cz^fatiuitis.± (litij of JSan of cz^zattfi SAN JOSE, CALIFORNIA 1947 Each year as interest in public health increases, more citizens and students ask for information concerning the work of the Health Department. San Jose Department of Health is always glad to welcome visitors and to show them its facilities. As the Department grows, it becomes increasing- ly difficult to give persons who are interested in health department activ- ities a complete panorama of its work in a short period of time. Eor the reason just mentioned, it has been suggested that we attempt to delineate the general activities of our health department in print, so that with some supplemental explanation any interested citizen of San Jose or visitor from elsewhere may secure a reasonable, accurate picture of the department’s functions. While it is true that this activity report will be accurate only as of January 1, 1947, modifications will be indicated by addenda as major changes occur. Plans have been made for changes each year in our depart- ment, for we realize that due to limitation of funds and personnel, our development cannot be completed for many years to come. Industrial hy- giene, dental hygiene, mental hygiene, as well as the further development of present departments will require considerable time and money to de- velop fully. As the City of San Jose grows, so must its Health Depart- ment grow. As new discoveries are made and science finds new ways of preventing disease and prolonging life, so health departments must accept new functions. With the thought that a health department is never a static, completed piece of work, the Health Department staff wishes to submit its activity report. The Health Officer wishes to express his appreciation to the City Manager and the Health Department staff for their work in preparing this manuscript. While much actual editing and art work has been done by the Health Education Division, other divisions of the Health Department have taken an active part in preparing their individual sections. All mem- bers of the Health Department have combined their efforts to make avail- able to the people of San Jose a true picture of the activities of their Health Department. ■ i;v V\, [vLAAAli/V)X) D. M. Bissell, M. D. j Health Officer INTRODUCTION Public Health needs change rapidly. Knowing this the department of Public Health is flexible in order to meet needs as they arise. It is de-. sirable at times, also, to discontinue a service when that service is no longer important to the health of the community. With this in mind, activi- ties done today may not be the activities of the future. By the same token, work not included in this report may be inaugurated at a later date. The duties and responsibilities of the department follow a fairly well established pattern, as shown on the chart, established in the sense that it is the accepted structure of most Health Departments in the United States. Every one on the staff considers his duty as a responsibility to the commun- ity and, as such, attempts to do the best he possibly can in each situation. In public health there are certain definite phases of work which are allocated to different levels of administration. In the following report one will find phases of the work being carried on by the California State Health Department, county Health Department and the local health department. This cooperative system has developed for several reasons,- First, because of the nature of the problem, disease knows no political boundary* Where a problem is handled best on a county wide basis as in the case of the Venereal Diseases or as in a state-wide consultation service such as with problems of Industrial Hygiene, then it is so arranged* Secondly, tl ere is the problem of finance. A city cannot always finance all the needs of a community and in cases where the problem is not specific to the area within the city limits, the local health depart-lent has, in several instances, worked with the county health department and the state health department. Each organization has contributes to the effort in either money or personnel. .s.n example of this is in the crippled childrens service, where the city and county furnish personnel and the county and state finance the undertaking. In the administration of the department it is arranged so that there are seven distinct divisions, also shown on the following chart. These divisions each have one person who is either appointed chief of the division in accord- ance with a title as set up by ordinance, or one person who assumes the re- sponsibility of the division. In this way the Health Officer, who is the chief administrative officer of the entire department, has one person in each division who is directly responsible for all the activities of that division. In accordance with this line of responsibility, this report is developed. At the present time the administrative office, the laboratory, the milk and dairy inspectors and the Sanitarians are located at the City Hall. The nursing division is located in Offices at the San Jose High School and the Health Education Office is located in the Municipal Auditorium. It is hoped that in the future the entire department may be housed under one roof. As will be noted in the report, the Health Department is responsible for preventive medical functions in the community. The school health program and the community health program have been combined so as to offer one uniform service. No medical treatment is given, with the exception of first aid in the schools in cases of emergency. Curative medicine is left to the private physician. When problems are referred to the Health Department, families able to pay for their medical service are referred to private physicians. Families which cannot afford to pay for medical services are referred to the County Hospital, CHART of HEALTH DEPARTMENT FUNCTIONS City Council City Ijlanager ' 'Advisory Board of“—Headrtfe Heajlth Officer Public Health Education Vital Statistics Miik and Dairy Inspection Laboratories Environmental Sanitation Public Health Nursing Medical Services Preventive Medical Service is concerned with the Public Health Problem of pre- venting sickness and the loss of life through educational methods. At this time the motivation is particularly aimed at the problem of maternal and infant care and the control of the communicable diseases, with emphasis on tuberculosis and venereal disease. Immunization and vaccination against preventable diseases are offered to persons desiring it. PREVENTIVE MEDICAL The growth of the Department of Health in San Jose has been a gradual one. As in many other departments, the work included chiefly food and environmental sanitation for the first years of the department and were concerned chiefly with enforcement of city ordinances and state laws. The scope of the health department had increased around 1920 to the need for public health nursing service, as well as for a full-time laboratory service. In the City Manager’s report in 1917, he said, ’’Pre-natal work is not being carried on, hut as this work is so important and as we expect to have a pub- lic health nurse next year, all cases that are called to our attention are given literature and any assistance within our means”. Smallpox vaccination and typhoid vaccination were supplied free of charge to persons desiring it at that time. Antitoxin for diphtheria was supplied free to all indigent persons. Today the medical services follow very much the same pattern. Free vaccinations are offered to anyone uho wishes them. Due to the very few cases of typhoid in San Jose, people seldom re- quest typhoid vaccination. Occassionally some- one asks for typhoid vaccination, when he is go- ing 'to travel in foreign countries or in sections of the United States where there is poor food and water sanitation. Because the isolation unit as at the County Hospital, patients secure antitoxin for diphtheria at the County Hospital rather than from the Health Department. However, free immunization against diphtheria with toxoid is provided as a preventive measure at the city clinics. Infants are also given protection against whooping cough and tetanus, if their parents desire it for them. The child health conferences which were mentioned in the 1917 city re- port are now being held in six centers scattered throughout the city where the need seems to be greatest. These child health conferences admit only well babies who cannot secure the service of a private physician. The phy- sician at these conferences examines all babies who are registered and ad- vises the mother concerning the habit training and feeding routine, as well as any other medical problems which may arise. No treatment is given child- ren and no sick children are admitted to the clinic. These clinics are held once a month in schools, churches, or other places. The schedule is not quoted here as it is frequently necessary to change the date. It would be best for persons desiring to bring their infants to this conference to call the health department office to be sure of the place and time of the confer- ence located nearest their homes. Medical services are rendered to practicing physicians in San Jose for their assistance. Free consultation service is given to doctos who request it for patients suffering from communicable diseases and blood Wassermann tests are taken and gonorrheal smears are accepted for diagnosis. Diphtheria nose and throat cultures, as well as stool examinations from a variety of causes are examined in the laboratory for diagnosis. Medical services are also rendered to the schools in the diagnosis of communicable diseases that may be found among school children who are ex- cluded from school. In order to facilitate giving these protective measures to school children, Immunization and vaccination clinics are held in the schools regularly. Tuberculin tests are given to school children as a pro- cedure of health education, as well as to discover active tuberculosis among school children and particularly among their parents. Any child who reacts to tuberculin is given a free chest X-ray on the Santa Clara County Tubercu- losis Association X-ray equipment and parents and other contacts of the in- fected child are urged to have their chest X-rayed. A tuberculosis director is maintained for Santa Clara County by the Santa Clara County Hospital. It is the director’s duty to conduct tubercu- losis clinics, treat and hospitalize indigent patients and refer others to proper facilities for treatment and care. Consequently, the San Jose De- partment of Health does not maintain tuberculosis clinics nor venereal dis- ease clinics. N Medical services in the field of venereal disease control are rendered by the Santa Clara County Health Department which maintains clinics for the treatment of gonorrhea and syphilis. Santa Clara County Hospital maintains a rapid treatment center for the hospitalisation and rapid treatment of ve- nereal diseases in the Isolation Hard. i Medical services in the field of industrial health, mental hygiene, and crippled children and rare communicable diseases are given on a consultation basis by the State Department of Public Health. The State Department of Public Health approximately every six months conducts a crippled children’s clinic in this area for crippled children residing in the City of San Jose. Local orthopedists usually conduct these clinics and determine whether the patients need medical and surgical care. Crippled children’s clinics are financed by the State Department of Public Health in cooperation with the. San Jose Department of Health, Santa Clara County Health Department, Palo Alto City Health Department and the Santa Clara County Medical Association. Non-orthopedic cases are generally referred to the State Department of Public Health and are assigned to specialists for examination and diagnosis. Only children who are medical indigents are authorized to be given free care by county funds. A crippled child has been defined as a '’person under twenty- one years of age who does not have complete use or control of his body or limbs, because of physical defects resulting from congenital anomalies or ac- quired through disease, accident or faulty development”. This includes, in addition to orthopedic or bone deformities and injuries, plastic reconstruc- tion of the face or body, orthodontia reconstruction in which the deformity is so bad that the child cannot adequately masticate his food, eye conditions leading to loss of vision, ear conditions leading to loss of hearing and rheumatic or congenital heart disease and other disabling or disfiguring de- formities. Funds for the care of crippled children are provided by a tenth of a mill tax on all property in the county. This money must be appropriat- ed by the Board of Supervisors and cannot be used for any purpose other than for crippled children. •In addition to the preventative medical services which are rendered in San Jose, the Health Officer also acts by ordinance for the Civil Service Commission and the City Manager in the verification of illnesses of city em~ ployees. either the Health Officer or his representative makes a visit to the home of each city employee who is on sick leave for three days Or mere. This is for purposes of verification of the illness and to assist the city employee to recover more rapidly, if possible. No medical care is given on these visits. The Health Officer also acts as advisor to the City Council in legislative matters in which they request his consultation. He also acts as a consultant to the City Manager when requested on city business which requires a medical opinion. Unofficially and without reference to his regu- lar employment, the health officer also cerves on the Board of Directors and other committees of the voluntary health agencies in the community, such as the Visiting Nurse Association, Infantile Paralysis Foundation, .American Cancer Society, American. Rod Cross, Boy Scouts of America and several other organizations. He is, in addition, on the staff of the San Jose Hospital, O’Connors Hospital and the Santa Clara County Hospital. This is because of his work and interest in the field of communicable disease. The Health Officer is charged by law with the large variety of official, actions such as control of communicable diseases and acting in. an emergency to preserve the public health of the citizens of the city; as, for example, when the water supply should suddenly become contaminated or food should become unfit for human consumption. The Health Officer is also appointed as Registrar of Vital Statistics for the United States Public Health Service by the Califor- nia State Department of Public Healtlm The objective of the Division of Sani- tation is the maintenance of safe standards of environmental sanitation, so that all may live in comfort and safety; together with the reasonable interpretation of the law governing these standards through health educa- tion and enforcement. ENVIRONMENTAL SANITATION 700 D fi/i £ -ofix a? i o/v The Health Department is charged with the re- sponsibility of maintaining in San Jose a olean, sanitary and uncont.aminated food supply. In order to carry cut such a charge, it is necessary that a cor.starc vigilance be maintained over all food storage, food prop me®, tics and food serving in the city’s many'food establishmentst Tins is accomplished Vy inspections and the correction of any deficiencies in the methods or equipment used in these establishments. Inspections are made at regular intervals, some more often than others, where conditions warrant a closer control. All food es- tablishments within the city are inspected; the following is a list of the types visited: restaurants and taverns soft drink retailers and bottlers all types of food factories bakeries sausage manufacturing plants meat, fish and poultry houses vegetable, fruit and grocery stores school cufeterias circus and carnival stands. Many communicable and non-communicable diseases are spread by foods. The danger of spreading disease is greatly increased when foods are handled commercially. The number of people involved, and the equipment and methods used, are constantly scrutinized by the health department to lessen any chance of such diseases spreading. Each inspection of a food establishment includes the following features: adequacy of the building for the purpose used adequacy of the equipment cleanliness of the equipment cleanliness of the premises food handling methods storage facilities disposal of refuse sanitary conveniences for per- sonnel and public rodent and insect infestation general condition of all equipment and operational methods. The sanitarian of the Health Department enforces the provisions of California Agricultural Code, California Health and Safety Code* Food Sani- tation Act, Food and Drug Act, the City Ordinances, and the Health Officer’s rules and regulations. Violations are « by xtjxm and 1KV-.+ : rt , -pci +;hfln hv Any foods found unfit for human consumption are either condemned or quarantined. In the case of quarantine, the foods are not released until proved to be good foods. For such proof, the department submits samples to our own laboratory, or other reliable sources of investigation and informa- tion, usually the laboratory of the State Department of Public Health. In addition to the routine inspections of all food establishments by the division, bacterial tests are made on utensils, glasses, and crockery used by taverns, restaurants and soft drink establishments. These tests are indicative of the dishwashing efficiency and the food handling methods in the establishments. Tests-are continually being made throughout the city, and as in the case of the inspections, the establishments needing more rigid control are tested most often, '/here high bacterial counts are obtained, the establishment is re-tested and the procedure of dishwashing and food handling is thoroughly explained. The inspector often has to spend many hours checking each operation to find out where proper technique and methods are not used. The department investigates all cases of food poisoning that are re- ported to the health department. A thorough investigation of each case is made in cooperation with the nursing division and the patientTs private phy- sician. A complete epidemiological study of the problem and the tracing of any contaminated foods is made to find the source of the trouble. It has not always been possible to find the contaminated foods, but the department has been very successful in discouraging the use of questionable food pro- ducts and raising the standard of food handling and storage methods. At present, the garbage and refuse disposal sys- tem in San Jose is handled by a private contract- or, the San Jose Scavenger Company. It is their job to collect and dispose of all the city’s refuse. It is the responsibility of the health department to see that this job is done in a satisfactory manner. The health department’s position is that of mediator between the public and the collector. Complaints of poor service by the scavenger company and poor cooperation on the part of the public are screen- ed through this office and investigations are made to remedy the faults. The sanitarians make inspections of the disposal methods of the city’s many markets, restaurants and commercial establishments to expedite the work of the scavenger company. This is done by requiring size contain- ers in good repair, proper storage of containers, adequate bins for waste paper, and definite hours for setting out the refuse. The department has inaugurated recently a policy of early morning inspections in the downtown area to correct any irregularities in the proper disposal and collection methods. A city-wide survey to determine which homes in San Jose are without adequate garbage service has been partially completed. So far, over six hundred new accounts have been added to the accounts of the scavenger com- pany’s list due to the efforts of this department. It is the aim of the health department to have 100$ collection service in the city . This is an educational procedure and has been found to be very worthwhile when one considers the results. 7 sThe necessity of mosquito control was first em- phasized to health authorities in California by William B. Hems, Doctor of Science, professor of Parasitology, University of California, in 1911. In San Jose mosquito control is impor- tant from two points of view: first, to carry on mosquito'''control as a routine procedure in order to reduce biting annoy- ance; and second, to minimize the possibilities of an epidemic of any of the mosquito-borne diseases. These mosquito-borne diseases are yellow fever, malaria, dengue, filariasis, equine encephalitis and, perhaps, poliomyelitis. Although rare cases of malaria have been reported in San Jose, and new strains may be introduced from other countries, of which local insects may become vectors, local mosquitoes constitute more of a nuisance problem than one of health. Numerous complaints are received, not only from areas within the city, but also from outside areas, which testifies that the problem is not localized, but involves County areas, also. Mosquito control necessitates a knowledge of mosquito biology: the various species, varia- tions of breeding places, feeding, pestiferous habits, flight range, and variations in disease transmission to man and animals. Control in San Jose requires the monthly oiling of approximate- ly 2,000 catch basins, the Guadalupe Creek in the dry seasons, and certain accumulations of waste water. Surveys are in constant progress during the breeding season, and specimen are collected and identified for the purpose of locating breeding places. Several thousand mosquito fish are distributed annually, free of charge, for control in ornamental back yard pools,. Infor- mation is made available* regarding'the use of insecticides and repellents. Citizens are urged to eliminate from their own premises such standing water as may be found in tin cans, tires, barrels, buckets, obstructed roof gutters or other receptacles. Leaky water faucets and defective plumbing provide potential breeding places. Periodic newspaper articles inform the public on the importance of mos- quito control and the necessity for everyone's cooperation. Information is also available regarding the control of such common household pests as ants, weevils, drugstore beetles, cockroaches, gnats, silverfish, fleas, lice, bed- bugs and bats. While some infestations may be eliminated by specific poi- sons and insecticides, others require the services of a State-licensed ex- terminator . Rodent control, from an economic and public health standpoint, is important and requires foresighted planning if favorable results are to be expected. It is estimated that San Jose’s rat infestation is costing about $160,000 a year, due to destruction of wholesale food sup- plies , buildings, merchandise, and to disastrous fires. They are responsible for the transmission of bubonic plague, endemic typhus fever, infectious jaundice, trichinosis, rat-bite fever and dermatitis. The following measures are commonly used in the destruction of rodents: the protection of all food supplies against rodents; rat extermination by poisons, traps and fumigation; erection of rat-proof buildings; the re- modeling of non-rat-proof buildings; the closure of all openings in exist- ing, supposedly, rat-proof buildings; the removal of material, such as rub- bish, which provides a refuge for rodents. The health department promotes rodent control by furnishing authentic information regarding methods of extermination and a free distribution of rodenticide. Health department personnel eliminate rodents on all city properties, such as refuse dumps, parks, buildings and sewer mains. A city- wide survey was started in 1945, one purpose of which was to eliminate rat food supply and harborage by requiring adequate garbage disposal, and cor- rection of insanitary accumulations of rubbish and brush on vacant lots and premises. Information and ordinances from other cities regarding the rat- proofing of buildings are being gathered for the purpose of enactment of regulations which will tend to "build out the rat" and remove his harborage in buildings. A city ordinance, at the present time, prohibits in trailers within the city limits with- out special permission of the health officer. The permission for such has never been given due to insanitary conditions which usually exist in such inadequate housing structures. Observance in'other cities where this practice is permissable shows that inadequate sewage and garbage disposal, water supply, and lack of air space are not conducive to a clean and healthful city. This ordinance is enforced by re- quiring the trailer to be vacated or moved outside the city limits to li- censed trailer parks. San Jose does not have a licensed trailer park. Approximately thirty-one business concerns giv- ing laundry service in San Jose are required to be licensed and must be inspected monthly. These are located throughout the peninsula, including San Francisco and Oakland. General methods of operation are studied and the degree of final cleanliness of wash is determined by bacterial analysis of final rinse water samples. General sanitary conditions pertaining to lint and grease accumu- lations, lavatories, floors, walls, ceilings and fly infestations are noted. All washing operations must be installed on a non-permeable floor material such as cement, and all wash water is drained directly into the sewer. De- spite lack of manpower, maintenance materials, and machinery, satisfactory renovations have been made and the cleanliness of wash has been satisfactory. PUBLIC P7LPLIU The objective of the Public Health Nurse is to help make known scientific facts about health; to help create positive attitudes toward the acquisition and maintenance of health; to encourage and teach the use of medical resources; to contribute toward the adjustment of social conditions to the end that the individual and family will become re- sourceful in meeting their health needs1. PUBLIC HEAlTH In San Jose there has been developed a general- ized Public Health and School Department nur- sing program in which each nurse is assigned to a district and is responsible for all health services in that district. The nurse is inter- ested in the entire family and is ready to give guidance and help with problems in health and related problems in social and economic living, utilizing local resources ¥;henever possible to assist the families to make plans for themselves. Bedside care is not part of the gen- eralized program in San Jose. In the field of tuberculosis control the public health nurse makes home visits on all cases that are reported by the Santa Clara County Tuberculosis Sanitorium and federal hospital facilities. The purpose of these visits is to teach the patient and his contacts the cause, treatment and prevention of tuberculosis. The nurse also endeavors to find out the source of the infec- tion and to find out if any of the contacts have developed the disease. Fre- quently social, economic and emotional factors enter into the problems of the tuberculosis patient. The public health nurse helps the patient and family meet these situations. Patients of private physicians are visited by the nurse upon request of the physician. In an effort to promote maternal and child health, the public health nurse visits expect- ant mothers. The Santa Clara County Hospital pre-natal clinic refers the name of pre-natal patients living in the city. Intelligent care during pregnancy, proper diet, exercise and good mental hygiene; preparations of the layette, understanding of infant care; all are essential in safeguarding the health of the mother and the new infant. Frequently, expectant mothers are found who have not secured medical care. These patients are referred to the private physician, or to the Santa Clara County Hospital pre-natal clinic for medical supervision. Welfare a- gencies and the public, also, frequently refer cases for investigation and care. These cases usually have health problems brought on by old age and low income. Control of communicable disease is still of major importance. Quaran- tine according to law, isolation .and epidemiological investigation is made by the nurse on all communicable disease, and the case reported. Protection against diphtheria, smallpox and whooping cough is necessary and all efforts are made to have the public protected, either by their private physicians or by attendance at established c.ity clinics for this purpose, or at an estab- lished child health conference. There is keen interest in the prevention and control of noncommunicable diseases and illnesses, which are of public health significance, such as: cancer, disabling heart conditions, dental defects among children and, also, in the development of interest in the never concepts of mental hygiene. In addition to family health and counseling on a district basis, each nurse is responsible for all the schools in her district and the health of all her school children. Good health is one of the primary objectives of school education. The teachers and the nurses work together to fulfill this objective. Many remedial defects and causes of poor health are discovered by the teacher and nurse. The teacher, with her opportunity for almost continuous daily observation of the child, should be, and frequently is, the first per- son to notice signs of physical and emotional difficulty. Any child showing deviation from the normal is sent to the nurse for check-up. Common condi- tions noted are vision defects, hearing loss and skin rashes. The nurse, after consulting with the teacher, arranges for preliminary tests, depending upon the nature of the defect or deviation under consideration In certain cases, as in problems concerning hearing and vision, the tests are given by the nurse and then, where indicated, a visit or conference is held with the parents regarding the need for further medical supervision. For correction, the child is always referred to his private physician. The physical examination is a definite part of the educational program of the school as well as a part of the health activities of the child. Routinely, at certain grade intervals, all children are given a physical examination; how- ever, teachers may refer children at any time to the school physician for ex- amination. During the last few years, our records show that an increasing number of children are examined by the school physician as a result of the re- ferral of the nurse-teacher conference. The object of such examinations is twofold: first, to find defects so that the condition may be treated and the child may develop into a normal in- dividual, capable of all the activities of physical, mental and emotional need. Second, it serves to educate the child and parent regarding the advisability of good medical supervision. Whenever possible, teachers and parents are called upon to participate in the health activities of the children. When this is accomplished, the true value of such health activities is further enlarged upon in that the child gains by a realization of the need of good health habits and obtains a certain satisfaction that others are interested in his problems. The parent obtains an understanding of the importance of good medical supervision and counsel. The school gains the cooperation of the parent. The community gains through the knowledge that its citizens are maintaining high standards of health and physical fitness. The school health nursing service maintains a regular schedule, throughout the year, of immu- nization and vaccination clinics for school children. Every year children who have not pre- viously been vaccinated against smallpox, or who have not been vaccinated within a five-year per- iod, are given this very important protection. However, before a child can be given this protection, the parents must give their approval. This is nec- essary for every health activity of the child. In addition to the smallpox vaccination, innumization for diphtheria is given. Immunizations are repeated about every three years. In this way, the school child is completely protected. A very interesting health protection activity available to school child- ren is the use of the tuberculin test. This is a skin test given to the child. A positive reaction to the test indicates evidence of tuberculosis infection. All children producing a positive tuberculin test are given a chest X-ray at a later date. In every case of a positive skin test, the parent is notified by the school and is advised to obtain a chest X-ray as very often children are infected by parents. A positive skin test in a child usually indicates that the child is in continuous contact with one or more persons suffering from tuberculosis. One of the major responsibilities of the City of San Jose Health Department is to find the source of infection for tuberculosis, and to do everything possible to find active cases in the community. Another responsibility of the Nursing Division is the supervision of crippled children in the city. The first objective of this program is to find*children suffering with a crippling con- dition, and second, to get them under medical care. Home visiting, school inspections, tea- chers’ observations, and private physicians, are sources of finding these cases. The California Department of Health and the local health department spon- sor a free diagnostic clinic, which is held four times a year- Certified or- thopedic specialists attend these clinics, examine these children and make recommendations for care. Parents of children needing surgery, appliances, or medical supervision are investigated to determine whether or not they need financial assistance in following through the recommendations made at this clinic. All children with a crippling condition are to be given medical or surgical care, regardless of the responsibility assumed by the parents. Added supervision is necessary after these cases are found and diagnosed. The nurse visits the home or confers with the patient and parent in her office helping them to carry out the doctor’s recommendations. Frequently, emotional factors hinder a complete recovery, but knowledge and guidance by the nurse helps the family and patient understand and solve their problem. The conviction that the infant and pre-school child benefits by careful health supervision is the basis for establishing child health confer- ences. The objective of the City of San Jose Health Department in this area of service is to provide regular medical and nursing supervision for the children whose parents are unable to carry the full expense of private medical care. Service is given to the well baby and diseased conditions are referred to private physicians. The child may be seen by the dental hygienist who discusses the impor- tance of early dental care and the hygiene of the mouth and diet for good tooth development. The physiotherapist gives valuable aid to the parents in helping them to recognize the realtionship of early care and training to fu- ture good posture and proper function of the whole body. The child is viewed as a part of a family and every effort is made to help the parents to plan for better health for their families. Aid is given to the family in obtaining financial assistance, if indicated, from the prop- er agencies. The health of the individual child is dependent on the health of the family, and so the nurse is interested in the health of the entire family Because mental health is assuming its proper place in the total field of health, there is concern over this problem. The public health program expands and develops only as far as its educational aspects expand and develop. The child health conference is another tool in the program of edu- cating the public in good health, how it can be developed in children and how it can be preserved in adults. The need for placing a child under early dental supervision is clearly indicated by the number of decayed teeth found in children. It is es- timated that 90$ of all children in the five- year age group have some form of tooth defect. Children with bad teeth cannot do school uork well. f As part of the school health service, a dental hygienist works with the teachers, nurses and children. Her task is concerned chiefly with children in the elementary grades. It has been found that young children experience the maximum benefits from dental examinations. It is, also, very important to find the dental defects before they have become a serious problem to the child. When dental defects are discovered in a child, the parents are sent no- tices describing the defects and urging dental care for the child by a dentis*: The dental hygienist also gives the classroom teacher the names of children needing dental care in order that the teacher may continue to urge parents to give the teeth of their children proper care. In addition, the dental hygienist visits parents in their homes and dis- cusses the dental problems with them. It has been noticed that the child whc is given early and regular dental care experiences pleasant relationship with his dentist, and in later years is more often the individual who will visit the dentist for a regular annual check-up. Classroom discussions with children, tooth brush drills in which the children learn about approved tooth brush design and the proper use of the brush are parts of dental health education. The teacher is given authoritative material to use for classroom discussions and to aid her in her work. While most of the work is done in the lower grades, examinations and dental health education is also done in the Junior and Senior high schools. The dental hygienist gives talks before science and home-making classes during the time the classes are studying problems concerning teeth. Due to the financial inability of some parents to take proper care of the dental problems of their children, many children do not receive adequate care. Limited funds are available for this use from the Community Chest, Parent-Teacher Association and other civic organizations. Through the coop- eration of the local dental society, these funds are made to stretch over a much larger number of cases than would otherwise be possible. rnjrr mm n/j/a / / / ! j / -a—j / / / / / / -/— / \ (y i in p n.r n / ir)ri i/LV LL / I The objective of the Dairy Division is to properly supervise and control the production, processing and distribution of milk and dairy products; thus making it safe and healthy for all people both young and old to consume and enjoy all dairy products. DIVISION OF M LK AND DAIRY INSPECTION The increase in milk consumption paralleled the increased confidence of the public in the safe- ty and wholesomeness of their milk supply'*, so stated Dr. George Uhl, Health Officer of the City of Los Angeles in an address before the Dairy Institute of California, on August 28, 1946, at Santa Barbara, California. After reading Dr. Uhlrs address, we began to wonder just what this meant in terms of San 1036*3 milk supply. Has consumption of milk increased in San Jose, indicating confidence of the people in the safety and wholesomeness of the supply? In 1941 San Jose was consuming about 15,000 gallons of milk per day; more than a 20% increase in the daily consumption of milk. Part of this, of course, is due to an increased population. In 1941 the San Jose milk supply came from a relatively small area. Gradually, as the demand increased, the milk-shed area . increased in size. The milk-shed area increased, until now the milk and dairy inspectors cover an area including six counties, from Alameda on the north, to Fresno County on the southeast. To insure maintenance of standards, last year the inspection staff made over 2,300 inspections. These inspections covered a check on the milk supply from the cow to the milk bottle. As a result of constant inspection and ex- cellent cooperation on the part of producers and distributors, 90% of the milk entering San Jose meets Grade A standards. The remaining 10% is used as man- ufacturing milk and shipped to factories to be made into cheese and other milk products. One of the interesting outgrowths of consumer demand is the development of the mid-morning milk program in the city schools, sponsored, by the Parents- Teachers Association, and the increase in milk consumption by students in the city school cafeterias. This development alone is responsible for over 10% of the increase in milk consumption. rJhen one realizes that a large percentage of the youngsters of school age are drinking milk, the significance of obtain- ing and maintaining a safe wholesome milk supply becomes especially important. Guaranteeing San Jose milk consumers a clean, wholesome milk is a real task. The problem of supervising the inspection work in the milk-shed is par- ticularly difficult. When one considers the need for inspection service on three levels of production, the producer, the distributor-producer and the distributor, and that these three operations occur in all parts of the milk- shed at any one time, the responsibility of the Division of Milk and Dairies is evident. The San Jose milk shed is comprised of 126 dairy farms and 14 milk pro- ducts plants. The dairy farms are located in Alameda, Santa Clara, San Benito, Merced, Madera and Fresno Counties. The milk processing plants are located within the city of San Jose and in Santa Clara and Merced Counties. The 126 Dairy farms of the San Jose milk-shed are regularly inspected and the following items are checked for sanitation or construction, as the case may be. Milking Barn: location, construction, light and ventilation, drainage,, cleanliness, corrals, storm shed, and feed barns; location, construction, if properly graded and drained, if satisfactorily maintained, if proper distance from milking unit. Milk House; location, construction, light and ventilation, proper rooms, properly fly-proofed, adequate washing and sterilizing facilities, if free from contaminating surroundings, drainage adequate and sanitary. Milk Handling Equipment: construction, hooded pails, if properly washed, rinsed, sterilized and dried; protected from contamination. Milking and Handling of Milk: cows* udders, flanks, hind legs properly washed and dried; flanks and udders properly clipped and tail bobbed; clean milking suits; milkers hands clean and dry; clean milking stools; immediate removal of milk t6 milk house; milk properly filtered, cooled and aerated; receiving and holding vats properly covered. Miscellaneous Items: water supply clean and fresh (water samples regular- ly), water trough clean, feed and water for stock clean, wholesome and proper storage; control of fly-breeding places; wash basin, soap and towels; toilet properly located, fly-tight and clean; general surroundings clean; animals apparent good health and disease control measures observed. After the inspector completes this inspection and all sanitary deficien- cies have been noted, the dairyman is given written Instructions to correct all such defects within a specific time. In making milk products plant inspections, the following items are checked by the inspector: Location: surroundings clean, sanitary and or- derly. Arrangement: adequate number of rooms, conven- ient, proper construction. Floor, walls ,Veiling: smooth, proper construction and clean. Doors and windows: screened, good repair, self closing, clean. Light and ventilation: adequate, evenly distributed. Water supply: approved source, hose satisfactory, sufficient outlets. Toilet: good repair, vestibuled, ventilated, self closing doors, clean basin»soap and towels. Dressing rooms: clean, orderly, properly ventilated. Cold Storage Rooms: construction, proper temperature adequate, clean. Waste Disposal: sewer facilities, covered waste containers. Washing facilities: adequate, efficient, temperature indicators. Containers: condition, open seams, rust free, clean,sterilized, dried, protected storage. Vats: smooth, tight surfaces, exposed copper, clean, sterilized and dried. Thermometers: accurate, sufficient, indicating thermometers; charts properly recorded and filed. Other equipment: adequate, good repair, clean, sterilized, dried, pro- tected . Protection of the Product: from contamination (flies, dust, etc.), proper delivery temperature and properly labeled. Personnel: sufficient, clean habits, clean clothing, health certificate. Transportation vehicles: protected, clean products properly iced. Storage of clean, orderly, rodent proof, properly protected. Milk Samples: In milk plants the inspector col- lects samples at the receiving vat from individ- ual milk producer shipments and from tank truck shipments. After the milk is processed and pack aged for retail distribution, the inspector also collects samples of the different grades or kind of milk. All samples are then taken to the department laboratory where they are analyzed for bacteria, fat, solids not fat, and given other tests. Water Samples: Samples are collected from the dairy farms and from those milk product plants having their own water supply. These samples are taken tc the department laboratory where they are analyzed. Sediment Samples: All milk from the dairy farms is sampled for sediment by the plant inspector. A clean sediment dick denotes that clean cows are pro ducing the milk. Swab Test: These tests are made at the dairy farms of all the equipment and in the production of market milk and is used as an index on methods in clean-up work. Physical Examination of Cows: During milking time, the inspector makes routine examinations of the milking cows, for cleanliness as well as for mani- fest evidence of diseases. The dairy herd must have had bovine T. B. tests, which are administered by the State Department of Agriculture yearly. New Construction: The new construction of dairy farm buildings or milk products plants are under direct supervision of this department. Full sets of plans and specifications, approved by the Bureau of Dairy Service, are a- vailable for dairymen. This department locates the building site and issues instructions as to the drainage, elevation, etc. During the course of con- struction, the inspector makes regular calls to see that the plans and speci- fications are conformed to by the contractor. Milk Handlers Health Certificates: All milk handlers must furnish the de- partment with a certificate of health showing that they are not afflicted with any communicable diseases. Operators of Pasteurizing Equipment: Shall hold a pasteurizer’s permit and must have passed an examination given by this Department before being granted permission to pasteurize market milk and cream. 38,800 gallons of market milk and market cream' are pasteurized daily for distribution. 17b gallons of raw market milk is packaged daily for distribution, (This is only 0.4b of our total milk supply.) TS. 5 T0 OF A l L MIL K. IN SAN: -JOSEIS PASTE U RUSD r JQf^hj Tho Public Health Laboratory is estab- lished to maintain recognized standards of public health procedure for protec- tion of all, by carefully controlled and accurate analysis of water, milk, and other foodsj to aid in the con- trol and diagnosis of the communicable and other diseases of man. PUBLIC HEALTH LABORATORY In the spring of 1919, the City Council of the City of San Jose passed an ordinance creating a position of Public Health Bacteriologist, and thereby organized a public health laboratory. With the steady growth of the city, the labora- tory has grown until at the present time three full-time laboratory workers are employed to check water and milk supplies, to perform blood tests, and all the necessary laboratory tests which are a part of the routine of a public health laboratory. The test to discover the common colon bacillus or its immediate relatives is standard proce- dure, because no enteric diseases are transmitt- ed by water where these bacteria are absent. When these indicator organisms are found in a water supply, public health procedures are im- mediately instituted to find the source of contamination and to eliminate the contaminated supply. Daily samples are collected from different parts of San , Jose and analysed according to standard methods to insure that they meet the rigid requirements of the United States Public Health Service. From a dietary standpoint, there is no known food which is more nutritious than milk. Un- fortunately, milk is a perfect food for bacteria. Therefore, a great amount of effort is made by the Public Health Laboratory and the Department of Milk Sanitation to insure a safe and sanitary supply of this valuable food. Bacteriologically, the standard plate count is considered an index of the sanitary quality, although, like water, a high count may be misleading. Tests for colon bacilli are frequently run on milk. At times the laboratory is called upon to examine milk for the presence and differentiation of various species of streptococci, and staphylococci, myco- bacterium tuberculosis, and the organism responsible for undulent fever, bru- cella militensis. Chemically, milk is analysed for total fat, total solids, solids not fat, sediment, added water and preservatives. The phosphatase test is also perform- ed. This test is very valuable in determining if milk has been properly pas- teurized. In accordance with the requirements of the California Department of Ag- riculture, the San Jose Health Department Laboratory analyses between two hun- dred and three hundred samples of milk each month. Standard methods of analy- sis of the American Public Health Association are strictly adhered to in all analyses. LA BO RATO RY TESTS ON WATER.ASSURE PUlU WATER TO THE commUni T Y c/s/nns /.ixi trm x 3oo The. micro-organism responsible for diphtheria, the Klehbs-Loffler bacillus, is sought for by culture in the normal throats of all children entering day nurseries, and all children going to summer camps. In certain cases, food handlers and milk handlers are required to have throat cultures done. Those individuals having sore throats are examined to determine if their infection is diphtheria or some less serious throat infection. Most typhoid cases encountered in these days of rigid milk and water con- trol are cases from sparsely settled areas where there are no public health control measures. Laboratory diagnosis depends on a positive agglutination test on blood serum, commonly known as the Widal test, and the finding of the typhoid organism in the blood, urine, or stool. The laboratory plays an im- portant role in the control of this disease not only in the initial diagnostic test, but in subsequent examinations to determine if the individual has over- come his infection, as many who develop the infection may carry the organism for months and, in rarer instances, even years. For these reasons, those peo- ple who are directly responsible for the handling of foods, such as sandwich and salad makers, should be laboratory-tested if they have a history of typhoit or of any other type of enteric infection. Paratyphoid infections resulting from the ingestion of foods contaminated with organisms of the salmonella paratyphi group are not so serious as typhoid, though more widespread, and here the laboratory plays an important role in tracing cases, in finding carriers, and infected food samples. The organism causing tuberculosis is sought for microscopically in stain- ed smears or cultured on special culture medium. When these fail to detect the organism, the suspected material is injected into a susceptible laboratory animal, usually a guinea pig, which is the most sensitive test of all. Mat- erial examined for tuberculosis may be milk from a cow suspected of having the disease, sputum from an individual with a persistant cough, or chest, or joint fluids from individuals with or without history of tuberculous infection. Blood smears for malaria are frequently examined from those individuals who have served with the armed forces in tropical countries. Malaria patients respond to treatment with specific chemicals, so a diagnosis is important that the use of these specifics can be instituted without delay. The discovery of the spirochete of syphilis and principles of the comple- ment fixation test Y/ere great discoveries. The technique for the dark field examination depends on a thorough knowledge of the workings of the microscope. This test is done satisfactorily only by a skilled technician. Likewise, the complement fixation test, commonly known as the Wassermann test, requires great care in its performance. The test, which is a bio-chemical test, does not detect the causative agent of syphilis in the blood stream, but, by chem- ical means, detects the chemical substance which the body manufactures as a defense mechanism to this infection. These tests are all done in the labora- tory as a regular part of the Serological work. // v Ji j To collect and file birth and death cer- tificates which have been carefully checked for completeness and accuracy. To make available to any department needing or desiring the information, data obtained from the punch cards of births and deaths. To present statistical material to other departments for their interpretation to the public. To impress upon the public the importance of securing certified copies of birth certificates, not only from the stand- point of the certificate being a citizen most valuable personal document, but with the view of promoting 100$ registration. VITAL STATISTICS Recording births, deaths, and the vital data which occur between these two major events, is the task of the Vital Statistician. Records of vital events play an ever-increasing part in our daily lives. Rarely a day passes in the health department without a request for a certificate to prove birth or death. It is important for everyone to make certain that his birth certificate is on file and that it is correct. Cer- tificates improperly filed may be changed, but only with considerable diffi- culty. Probably the most important factor governing the filing of the death certificate is the cause of death. For the protection of the public, it is most important to know the occurrence of the causes of death in the commun- ity, particularly if deaths are caused by preventable, communicable diseases. Statistically, it is important to know the occurrence of death in relation to various age groups. To record the information on the birth and death certificate in San Jose, a special recording punch card form is now used. Periodically, these cards may be placed in a special tabulating machine from which the vital informa- tion may be obtained. By this method, comparisons can be made within this community and, if desired, comparisons can be made with other communities: Births and deaths of San Jose citizens occurring elsewhere are reallo- cated to San Jose, and by the same token, these events occurring in San Jose, affecting citizens of other communities, are reallocated to the residence of the individual concerned. A birth certificate plays an important role for statistical purposes in the field of public health, social welfare and government; it is also the most valuable personal record used by a citizen. A birth certificate is proof of the birth date and, as such, is necessary in regard to the following: entrance at school first work permit automobile operator’s license pilot’s license radio operator’s license permit to carry firearms right to vote right to marry right to enter civil service entering military service obtaining employment in certain industries passports establishing citizenship for immigration for proof of parentage tracing of ancestry social security benefits city, county,, state or federal pensions right of inheritance right to insurance benefits legal responsibility in dependency cases claim for servicemen's depend ents Birth certificates are carefully checked for ©missions before filing. In order to insure correct spelling of names, the certificates are signed in the margin by the mother at the hospital. She also verifies all the in- formation on the certificate. Because no change is allowed on a birth cer- tificate after it is filed, without an affidavit of correction signed by both parents before a notary public, great care is given to complete accur- acy, Usually parents select the name of the child before birth, but if there should be some indecision as to the name of the child, supplemental report of birth is mailed to the mother. Special attention is given to still- births as they are rarely complete upon presentation for a burial permit due to the detailed information required. Double post cards are sent to all new mothers giving name of the child, date of birth, names of father and mother and place of birth. This card serves as a notice to new mothers that certified copies of birth certificates are available for one dollar at the health department. If a mother indicates on the returned card that she would like literature on baby care, two book- lets are mailed to her: "Infant Care" and "Straight from the Start". These are excellent booklets published by the Children’s Bureau, United States De- partment of Labor and the California State Department of Public Health. If the dollar fee is enclosed, a certified copy of the birth certificate is mailed and a mimeographed sheet, "A Certified Copy of Birth Is a Valuable Document” accompanies the certificate. This leaflet lists the various pur- poses for which a birth certificate'is-used. If a person does not have a birth certificate on file, he may file a "delayed birth certifi- cate" . Approximately three years ago when peo- ple v;ere having a difficult time securing their birth certificates and found that they had no certificate on file, a bill passed by the State legislature made it possible for them to file a delayed birth certificate with the State Department of Vital Statistics. These certificates are issued by the health department with instructions for making out the certificate. The attendant at birth, parents or relatives are required to sign, and two documentary evidences must accompany the certificate. This birth certificate, after being properly executed before a notary public, is sent to the state department for final passage. In approximately six weeks the delayed birth certificate is placed on file in the health department. Since searching for birth and death records in- volves a great deal of time, state law provides that local health departments may charge a fee of one dollar. If the certificate is found, a certified copy is made of the record. INFO RMATION FOR THE FILING OF 6I FT,hi C [ f.7 if i C ATE IS A VA I LA 0 L E Calls are received from lawyers and hospitals regarding procedure for filling out a'birth cer- tificate for an illegitimate child and for adop- tion procedures. An illegitimate or legitimate child, after adoption, may have a new birth cer- tificate filled out in the State Department of Vital Statistics, giving the names of the new parents with no indication as to his illegitimacy nor of his adoption, thereby giving him the same rights as any other child to a birth certificate. This law was passed by the state legisla- ture about four years ago, when the difficulty and embarrassment these children experienced when asked to present their birth certificates became apparent. The original birth certificate is sealed in the health department and can be shown only by court order. Death certificates serve to furnish official statistics for health departments to establish causes of death, to prevent disease and to plan health programs and clinics. Life insurance companies use statistical information to estab- lish premium rates. The Bureau of the Census makes many compilations of mortality statistics by location of death, residence, age and cause. Mortality statistics are used to estimate populations, determine average age of death and to compare the healthfulness of one area with another. Certified copies of death certificates are used for the following: tracing ancestry life insurance claims transfer of bonds bank and building and loan funds civil service and union pension for family of deceased establishing aid by welfare departments for family of deceased if a veteran, widow’s pension claim if a veteran, government insur- ance if a veteran, for burial Tee i rp /inTir U/ /// / u J /' /-// . 7 pjl to /] T>nn J i\J / Health Education is concerned with the problem of making available to the community the beet and most reliable information in the art of healthful living and to assist the community in finding and solving for themselves their health problems and needs. Health education looks toward the fu- ture with consideration of the past, looking for a place in which the two may meet. HEALTH E DUCAT I ON It can be readily observed how different health department activities are today as compared witl those of twenty years ago. Many changes have been made, not only in the work, but in the pro- cedures and technique. Even the emphasis has shifted from certain activities to others which at the present appear to be more important. When public health work was first started in San Jose, emphasis was made on problems of sanitation and achievements were measured in terms of police powers of the health office. It was not too difficult a matter to force a citizen to keep his pigs confined or to clean up a rear yard when one threat- ened the individual with arrest. Later when other health activities, such as the problem of small pox vac- cinations occurred, it became necessary to change enforcement techniques. It was soon learned that the average citizen could not be vaccinated by force. Gradually health procedure changed. No longer could the police power be used as before. Now health activities concerned people. The average citizen de- sired health; he wanted to be free of disease. He wanted to know the public health reasons behind every public health activity. It was at this point thal health education made its first advantages felt in the development of health programs of a community. At first communicable disease control activities were chiefly those in which there were problems of checking epidemics. It became apparent that health protection was more effective if the disease was prevented, rather thar by trying to stop it after it had gained the force of an epidemic. Here agair health departments had a problem. The community did not want epidemics of di- sease, but they did not always understand that the way to prevent small pox, for example, was to be immunized in advance of a potential epidemic. The peo pie of the community had to learn the advantage of immunization as a regular part of healthful living. This process was a health education procedure and still is a pressing problem. Step by step, as the health department activities increased, the value Oj the modern health education procedure became recognized. Every member of the health department began to use educational procedures in some form. Gradually it has become recognized that best-results are not obtained by law enforcemen* It is definitely known that an informed community is a healthier community. Persons who know why and how diseases spread and can be prevented more often do something about the noncommunicable problems of man; those such as heart disease, cancer, diabetes and accidents in the home and on the streets* The attack against these problems again is not by enforcement of laws, but by education of all persons living within a community. As the health department grew and began to take'on its increasing list o responsibilities, this problem of coordinating the activities of each division became evident. It was soon seen that a nurse going into a home had a splen- did opportunity to do a considerable amount of health education. She could not only present nursing, but any other health problem in which the family wa. interested. This experience also applied to the activities of other members of the department. As problems began to be recognized it became evident that health problems were not just confined to the circle within a family, but were of community interest, too. Health information passes from one person to an- other, to become of concern to all. Faced with this, the health department found that it was necessary to develop techniques of getting information to all the people. This necessity brought on the development of community forum; on health, study groups concerned with specific health problems, conferences where many people could exchange opinions and solve health problems. All the people of a community should have the advantage of whatever information was at hand. All these procedures became important and are now recognized as part ol a well developed and planned health program. Health problems of a community can best be solv- ed by the people of the area working together ■ toward one health objective. When a health department is so organized as to make available to the public its services in a way that these services can be used by the com- munity, then that community can best be served and the health problem can be better met. Through a division of health education, the activities of the health de- partment may be made available to the people of the city. The health educa- tion division is arranged as a Health Education Center; with facilities for the community to use. It is the aim to have available reference material on all phases of health activities and subjects, visual aids for use of all the groups, and to arrange for -channelling of the services of the entire depart- ment to meet the needs of the community. The Health Education Center should be a meeting place for all groups interested in health, for the health depart ment is a facility for the people to use. Just as individuals approach the various divisions for assistance on in- dividual health problems, community groups may approach the Health Education Division for assistance and consultation on solving the larger health problem of the community. Just as the health educator works within a health depart- ment, so does he work within the community. It is a responsibility of the health department to bring together all persons interested in health so that there may be one concerted effort. Health education, as a community ser- vice, is charged with this duty and it is for this purpose that the Health Education Center has been established. A community best informed on health matters may be said to be that com- munity which is acquainted with the total health program. It takes all the efforts of a community 7/orking together to solve health problems and to meet real health needs.