing. Did you pay taxes on real estate last year? Yes, No. Were your taxes over $100? Yes, No.” Only 16 persons in Cattaraugus and 11 in Steuben reported that they were not taxpayers, while, of course, some failed to answer. Dr. Shuttleworth in his full 264 Health on the Farm and in the Village analysis has compared the groups paying less and more than $100 in taxes and the majority in both counties were in the latter class, with no very significant differences between the opinions of the two groups. Clearly, the persons replying to this question- naire were fairly substantial county citizens. The results of this questionnaire, including 151 replies from Cattaraugus and 163 from Steuben, may be summarized as follows: * “Question I. What do you consider the most important duty of a city or county Department of Public Health? Please mark the items in the list below, 1, 2, 3 and 4 (1 being most important, 4 least important). “To make people keep their back yards clean. “To teach people how to keep healthy. “To quarantine houses where people have been sick. “To provide public health nurses so that sickness in the home can be cared for.” Our idea was that a higher comprehension of the real values in a modern public health campaign would be indicated by placing health education and nursing ahead of the more primitive and traditional activities of nuisance inspection and quarantining. The essential results may be summarized as follows: Per cent replies classing health education as (1) or (2): Cattaraugus 77 Steuben 79 Per cent replies classing public health nursing as (1) or (2): Cattaraugus 54 Steuben 49 Per cent replies classing quarantine as (3): Cattaraugus 35 Steuben 39 1 The percentages cited below are based on the actual total of usable replies to each question which was of course less than the total of 151 replies from Cattaraugus and of 163 from Steuben. Psychological Reactions to the Health Demonstration 265 Per cent replies classing clean back yards as (4): Cattaraugus 47 Steuben 41 The emphasis laid on health education in both counties is highly encouraging, but it is somewhat disheartening to find public health nursing ranked as first or second by only half the re- spondents and cleanliness of back yards as fourth by less than half. Cattaraugus shows a slightly better appreciation of the pub- lic health nurse as compared with the clean back yard, but the dif- ferences are not statistically significant since only 83 answers to this question from Cattaraugus and 75 from Steuben were usable. The other four questions are related in one form or another to the attitude of the taxpayer toward public health expenditures. The results may be summarized as follows: “Question II. In 1928 one rural county in New York State spent only 8 per cent of its tax levy on all forms of public health work. Do you consider this an example of wise economy? Underline Yes, No.” Per cent underlining “No”: Cattaraugus 77 Steuben 78 “Question III. In 1928 another rural county spent 13 per cent of its tax levy or $1.29 for every person for health con- servation. Do you favor expenditure to this extent? Under- line Yes, No.” Per cent underlining “Yes”: Cattaraugus 75 Steuben 67 “Question IV. Would you favor expenditure for public health work to the extent of $2.00 per capita? This might, of course, mean increased taxes. Underline Yes, No.” Per cent underlining “Yes”: Cattaraugus 41 Steuben 38 266 Health on the Farm and in the Village “Question V. The law requires that every school child have a medical examination. Some school districts spent as little as 25 cents for each child’s examination. Some spend as much as $1.00 per child. Would you be in favor of spending $1.00? Underline Yes, No.” Per cent underlining “Yes”: Cattaraugus 81 Steuben 72 To the writer, the results of these four questions are most surprising and encouraging—for both counties. The actual per capita amounts of money named, of course, mean little to the layman; but the general trends are unmistakable. That three- fourths of a group of substantial taxpayers should deprecate un- due economy in health work and favor a maximum payment for school health examinations, and that about 40 per cent should step up the desirable health appropriation to $2.00 per capita “even though this might mean increased taxes,” should give heart to the most timid protagonist of public health. In two of the four financial questions (II and IV) there is no difference between the two counties. Question III, however, shows Cattaraugus citizens distinctly more favorable than those of Steuben to general health appropriations and Question V shows them distinctly more ready to pay for medical school inspection. In neither case, however, is the difference great enough to be statistically reliable. Dr. Shuttleworth is surprised that differences were not greater; but public opinion moves slowly and it would be quite unreasonable to expect a revolution in seven years. On any public question votes are apt to be evenly divided. A change of 8 per cent in public opinion would decide most elections. Furthermore, Cattaraugus has actually made great financial sacrifices for its demonstration. The taxpayers might have been expected to be extra-conservative. Yet they show that they have, on the other hand, been educated to demand even more. If these questionnaires fairly represent the opinion of Cattaraugus taxpayers, the demonstration may be considered as succeeding, Psychological Reactions to the Health Demonstration 267 modestly but securely, in its most important psychological objective. It may be that we have lacked courage and vision in our public health program. It is possible that the public is more ready than we have realized to support such a program when it is wisely con- ceived and soundly executed. If such is the case and if our leaders move forward sanely and boldly, the safeguards of modern medical and sanitary science may yet be brought to the dweller in farm and village. 1 . ] 4 INDEX Adam, J. N., Memorial Hospital, 219 Adenoids, removal of, in school children, 153, 154, 167 Advertising, See Publicity, newspaper Age distribution in Cattaraugus County, 31,211 Agricultural pursuits County, 32-33 Allegany, population of, 30 water supply of, 106 Allegany Indian Reservation, 27 population of, 30 Allegany State Park, Children’s Health Camp at, 48, 53, 57, 132, 133 dietary planning in, 165 sanitation at, 111 Allegheny River, 26 Allen, Dr. H. C,, 85 American Public Health Association, 58, 102 appraisal score of, for Cattaraugus County Health Demonstration, 4 American Red Cross, child health demon- stration of, 1921, 36 child health demonstration of, at Mansfield, Ohio, 1922, 38 health demonstration units of, 1 in Olean typhoid epidemic, 63 American Social Hygiene Association, 56 venereal disease survey in Cattaraugus, in Cattaraugus 83 Anderson, Mrs. Elizabeth Milbank, death of, 38 establishment of Milbank Memorial Fund by, 37 philanthropic work of, 37 Atkins, Dr. Leslie J., 88 Atwater, Dr. Reginald M., vi, 73, 74, 81, 117, 257, 261 annual report of, on “Public Health in Cattaraugus County”, 1928, 67-71 on dairying in Cattaraugus County, 34 on public health nursing, 186 Armstrong, John, 48, 55, 252 Asquith, R. M., 55, 56 Automobile accidents, campaign to re- duce, 58 deaths due to, 1919-1921, 210-211 deaths due to, 1920-1929, 215 269 Bath-Steuben Courier, 254, 255, 258 Bellevue-Yorkville Health Demonstration, 52 Biggs, Dr. Hermann M., 39, 246 on public health, 21 Birth rate, decrease of, in Cattaraugus County, 216 Birth statistics of Cattaraugus County, 143-144 Board of Supervisors of Cattaraugus County, 29, 240, 241, 245 resolutions of, regarding proposed health demonstration of Milbank Memorial Fund, 42 Boarding homes, supervision of, 202 Both, B. J., 55 Bourne, Dr. P. H., 85 Bovine tuberculosis, campaign for eradi- cation of, 115 work on, 1923, 47 work on, 1925, 54 work on, 1927, 60 Boyd, Miss Susan M., 61, 197 Bradford, tonsillectomies in, 155 Bradley, Mrs. Florence, health activities of, 36 Bristol, Dr. Leverett D., 44, 46, 47, 52 Budgeting and budgets, health programs, annual budgets for, 1922-1930, 228, 229 adequacy of budget, 229, 231 maintenance of, 232-234 per capita cost, 227-228 per capita expenditure, 232 planning, 236 Buffalo, New York & Philadelphia R.R., through Cattaraugus County, 28 Buffalo & Pittsburgh Railroad, coming of, to Cattaraugus County, 28 Buffalo & Washington Railroad, 28 Burnham, Dr. A. C., 236-237 Burritt, Bailey B., 39 Burroughs, Dr. Travis, 71, 72, 73, 81, 84 Bushnell, William C., 44, 62 Byington, Miss Margaret, v, 184, 190, 193, 197, 198, 200, 202, 204 Camps in Cattaraugus County, diarrheal outbreaks in, 111 270 inspection of, 111 sanitation of, 110, 121 water supply of, analysis of, 111 Cancer, mortality rate, 1920-1929, 214, 216 mortality rate, 1919-1921, 210-211 Cattaraugus County age and sex distribution in, 31 agricultural pursuits in, 32-34 application of, for American Red Cross child health demonstration, 1921, 36 appraisal score of, 4, 58 appropriations for public health work in, 2 Board of Supervisors of, 29 Bureau of Maternity, Infancy and Child Hygiene established in, 2 cash funds among farmers in, lack of, 34 climate of, 27 community health program of Milbank Memorial Fund established in, 2, 42 county health district organized in, 44 county health program established in, 2, 44 county health service established in, 1 crippled children in, See Crippled Children dairying in, 33, 34 death rate in, prior to 1923, 36 district organization in, 87 economic status in, 31-35 families in, number of, 31 farms and farmland in, 32-33 foreign born residents in, 31 general considerations of, 1 geography of, 26 health demonstration, See Health Dem- onstration, Cattaraugus County health education tests of children in, 157-163 health instruction in, establishment of, 2 health provisions in, prior to 1923, 36 health situation in, prior to 1923, 35 history of, 27 income per capita, annual, 34, 233 industrial establishments in, 32 infant mortality, studies of, by Milbank Memorial Fund, 74 laboratory service in, § nursing service in, 2, § occupations in, 28 oil wells in, 28 pioneer settlers of, origin of, 28 population of, 29 railroads in, coming of, 28 Index sanitary engineer appointed in, 2 sanitation problem in, importance of, 2 school hygiene service in, development of, 2 schools in, history of, 29 selection of, for rural health demonstra- tion of Milbank Memorial Fund, 42, 44 social service organization in, develop- ment of, 2 tuberculosis sanatorium established in, 1 tuberculosis work in, § venereal disease control in, beginning of, 2 white settlements in, 27 Cattaraugus County Medical Society, breach between health demonstra- tion authorities and, 1926, $59, 242, 243, 245 friction of, with health demonstration authorities, 3, 242 report of, commending the work of health demonstration, 59, 242 resolution of, favoring termination of Milbank Memorial Fund aid in health work, 1927, 61, 243 resolution of, regarding proposed health demonstration of Milbank Memo- rial Fund, 43, 241 Cattaraugus County Tuberculosis and Public Health Association, See Tuberculosis and Public Health Association Cattaraugus Creek, 27 Cattaraugus Indian Reservation, 27 population of, 30 Quaker School in, 29 Cattaraugus Times, 253, 255, 257, 258 Cerebral hemorrhage and apoplexy, mor- tality rate, 1919-1921, 210-211 Chatham County, Georgia, health serv- ice, 4 public health nursing in, 187 Chautauqua County tuberculosis serv- ice in, 137 Chenango County, survey of crippled children in, 169 Chlorination of water supplies, 105, 106, 107, 108 Child health conferences, 56, 61 Child hygiene services outside New York State, influence of Cattaraugus County Health Demonstration on, 13 Child Welfare, Board of, widows’ aid handled by, 193 Childhood, hygiene of, 146, 149, ff. Index 271 preschool, 146 school age, 149 Children, defects in, correction of, 223, 225. See also School Children of school age, public health nurse visits, 177 preschool care of, public health nurse visits, 177 social service work in relation to, 197, 200-201 Children’s Aid Society, New York, 37 Children’s Health Camp, Allegany State Park, $3, 57, 132, 133 Children’s Home at Randolph, scarlet fever epidemic at, 1928, 65 Clarke County, Georgia, health service, 4, 134 Cohocton Valley Times-Index, 254, 258 Communicable disease control, outside New York State, influence of Cat- taraugus County Health Demon- stration on, 13 Communicable disease in Cattaraugus County, control of, 116, 122. See also Special disease epidemics hospitalization for, 117 measures for control of, 116 public health nurse visits, 177 Communicable Diseases, Bureau of, or- ganization of, 47 Community health program of Mil- bank Memorial Fund, announce- ment of, 1 establishment of in County, 2 Congdon, H. K., §§ Consultation service, medical, in Catta- raugus County, 9 Corning Evening Leader, 253, 255, 258 Cortland County, New York, public health service in, 10 County and local health departments, law reorganizing relations be- tween, 72 County Board of Health, annual report of, 1928, 67 budget of, 88, 89 headquarters of, 46, 84, 85 mileage traveled by, 90 organization of 46, 48, 81, 85, 86, 88 per capita expenditure of, 90 sanitary engineer appointed to, 64, 65 work of, 81 County health program, full-time, ade- quacy of, 98 as to budgets, 99 as to public health nurses, 100-101 Cattaraugus appraisal scores of, in counties having highly developed machinery, 102 comparison of Cattaraugus County program with other counties, 99 in general, 99 with counties having highly devel- oped machinery, 4, 102 development of, in the United States, 96 establishment of, in Cattaraugus County, 2 appraisal score of, 4 financial limitations of, 97 per capita expenditures in, 4, 99 County health service in Cattaraugus County, establishment of, 1 County health unit, effectiveness of, 7 County Tuberculosis and Public Health Association. See Tuberculosis and Public Health Association Crippled children in Cattaraugus County, 168-169 care of, 9, 48, 160-170, 199 causes of crippling, 170 committee on, 170 rehabilitation of, 70, 170 survey of, 51, 168 Crowell Publishing Company, “The Na- tional Market, 1926”, 22 on Cattaraugus County per capita income, 34 Cushman, Miss Eva, 49 Dairying in Cattaraugus County, 33, 34 Death rate in Cattaraugus County prior to 1923, 36. See also Vital sta- tistics, mortality rate Devine, James, 240 Diabetes, mortality rate, 1919-1921, 210— 211 mortality rate, 1920-1929, (Table 46) 214 Dick test in immunization against scar- let fever, 116 Dick testing and immunizing campaign, 1928, 65 Diphtheria control, 117, 121 Diphtheria immunization, 1928, §1, §3, 6s, 117 extended to children of preschool age, 57 Diphtheria, mortality rate, 1920-1929, 213, (Table 46) 214, 216 decrease of, 217 1922-1929, area comparisons, (Table 49) 218 reduction in, 218 1925-1928, 65 272 Diseases, mortality rate, 1920-1929, 213, 214-215 Douglass, Dr. Stephen A., 47, 52, 60, 323,257 Downes, Miss Jean, 66, 221, 225 Dublin, Dr. Louis I., 225, 226 Dusenbury, William A., vi, 44, 240 East Olean, water supply of, 106 Economic status in Cattaraugus County, 31-35 Edwards, Dr. H. R., v, 180, 251 on maternity, infancy and childhood hygiene program, 142, 145, 146, 149, 153, 154, 155 on tuberculosis control program in Cattaraugus County, 123, 128, 132, 134-135, 139 Elko, population of, 30 Ellicottville, prenatal conference at, 1927, 60, 143 tuberculosis study in, 1929, 73, 140 Ellicottville Post, 253, 255, 257, 258 Emerson, Dr. Haven, 40, 163 Epidemiology in Cattaraugus County, 116, 122 Erie Railroad, coming of, to Cattaraugus County, 28 Expectation of life, Cattaraugus County, 74 Eyes, care of, in school children, 153, 154, 167 defective, in school children, (Table 54) 225 examinations for, 57 Families in Cattaraugus County, number of, 31 Fancher, Senator Albert T., 240 Farms and farmland in Cattaraugus County, 32, 33 Farm Bureau, County, 47 Farrand, Dr. Livingston, 39 Ferrell, Dr. John A., 96, 98, 99 on public health service, 17-18 Financing, See Budgeting and budgets Fisher, Dr. Myron E., 44, 85 Fishbein, Dr. Morris J., 258 Folks, Homer, vi, 39, 40, 156, 168, 236 Food inspection in Cattaraugus County, 113, 121 Foreign born residents in Cattaraugus County, 31 Flatiron Rock, 26 Framingham, Mass., tuberculosis control health demonstration of Metro- Index politan Life Insurance Company at, 1917, 38, 123, 126 Franklinville Town, population of, 30 Franklinville Village, population of, 29 Fuller, N. M., vi, 65, 72, 81, 104, 107, 111, 112 Gaines, J. J., 258 Gamble, Miss Laura A., vi, 49, 50, 52, 81, 172 Garbage and refuse disposal in Cattarau- gus County, 110, 121 Garen, Dr. Joseph P., 47, 52, 241, 242, 244 Gates, Professor, 160 Gates-Strang tests for health knowledge, 158, 159 Gilbert, Dr. Ruth, 120 Goldberger, Dr., death of, 258 Gorgas Memorial Institute Staff, 258 Government, per capita cost, 232 Gowanda, hospital facilities in, 92, 93 milk pasteurization in, 114 nursing committee in, 79 nursing service in, 81, 86 population of, 29 Gowanda State Hospital, 56 Graves, Miss Frederika, 56 Graves, Dr. F. P., 156 Greenleaf, Dr. C. A., vi, 35, 36, 42, 48, 50,51, 81, 149, 150, 151, 154, 155 Guckes, Miss Sybil, 49, 52 Hammond, Dr. H. W., 85 Hammondsport Herald, 254, 255, 258 Hardwick, K. D. (Miss), 183 Haupt, Alma C,, v, 171 Health Camp, See Allegany State Park Health demonstration of Cattaraugus County achievements of, 4—6 administrative handling of, 235 appraisal score of, 4 for 1923-1929, 75 for 1928, 74, 75 appropriations for 1923, 45 for 1924, 49 for 1925, 53,55 for 1928, 62 for 1929, 72 future, 7 basic activities of, 104-122 summary of, 120 Board of Supervisors’ resolution re- garding proposed, 42 control of, 206 cost per capita of, 4, 17, 19 Index County Medical Society and relations between, 3, 43, 59, 61, 241-252, See also Cattaraugus County Medi- cal Society decentralization of service in, 85 development of, summary, 75 educators in favor of, 262 effectiveness of, proved to County au- thorities, § essential requirements for demonstra- tion areas, 43 future development of, 6 appropriations for, 7 in maternity, infancy and hygiene, 6 in school health instruction, 7 in social hygiene, 7 in venereal disease program, 6-7 influence of, on public health move- ment, 9-14 in New York State, 10 outside of State, 10 on child hygiene services, 13 on communicable disease control, 13 on codrdination of nursing and social services, 11 on laboratory service, 11 on per capita expenditure, 11 on school health service, 12 on tuberculosis work, rural, 12 on sanitary service, 13 initiation of, 44 major lesson of, 16-19 maternity, infancy and childhood hy- giene in, 142-170 medical profession, individuals, atti- tude toward, 249-252 County Medical Society, 241-249. See also Cattaraugus County Medical Society relationship, 251-252 mental hygiene problems in, 15 mortality rates reduced by, § nursing service in, 171, ff. development of, 171, 186 nutrition programs in, 163 family survey in, 164 organization of, changes in, 1928, 62 policies between administrative groups, 237-240 policy of, 39-40 political relationships, 240 press reactions toward, 252-260, 261 program of, 38 cash value obtained, 225-226 compared with other rural counties, 96-103 child 273 per capita cost, 227-228 success of, 3 program of, present, 78, ff. central and local services in, 84 County Board of Health in, 81 deficiencies in, 88 hospitals facilities in, 91 indigent in, care of, 94 medical facilities in, 93 nursing facilities in, 94 organization of, general, 78 school hygiene in, 79 venereal disease control in, 82, 88 progressive development of, 46, ff. psychological reactions regarding, 235 public opinion regarding, 260, 262-267 questionnaire, 262-266 rural health service important prob- lem of, 16-19 significance of, 23 social service problem encountered in, 14, 15 social service program in, institution of, 14 social worker added to staff, 195 specific achievements and lessons of, 7-9 consultation service, county health unit, 7 crippled children, care of, 9 laboratory service, 9 nursing service, 8 nutrition studies, 9 school health service, 7 statistical studies, 9 tuberculosis control, 8 training center for workers from other agencies, 91 tuberculosis control service in, 123-141 visitors to, from other agencies, 91 work of, 1923, 46 work of, 1924, 48 work of, 1925, 52 work of, 1926, 54 work of, 1927, 60 work of, 1928, 62 work of, 1929, 71 work of, summary, 1923-1929, 75 Health education in Cattaraugus County, 82 development of, 2 organization of, 1923, 48 Health education of school children, 156 lectures to teachers on, 157 special tests of, 157-163 Health district, general, organized in Cattaraugus County, 44 Health officers, course for, 1924, 51 medical, 9 274 Health provisions in Cattaraugus County prior to 1923, 36 Health services in Cattaraugus County, 1928, Dr. Atwater’s report, 67-71 Health situation in Cattaraugus County prior to 1923, 35 Health survey of American Child Health Association, 162 Hemsath, Dr. Frederick A., 62, 71 Hillsman, Dr. M. L., 49 Hinsdale, water supply of, dangerous, 108 Hiscock, Prof. I. V., v, 104, 116, 149 Hogan, H. P., 55 Holland Land Company, 28 Home delivery care in maternity cases, 144 Home Hospital for the Treatment of Tuberculosis, 37 Home treatment of tuberculosis cases, 130 Hookworm disease control, campaign for, by Rockefeller Foundation, 96 Hornell Evening Tribune-Times, 253, 255, 258 Hospital delivery care in maternity cases, 143 Hospital facilities in Cattaraugus County, 92 for communicable diseases, 117 Hospitalization of tuberculosis cases, 130 reduced demand for, 137 Hunt, Mayor, 241 Incomes, rural, annual, 17 of rural counties in the United States, 21-23, 24 per capita in Cattaraugus County, 34 Indian Reservation, nursing service in, 86, 172 Indians in Cattaraugus County, 27, 30 mortality rate among, cause percen- tage, 1919-1929, 211-212 Indigent, care of, in Cattaraugus County, 94 home care of, State law for, 95 Industrial establishments in Cattaraugus County, 32 Industrial hygiene problems, survey of, 5 Infancy, hygiene of, program of, 144- 146 appraisal score for, 145 medical conferences for mothers in, 144, 146 mortality in, decrease of, 145. Infant mortality nursing seryice in, 145, 177 See also Index summary of, 146 teaching of, to girls in upper school grades, 61 welfare work, 1928, 68 Infant mortality, 144, 146-149 rate of, 1915-1929, 220-223 decrease in, 60, 221 diphtheria a cause of, 224 infants under one year, 221, 222 tuberculosis a cause of, (Fig. 8) 224 studies by Milbank Memorial Fund, 74 Infantile paralysis, See Poliomyelitis Influenza epidemic, 1929, 258 Influenza, mortality rate, 1919-1921, 210 mortality rate, 1920-1929, (Table 46) 214 Jensen, Dr. William C., 49, 52, 53, 123 Johnson, Dr. J. A, Jr, 85, 111, 117 Judson Health Center, 37 Kenneth Dow’s Foundation for tubercu- losis research, 60 King, Miss Frances, vi, 52, 81, 89, 120, 178 Kingsbury, John A., 39, 239 Kline, Dr. E. K., vi, 71, 81 Korns, Dr. John H., vi, 62, 74, 81, 125— 131, 137, 140 Krause, Dr. Allen K., 60 Laboratory, Cattaraugus County, ap- praisal score of, 81 headquarters of, 84 organization of, 47, 118 service of, 3, 9, 51, 62, 72, 118, 122 cost per capita of, 119 in analysis and examination of speci- mens, 57-58, 118 in research work, 119 Laboratory service outside New York State, influence of Cattaraugus County Health Demonstration on, 11 Laughlin, Mrs. Nancy Bartlett, 85 Lime Lake, 27 Limestone, water supply of, 106 Living conditions, rural districts, 190-193 Los Angeles health service, 4, 102 Lumsden, Dr. L. L., 96, 97 on rural health service expenditure, 18-19 Lynde, Victor R., 62, 71, 240 Index MacFadden, Bernarr, 258 Mansfield, Ohio, American Red Cross child health demonstration at, in 1921, 1, 36 in 1922, 338 Marion County, Oregon, health service, “Market Data Handbook”, on income in Cattaraugus County, 22, 34 Maternity, hygiene of, program of, 142— 144 home delivery care, 144 hospital delivery care, 143 medical conferences for mothers, 143, 146 nursing service in, 1928, 67-68 prenatal nursing service, 142-146 appraisal score of, 144 Sir Arthur Newsholme on, 58-59 summary of, 146 vital statistics, 144, 146-149 Maternity, infancy and child hygiene, future development of, 6 program in Cattaraugus County, 88 need of greater budgetary allotment for, 91 work in, 1924, 51 work in, 1925, 56 Maternity, Infancy and Child Hygiene, Bureau of, established in Cat- taraugus County, 2, §§ work of, 1929, 73 McLoughlin, S. P., 55 Measles, epidemics of, 116 immunization of infants against, 1928, 65 mortality rate of, in 1919-1921, 210 in 1920-1929, 214 Medical facilities in Cattaraugus County, 93 Medical profession, attitude toward health programs, County Medical So- ciety, 241-249 individuals, 249-252 Mental defectives, departmental activi- ties in connection with, 201 in rural districts, 191-193 Mental hygiene, clinics for, institution of, 1926, 56 problems of, 15 Metropolitan Life Insurance Company, prospective tuberculosis control demonstra- tion of, at Framingham, Mass., 1917, 38 Milbank, Elizabeth Lake, 37 Milbank, Jeremiah, 37 Milbank Memorial Fund, 37 Advisory Council of, 39 275 community health program of, an- nounced, 1, 39 establishment of in Cattaraugus County, 2, 42 Division of Research of, study of health status in rural schools, 66 establishment of, 37 friction between County Medical So- ciety and, in health demonstration work, 3, 243 health demonstration of, policy of, es- tablished, 38 program of, 38, 39, 40. See also Health Demonstration of Catta- raugus County infant mortality studies of, 74 policy of, 39-40 relations of, with State and County health agencies, 3, 239 Technical Board of, 39, 156 Miller, Dr. James Alexander, 39 Milk Code, State, 73, 111 Milk supply in Cattaraugus County, 111 bacterial analysis of, 114 care of, 1929, 72 dairy scores in, 112 inspection of, 111, 112 conflicting requirements for, 112 State Milk Code, 111 pasteurization of, 112, 114 tuberculosis eradication from, 11§ Monmouth County, New Jersey, health service, 4 public health nursing in, 187 Moore, Dr. Veranus, 47, 54, 60 Mortality rates, reduction of, §. Vital statistics Mothers, medical conferences for, on in- fant hygiene, 144, 146 prospective, medical conferences for, See also 143, 146 Mountain Clinic, hospital facilities at, 93 Murray, Dr. Doris A., 55, 56, 60, 73, 142 National Child Health Council, 38 National Committee for Mental Hygiene, 37 National Tuberculosis Association, direc- tion of tuberculosis control demonstration by, at Framing- ham, Mass., 1917, 38 New Albion, population of, 30 New York Association for Improving the Condition of the Poor, 37 New York Commission on Ventilation, 37 New York City, death rate in, 20. See also Vital statistics 276 New York State, death rate in, 20. See also Vital statistics. Newsholme, Sir Arthur, on Cattaraugus County Health Demonstration, 58, 39, 67 on maternity care, 58-59 prediction of, on Cattaraugus County Health Demonstration, § Newspapers, in relation to health demon- stration, health advertising, 258 reaction to, 253-260, 261 summary of published material, 255 type of articles, 256, 257 type of health advertisements, 259 Nicoll, Dr. Matthias, Jr., 64 Nome, famous antitoxin-carrying dog team of, 54 Nurses, private duty, in Cattaraugus, 94 practical, in Cattaraugus, 94 public health, rural, in comparison to population, 100-101 training course for, §7 Nursing facilities in Cattaraugus County, 94 Nursing service, public health, in Cat- taraugus County, § a separate bureau, 2, 172 among adults, 70 appraisal score of, 177 as a training center, 186 bedside care in, 181-183 costs of, 178 development of, 171 summary of, 186 in infant welfare work, 1928, 68 in prenatal work, 1928, 67 in tuberculosis control, 128 in typhoid epidemic at Olean, 1928, 63 medical social service and, 183-186 Nursing Advisory Committee an aid to, 173 nursing supervisor of school hygiene in, 1923-1929, 172 Olean Red Cross, additional nurse, 172 prenatal, 142, 146 appraisal score for, 144 public health, organization of, 47, 85— 86, 172 social problems revealed in, 51 personnel of, changes in, 1923-1929, (Table 37) 171, 172 general meetings of, 174 new members, 174 prior to demonstration, 171 training and service of, 173-174 public health nurses in, budget per- centage allotment, 172 classes conducted by, 179 Index classroom inspections by, 179 examination of school children by, 150 quality of service, 179-181 sanitary inspections in schools, 179 special duties and service in, 179 special problems, visits in connection with, 177 supervision of, 179-181 time distribution in field visits, 178, 179 work handled by, 176, 177 psychiatric work in, 185-186 purpose of, 173 ratio to population, 204 records, 175-176 social case workers appointed, 183-184 social service consultant, 184 social service and, cobperation be- tween, 184 social service problems, contact with, 183 success of, 8 work in, 1923, 47 work in, 1924, 50, 51 work in, 1925, 52, 54 work in, 1926, 57 work in, 1929, 73, 173 Nursing service outside New York State, codrdination with social service, influence of Cattaraugus County Health Demonstration on, 11 Nutrition, education in, 1925, 54 studies of, in Cattaraugus County, 9, $2 Nutrition programs in County Health Demonstration, 163 family survey in, 164 improvement of dietary standards in, 164 lectures on, at farms, 165 success of movement, 165-166 work in schools, 165 Occupations in Cattaraugus County, 28 Odell, Miss Ruby M., 54, 55, 163, 164— 166 Oil wells in Cattaraugus County, 28 Olean, application of, for health demon- stration of American Red Cross, 1 clinic for school children in, 151 economic status in, 31 food handling in, 115 geographical location of, 26 health service program of, 1916, 36 health work in, prior to 1923, 35 hospital facilities in, 92, 93 Index medical inspection of school children in, 151 milk inspection in, 111, 112 milk pasteurization in, 114 milk supply of, progressive improve- ment in, 112-113, 114, 121 mortality rate in, 1926-1929, area and disease comparisons, 217 nursing service in, 86 local Red Cross in, 79, 172 open-air classroom of, 132 population of, 29 school children of, health status of, 66 school hygiene in, 81 school hygiene program of, 223 school registration in, 79 smallpox in, 1929, 72, 116, 122 social service work concentrated in, 197 social welfare activities in, 193-194 typhoid fever epidemic of, 1928, 62, 63, 116, 216 causes of, 64 nursing in, 63 results of, 64 water supply of, 63, 105, 106 Olean Chamber of Commerce, county health service in Cattaraugus es- tablished by, 1 Olean clinic, venereal disease control by, 82 Olean Creek, 63, 105 Olean Evening Times, 253, 255, 257, 258 Olean Herald, 253, 255, 257, 258 Olean Red Cross additional nurse, 172 Olean Tuberculosis Association, 35, 73 Open-air classroom in tuberculosis con- trol, 132 Orthopedic clinics, institution of, 1924, 51 Otsego, crippled children in, 169 Oyer, L. K,, 55 Park, Dr. William H., 47 Parran, Dr. Thomas, Jr., 83 Pattison, Dr. H. A., 44 Peale, Miss Alice Judson, 258 Perrysburg village, population of, 29 Persia, N. Y., population of, 30 Peters, Miss Lulu Hunt, 258 Physicians in Cattaraugus County, 93 relationship of public service work to, 71 Pierce, Miss Margaret, v, 181, 182 Platt, Miss Berneta N., 47 Poliomyelitis, mortality rate, 1920-1929, (Table 46) 214 277 Poor, care of, in Cattaraugus, 94 home care of, State law for, 95 Poormaster, social service handled by, 193 Population, age distribution and, 1920, 11 county, movement of, 52 per capita valuation of life, 225-226 Portville, nursing committee in, 79 nursing service in, 86 population of, 30 Prenatal nursing service, 142, 177 appraisal score of, 144 summary of, 146 work in 1927, 60, 61 work in 1928, 67 Preschool child, care of, 146 appraisal score for, 146 examination for detection of defects, 69 public health nurse visits, 177 service in 1928, 68 Public health, rural, 20 urban, 20 Public health service Public Health Nursing, Bureau of, staff of, changes in, 1923-1929, 171, 172 prior to demonstration, 171 Public health service, funds for, 230 possible sources, 232-234 importance of, in rural areas, 16 programs of, cash value, 225-226 per capita cost, 227-228, 232 Public opinion, concerning health pro- grams, 260, 262-267 Public welfare, programs in relation to vital statistics, 206 realization of problem, 203 Publicity, newspaper, health demonstra- tion, 253-260, 261 health advertising, 258 summary of published material, 255 type of articles, 256, 257 type of health advertisements, 259 nursing, See Nursing Quaker School in Cattaraugus Indian Reservation, 29 Randolph Home, 194 Randolph, population of, 30 tonsillectomy clinic in, 15§ water supply of, dangerous, 108 Randolph Register, 253, 255, 257, 258 Railroad wells in Salamanca, 107 Railroads in Cattaraugus County, 28 278 Records and Reports, Bureau of, organi- zation of, 47 Rockefeller Foundation, aid in health work, 22 health department data, 228 hookworm disease campaign of, 1914, 96 Rocky Crest Sanatorium, 35, 47, 49, 54, 62, 125, 129, 130, 131, 132, 137 dietary planning in, 165 direction of, 78 Rolling Thunder, 94 Rue, Miss Mabel J., 55, 57 Rural areas, economic status of, 21-23, 24 public health in, 20 Rural counties of fullest development, tuberculosis control work in, 134 Rural health program, full-time, ade- quacy of, 98 as to budgets, 99 as to public health nurses, 100-101 appraisal score of, in counties having highly developed machinery, 102 development of, in the United States, 96 financial limitations of, 97 of counties having highly developed machinery, 102 of counties, in general, 99 per capita expenditures in, 99 Rural health service in the States, 17 administration problems in, 21 Cattaraugus County example of suc- cess in, 23. See also Health Demonstration of Cattaraugus County economic problems in, 21 expenditure in, 18-19 as an investment, 18 cost per capita needed, 17, 19 Federal aid in, 22, 23 Foundation aid in, 22, 23 importance of, 16 State aid in, 17, 22 Rural incomes, annual, 17 Rural school child, inferior health status of, 66 Rutherford County, Tennessee, health service, 4 rural United Salamanca, economic status in, 32 food handling in, 115 hospital facilities in, 92, 93 milk pasteurization in, 114 mortality rate, 1926-1929, area and disease comparisons, 217 nursing service in, 86 population of, 29 Index railroad wells in, 107 school hygiene in, 81 school registration in, 79 water supply of, 106, 107 Salamanca Clinic, 83 Salamanca Republican—Press, 253, 255, 256; 257, 258 San Joaquin County, California, health service in, 4 public health nursing in, 188 Sanitary engineer, appointment of, on Cattaraugus County Board of Health, 2, 64-65 work of, 1929, 72, 73, 104 Sanitary service outside New York State, influence of Cattaraugus County Health Demonstration on, 13 Sanitary surveys, 1926, 56 Sanitation problem in County, 82, 88 need of greater budgetary allotment for, 91 Sanitation, basic problem in county health work, 2 environmental, 104, 120 school, 155 Saratoga, crippled children in, 169 Scarlet fever epidemic, 116 in Children’s Home at Randolph, 1928, Cattaraugus 65 Scarlet fever, mortality rate of, 1919-— 1921, 210 mortality rate of, 1920-1929, 213, 214, 216 decrease in, 217 mortality rate of, 1922-1929, comparisons, 218 reduction in, 218 School children, correction of physical defects of, 152-155 failure in, causes of, 154-155, 166 examination of, 1929, 72 for defects in vision, 57 food of, 162 health education of, 156 special tests for, 157-163 health of, review of general program for promotion of, 166 medical examination of, 168 rural, inferior health status of, 66 nutrition programs for, 163-167 Olean clinic for, 151, 155 School clinics for immunization against disease, 69 School heating and ventilation, 156, 168 School health instruction, future develop- ment of, 7 area 150, 1351, Index School health service of, 1924, 50 1926, 37 1928, 69 organization of, 1923, 47-48 outside New York State, influence of Cattaraugus County Health Dem- onstration on, 12 success of, in Cattaraugus County, 7 School hygiene, appraisal score in, 167— 168 correction of physical defects among school children in, 152-155 failure in, causes of, 154-155, 166 county nursing supervisor of, 1923- 1929, 172 direction of, 78 health education of school child in, 156, 167 special tests of, 157-163 heating and ventilation in, 156, 168 in 1928, 66 nutrition programs in, 163-167 primary objectives of, 152 program, 79-81 organization of, 79, 149 district health committees in, 150 medical examination of children in, 150, 151, 168 public health nurses in, 150 teachers in, part of, 150 review of general program for pro- motion of, 166-168 school sanitation in, 155 service in Cattaraugus County, 2 School sanitation, 155 in city schools, 155 in rural schools, 155, 156 School registration, Cattaraugus County, 1928-1929, 79 Schools in Cattaraugus County, history of, 29 Sears, Dr. Frederick W., 51 Seneca Indians, 27 Sewerage and sewage disposal in Cat- taraugus County, 110, 121 Sex distribution in Cattaraugus County, 31 Shuttleworth, Dr. F. K., v, 261, 262 survey of knowledge of health edu- cation of school children, 157-163 Sloane, John, health activities of, 36 Smallpox epidemic, 1927, 60 in Olean, 1929, 72, 116, 122 vaccinations for, 1929, 72, 116 Smith, Governor Alfred E., on county public health service, 10 Smith, Barry, 102 Smith, Dr. Theobald, 47 279 Smillie, Dr. W. G., 96, 97, 98 Social hygiene, educational campaign in, initiation of, 56 future development of, 7 Social problems, conditions in rural areas, 190-193 Social service, administrative personnel of, 204 available prior to 1923, 193 boarding houses supervised, 202 coordination between agencies, 205 emergency relief rather than recon- struction, 197-198, 199 financing of, 195 funds for, 230 in Cattaraugus County, development of, 2 medical, 183-186 Milbank appropriations for, withdrawal of, workers retained by County, 198, 203 need for, in rural area, 15, 190-193 nursing service and codperation be- tween, 184 outside New York State, codrdination with nursing service, influence of Cattaraugus County Health Dem- onstration on, 11 problem in Cattaraugus County, 14 program, institution of, in Cattaraugus County, 14 psychiatric work, 185-186 psychiatric worker appointed, 197 public support of, 200 results attained by, 195-203 staff of, coordination lacking in, 199 trained worker required in, 195 vital statistics in, relationship, 206 worker under Tuberculosis and Public Health Association, 183 workers and population, ratio between, 204 Society for the Prevention of Cruelty to Children, one untrained worker provided by, 193 Southern States, annual income in, 22 rural health aid in, 23 Sprague, R. A., 71 State Charities Aid Association, vi, 39, 156, 157, 169 health work of, 35 operating agency for demonstration, 39, 23s State Department of Education, work in public health program, 78 State Department of Health, work in public health program, 78 201, 280 State Hospital Commission, work in pub- lic health program, 78 Statistical studies in Cattaraugus County, 9 appraisal score of, 81 Steuben County, health education tests of school children in, 157-163 Stewart, P. F., 22, 34 Strang, Professor, 160 Suffolk County, New York, public health . service in, 10 “Summer round-up” of 1927, 61 of 1928, 146 Sydenstricker, Edgar, vi, 66, 206 Taggert, Dr. J. A, vi, 62 Teachers College, Columbia University, training course for public health nurses at, 57 Teeth, care of, in school children, 153, 166-167 defective in school children, 225 Thompson, Fred L., 47 Thompson, Mrs. L. S., 102 Tonsils, defective, in school children, 225 removal of, in school children, 153, 154, 155, 167 Tourist resorts, food in, 115 Toxin-antitoxin in diphtheria immuni- zation, 117 Trudeau Laboratories, 37 Trudeau scholarships, 251 Tuberculosis, activities for the control of, 48 “arrested”, 135 case-finding survey, 1923, 47 cases, 1926, §7 clinics, 1926, 57 reorganization of, 57 family case study of, in Ellicottville, 1929, 73 home supervision in, 54 mortality decrease, 53 mortality rate for 1915-1929, 218-220 for 1919-1921, 210-211 for 1919-1929, Indians, 212 for 1920-1929, 214, 217 for four counties, 1928 report, 207, 208 nursing by public health nurses, 73, 177 sanatorium in Cattaraugus County, establishment of, 1 scholarships, 47, 50 vital statistic graph trends, 209 work in Cattaraugus County, § appraisal score of, 81 in 1923, 47 Index in 1925, 53 in 1927, 61 work, rural, outside New York State, influence of Cattaraugus County Health Demonstration on, 12 Tuberculosis and Public Health Associa- tion, 2, 46, 48, 51, 57, 85, 95, 170 trained social workers of, 195 work of, 78-79 Tuberculosis, Bureau of, headquarters of, 84 organization of, 47 Tuberculosis control, in Cattaraugus County, 8, 123-141 case-finding in, 126 early work on, 123 factors complicating, 141 future in, 137 future work on, preparations for, 140 general program of, 123 health camp in, 132-133 home treatment plan in, 129 in 1924, 49 in 1928, 65 later age incidence in, 136 mortality in, rate of, 135 study of cases, 137-141 non-pulmonary type of, 140 nursing service in, 128 open-air classroom in, 132 organization of personnel in, 12§ organization of service in, 124, 125 program of, 124 program as a whole, 133 appraisal score for, 134 centralization and set-up of, 134 deficiencies of, 135 results of, 135 reduction in active cases in, 136 results of, 126 sanatorium care in, 130 reduced demand for, 137 Tucker, Miss Katharine, v, 94, 171, 180, 181, 184 Tunesassa, Quaker School for Indians in, 29 Typhoid carriers, 72, 116 Typhoid fever epidemic at Olean, 1928, 62, 63, 116, 216 causes of, 64 nursing in, 63 results of, 64 mortality rate for 1919-1921, 210 for 1920-1929, 214 vaccinations in typhoid epidemic of Olean, 1928, 64 Undulant fever studies, 1929, 72 Index United States Public venereal disease taraugus, 83 Urban areas, economic status of, 22 public health in, 20 Health Service, survey, in Cat- Vaccinations, smallpox, 72, 116 Vedder, Mayor, 241 Venereal diseases, care of, in rural dis- tricts, 74 Venereal disease control in Cattaraugus County, 88 beginning of, 2 in cities, 82-83 in rural areas, 83-84 in 1928, 71 need of greater budgetary allotment for, 91 program, 82-84 appraisal score of, 82 future development of, 6-7 organization of, 82 work in cities, 1929, 82 Venereal disease survey in Cattaraugus County, 83 Vincent’s angina studies, 1929, 72 Visitors to health demonstration from other agencies, 91 Vital statistics, chance variations in, 206 changes in, during ten-year period, 212 Indian, 1919-1929, 211-212 mortality rate, age table, 213 cause percentage, 1919-1921, 210 diseases responsible, 1920-1929, 214— 218, 216 for 1926-1929 area comparisons, 217, 218 reduction in, 212-213 of Cattaraugus County, study of, by Milbank Memorial Fund, 74 public health programs, relationship, 206 and disease Walker, Dr. Harold H., v Walker, Dr. W. F., 58, 74, 102, 111 on the influence of Cattaraugus 281 County Health Demonstration on health services outside the State, 10 Walrath, Mrs. Florence, health activi- ties of, 36 Walrath, John, 42, 44, 170, 240 on effectiveness of county health service, § report favoring work of health demon- stration, 60 Wassermann test service, institution of, 1924, 51 Watkins, Mr. and Mrs., J. H., v, 253, 258 Water supply, private, rural, 109 bacterial analysis of, 105 sources of, 109 wells for railroad purposes, 107 Water supply, public, of Cattaraugus County, 105, 121 appraisal score of, 109 at camps, 111 bacterial analyses of, 105 chlorination of, 105, 106, 107, 108 dangerous sources of, 108 grade of, 108 investigation and improvement of, 73 pollution of, 107 sanitary improvement of, 107 sanitary treatment of, 105 source of, 106 Watson, J. W., 49, 62 Welch, Dr. William H., 39, 40 Westchester County, New York, public health service in, 10 Whealdon, Rowan, §§ Wheeler, Miss Lilla C., vi, 42, 44, 240, 244 health activities of, 36 Whooping cough epidemics, 116 Widows’ Aid, handling of, 193 Wiehl, Miss Dorothy G., 221, 222 Wierman, Miss Genette, §§ Wiley, Dr. George W., 157 Williams, Mrs. Allan B., health ac- tivities of, 36 Williams, Dr. Linsly R., 39 029590000 J