Government Aids to Public Health. BY WALTER WYMAN, A.M., M.D., SURGEON MARINE-HOSPITAL SERVICE, WASHINGTON, D. C. Read in the Section of State Medicine, at the Forty-first Annual Meeting of the American Medical Association, at Nashville, Tenn., May, 1890. Reprinted from " The Journal of the American Medical Association," July 5, 1890. CHICAGO: Printed at the Office of the Association. 1890. Government Aids to Public Health. BY WALTER WYMAN, A.M., M.D., SURGEON MARINE-HOSPITAL SERVICE, WASHINGTON, D. C. Read in the Section of State Medicine, at the Forty-first Annual Meeting of the American Medical Association, at Nashville, Tenn., May, 1890. Reprinted from "The Journal of the American Medical Association," July 5, 1890. CHICAGO : Printed at the Office of the Association. 1890. GOVERNMENT AIDS TO PUBLIC HEALTH. At a recent meeting of a sanitary association, its President gave utterance to a sentiment which has often been expressed of late years in public bodies, to the effect that while the Government of the United States is most liberal in its provi- sion for all ordinary, material welfare of its citi- zens, in matters of public health it is parsimoni- ous and its aid is stinted. This, to my mind, appears unjust and has led me to make an inquiry as to what the Government, in its various branches, actually does for the public health. Without going into greater detail than is neces- sary, it will be pertinent to mention, first, what has been and is being done to prevent the introduction and spread of epidemic disease ; and under this head may be cited the recent establishment, on a broad plan, of the National Quarantine Service, at an expense of more than half a million dollars; the annual appropriations of fifty to eighty thou- sand dollars for the maintenance of the quaran- tine stations; the present epidemic fund to be used in case of emergency, amounting to about $100,000, and also the fund for the relief of yel- low fever sufferers, which is, in a sense, an aid to public health. In the matter of scientific commissions and es- tablishments, mention must be made of the recent commission of Surgeon George M. Sternberg, U. S. Army, whose thorough investigations into the methods of Freire and Carmona in their attempts at protective inoculation against yellow fever, are now of public record ; and the commission of Dr. B. O. Shakespeare, for the purpose of inves- 4 tigating the causes of cholera during its last vis- itation in Spain. As to scientific establishments, attention is called to the laboratory of the Marine-Hospital Service at Dry Tortugas, within the yellow fever belt, fitted with all the most recent appliances, and intended for the special and continuous in- vestigation of the cause of yellow fever ; also to the very complete bacteriological laboratory at- tached to the U. S. Marine Hospital at New York, in which are conducted investigations into the causes of disease, the value of germicidal agents, and the usual analyses and tests of a hygienic laboratory. Mention must also be made of the laboratory of the Bureau of Animal Industry, in the Depart- ment of Agriculture, for the detection and pre- vention of the spread of diseases among animals, and its consequent service in preventing the con- sumption of diseased meat. The laboratories of the Army and the Navy must also be enumerated. To the majority of physicians present reference only need be made to the work of the medical department of the U. S. Army in the establishment of its library and museum for the benefit of all, or to the Naval Museum of Hygiene, in whose laboratory chem- ical analyses of water and food are made, as well as bacteriological research. Among the other establishments maintained by the'National government for the preservation of public health, may be mentioned the Marine- Hospital Service, whose yearly treatment of 50,- 000 sailors in all parts of the country must surely have a decided effect upon the health of the body politic. It has been remarked by careful obser- vers of the habits and condition of the sailor, that his physical condition has within late years very materially improved. Stress is laid upon this point because it is by no means im- probable that a large proportion of the ordinary as well as contagious diseases of the human race receive their primal impulse among the lower 5 classes of society, by whom cleanliness and health measures are disregarded. The expendi- tures of this service amount to about half a mill- ion of dollars yearly. As to legislative enactments it may be said that very little additional action is necessary by Congress, if any, for the prevention of the intro- duction and spread of epidemic diseases through- out the United States. The recent passage of what is known as the Inter-State Quarantine Act marks an epoch in the history of National health legislation. In the light of the above statements, it is inter- esting to look back into the history of quarantine legislation and to study the wants of the Nation as urgently expressed by the Quarantine Conven- tion at Philadelphia in 1857, in Baltimore in 1858, in New York in 1859, in Boston in i860, in Jacksonville in 1878, in Philadelphia in 1885, and in Montgomery in 1889. The cry of these con- ventions was for a uniformity in quarantine laws, and such uniformity, at least in times of epidemic, is now assured. Other legislation relating to the adulteration of beer, the adulteration of drugs, the adulteration of foods in general, has from time to time been proposed and enacted by Con- gress ; and Congress in its management of the City of Washington set an example to all the cities of the world by being the first to make legal requirements regarding house drainage. Although the above consideration is a hasty one, enough has been shown, I believe, to con- vince the ordinary observer that Congress does take an active interest in matters pertaining to the public health. It has been the custom in some quarters to continually decry our legislative Solons for their want of knowledge and interest in such matters, but it may be well to ask our sanitarians whether we should not cast the beam out of our own eye before we seek to pluck the mote out of the legislative eye. It has been said that a sanitary millenium can never be until there has been developed a new class of 6 legislators, educated and aroused to the needs of public sanitation-sanitary legislators; but with equal truth it may be urged that there is need of another class of men, who may be called legisla- tive sanitarians-men who in their eagerness for sanitary reform will yet have legislative wisdom, who will not be blind or indifferent to.recognized laws and modes of procedure, nor to the ever present necessity of economic administration in this, as in all public matters. The legislative sanitarian will think twice before he lends his name to untried schemes, to experiments involv- ing large outlay, the failure of which will bring discredit on his legislative friends. He will not blindly follow in the lead of others and cast his vote for schemes whose logical conclusions lead he knows not where. With the eye of the legis- lator as well as the sanitarian he will advocate reforms with due respect to institutions already existing and founded with a wisdom equal to his own, and when possible will invoke their aid rather than opposition. Sanitary laws, after all, form but one element in the scheme of general welfare, and they must be in harmony with their surroundings ; they must catch the spirit of the other and even greater laws under which they are created. In a recent letter commenting upon the passage of an Inter-State Quarantine Act, a distinguished sanitarian says: "It seems to me that it is very much to be regretted, however, that the Act does not refer to the really dangerous diseases. ' ' The diseases he refers to as really dangerous are phthi- sis pulmOnalis, diphtheria, scarlet fever, etc. The diseases mentioned in the Inter-State Quarantine Act are: cholera, yellow fever, small-pox, and plague. He says, further, "None of the dis- eases .... more dangerous are mentioned in this Act, as might easily have been done by in- serting after the word 'plague' the words 'or other diseases dangerous to the public health.' '' The point of the criticism is that diphtheria, phthisis pulmonalis, scarlet fever, etc., should 7 have been mentioned in the Inter-State Quaran- tine Act. The insertion of these diseases would certainly have killed the Act, and in place of the all-powerful law which we now have to control the spread of yellow fever, small-pox, cholera or plague, we should, if this suggestion had been carried out, have had nothing whatever. It be- hooves, then, our sanitarians to have legislative wisdom, and not to lose all by grasping for too much at once. The question now follows, what should the Government do in aid of public health more than it is now doing ? This is a broad and deep ques- tion, and one which it would be an act of temer- ity to attempt to answer without the fullest con- sideration and deepest study. It may, however, be discussed without attempt at full answer being made; and as preliminary to answering this question we must make answer to others. At what do we aim ? At what degree of public health should we aim ? The standard can not be placed too high. The natural expectation of man should be to die of old age, and the ultimate aim of the sanitarian should be to eliminate dis- ease. It is not enough to keep out or to suppress epidemic disease; we would wish to crush domes- tic diseases. Phthisis pulmonalis, diphtheria, scar- let fever, small-pox, and all diseases whose mode of transmission is by contact, should surely all go. A good and practical beginning might be made with pulmonary tuberculosis. A lesson in the science of warfare against this disease may be well taken from our English cous- ins. Why is it that tuberculosis is rapidly disap- pearing from England, but is so rapidly increasing in the United States, where it causes between 15 and 20 per cent, of the total deaths ? How is it in the other countries, especially those which con- tribute most largely to the immigrant population of the United States ? The death-rate from tuber- culosis in these countries is undiminished. Now, it should be borne in mind that England receives no immigrants. The natural cleanliness and in- 8 telligence of the English people has caused a most remarkable improvement in the health of the nation. London is one of the healthiest cit- ies in the world. Its death-rate is much less than many of our small American cities. Said Benja- min Ward Richardson recently: "The results have even by this time become so remarkable that, with another four similar decades of prog- ress, we may look upon England as a new coun- try of healthfulness and social purity. ' ' Are we gentlemen of the Section, we, the Anglo-Saxon population of this country, less clean or intelli- gent than our English cousins ? If not, then our death-rate should improve, unless we are subject to causes from which they are exempt. To one such cause we are subject, namely : the stream of immigration. Then, why not attempt to purify the stream ? While driving out the dust of con- tagion from our own house let us permit only pure air, free from dust, to enter. Pulmonary tubercu- losis should be added to the list of diseases quar- antined against by the United States, at least among immigrants. _ As bearing upon the subject of English clean- liness in its relation to the diminution of disease, the writer refers to a visit made by himself to the slums of Rondon, in Whitechapel, in January, 1885. This neighborhood, besides being the re- sort of hawkers, pickpockets and thieves, is a tenement house district, and, notwithstanding the degraded condition of the inhabitants, the tene- ments which are subject to regular police sur- veillance and inspection-were found to be inva- riably clean. They are greatly crowded ; five small houses owned by one proprietor accommo- dated 600 men and women nightly, at a rate of 8 pence for a married couple, and 4 pence for men. One room was seen in which there were seventy sleepers crowded closely together. Notwithstand- ing this crowding, the tenements are kept clean, and a certificate to that effect, signed by the reg- ular inspector of the district, is neatly framed and hung upon the wall. In two of the districts which 9 were visited there were about 250 regular, com- mon lodging-houses which accommodate, nightly, 7,800 tenants, and only about one dozen of infec- tious cases had appeared in the district within a year. In further answer to the query, " What should the Government do in aid of public health ? ' ' one important fact is to be borne in mind-the neces- sity of absolute reliance upon ourselves. History furnishes no models for the construction of any sanitary institution adapted to the wants of this nation. Lycurgus, with his Spartan laws, adapt- ed to a small and peculiar province, the laws of Solon, the laws of Moses, the quarantine laws of the fifteenth century, the sumptuary laws of Rome -none of these furnish a sanitary framework for the United States. What modern nation is per- fect in its sanitary regulations ? What nation has such conditions of boundary and magnitude as our own? What has England, with its Govern- ment on a " tight little isle," and its possessions scattered over the earth, what can a nation with such physical conditions teach us? What can France, or Spain, each with a territory surpassed by a single one of the United States, teach us ? Or Germany, with scarcely any seaboard at all ? What conditions prevail in Russia, Italy, or Tur- key, that prevail here? We may adopt scientific appliances, we may study technique in foreign lands in establishing sanitary measures, but we must be a law entirely unto ourselves with regard to our sanitary policy. The United Statesis the omnium gatherum of the world. In the last ten years five and one-half millions of immigrants have come to our shores from all sections of the earth. We ourselves al- low no pestilence to breed within our domain, but the cholera from Egypt or India, the plague from Russia, the yellow fever from the Spanish main, come as parasites of our great commerce and im- migration. We send no diseases abroad, but by reason of our character as a haven, are constantly subject to disease from abroad. Our sanitary pol- 10 icy must be sui generis, must be formulated out of our own institutions, and must be influenced but little, either by ancient tenets, or by modern opinion of foreign countries whose circumstances are wholly different from our own. A sanitary policy should be adopted far-reach- ing in its effects, adapted not for the present dec- ade alone, but for decades to come. Its direct aim should be the ultimate intelligence and education of the average citizen in matters relating to his personal health, and the health of his Common- wealth. How this must be attained will be dis- cussed presently, but in anticipation thereof it is necessary to state that a sanitary policy must be entirely in harmony with the spirit of the Amer- ican Government, and no better plan for sanitary government appears at the present time than one modeled upon the structure of the general Gov- ernment itself. Broadly stated, this sanitary policy expects of each State a sanitary autonomy whose influence should be appreciated by every individual in every hamlet, however small, in its domain. It con- templates a State pride in the development of sanitation, a self-reliance and an unwillingness to surrender functions or call for aid from the gen- eral Government excepting after clearest convic- tions of propriety or necessity. This policy ex- pects from the general Government that since it controls commerce, both maritime and inter-State, it will prevent commerce from conveying disease ; that it will respect the sanitary institutions of the States; that it will have such organizations and establishments as properly belong to its sphere of action to supplement where States fail, and to en- able it to wield its peculiar power when urgency demands. It was a want of harmony with the spirit of American Government that led to the failure of the National Board of Health. That was a sanitary empire-or sought to be-within the boundaries of a republic. It was un-Ameri- can and it fell. In its very fall, however, it ef- fected a good result. Immediately the sanitarians 11 of the several States developed a marked State activity. Is there one who believes that if the National Board of Health had retained its powers, there would be the present advanced condition of State Boards of Health throughout the United States? It may be considered an axiom that the sanitary welfare of this country is dependent upon the development and perfection of the State Boards of Health. By means of State Boards only can the individual be reached. The reports which come from far off, perchance mountainous districts of out of the way counties, sent to the State Boards of Health, by them printed and transmit- ted to the world, furnish a stimulus to the com- munity from which such reports emanate, as well as valuable information for sanitary officials.. The sanitarians and the Government must give mutual aid. To control commerce that commerce may not be clogged and lay the hand of healthful restraint upon her for her own good ; to spread a net and hold it firm, to catch and throw back the vicious and diseased in the great wave of immigra- tion as it breaks upon our shores; to check the mer- chant or manufacturer when his absorbing greed for gain makes him ready to risk the lives of hun- dreds; to oppose the lawyer when by a legal twist in behalf of the individual he seeks to force a way around the sanitary barrier erected for the com- mon safety; to force the slow comprehension of legislators; to prick the conscience of the tardy doctor with the needle of the law, and even to sweep from the path the sentimental obstruction of mistaken priest and clergy-this is the mission of the sanitarian, the duty of the Government.