MARYLAND 
PUBLIC HEALTH IN WORCESTER COUNTY PUBLIC HEALTH IN WORCESTER COUNTY, MARYLAND 
Report of a 
Public Health Survey 
Conducted by 
Ira V, Hiscock, Sc.D. 
and 
lum Allen Pond, M.P.H. 
with the cooperation 
of 
The Maryland State Department of Health 
and 
The Maryland Tuberculosis Association 
1940 Preface 
In the appraisal of the public health program of Worcester 
County, certain features and resources as well as special problems which 
have impressed the survey staff, may be cited at the outset of our detailed 
report, as follows: 
Strong Points. Assets 
1. Administration by County Commissioners who are interested in 
public health* 
2* Fairly prosperous agricultural area with a reasonably high tax 
valuation in comparison with rural counties of the United States* 
3. Trained and energetic full-time health officer with a loyal staff. 
4. Considerable assistance rendered by the State Department of Health, 
although increased responsibility should gradually be assumed by the County, 
5, Important provisions for the sanitation of the environment, as 
follows: 
a. Pasteurization of practically all the milk used in 
Ocean City; 
b. Chlorinated water supplied in Pocomoke City; 
c* Effective sewage disposal plant in Berlin; 
d. Federal inspection of most of the meat sold in the 
County* 
6* Conduct of a pneumonia control program* 
7* Well organized and administered program for the control of syphilis 
and gonorrhea, although the latter should be stressed more than at presents 
8. Increasing interest in tuberculosis control with growing support 
of Christmas Seal Sale conducted by the County Tuberculosis Association with 
the assistance of the Maryland Tuberculosis Association. Good tuberculosis 
clinic service, possibly needing extension* 9, A newly organized County Public Health Association, and several 
Parent-Teacher Associations, and generally good cooperation from physicians 
and dentists practicing in the County. 
10, Fairly good provision for prenatal care service. 
11, Many excellent school buildings, although lighting facilities need 
study. 
12, Gradually developing program for community health instruction. 
13, Excellent cooperation between the school department, the welfare 
department, and the health department. 
14, Good provision for care of crippled children through the State 
Department of Health, with cooperation available from the Maryland League 
for Crippled Children, 
15, Gratifying progress in the promotion of public health in recent 
years. 
Weaker Points - Liabilities 
1, Fairly large proportion of the population over 45 years of age 
and high Negro population; excessive infant mortality rate (coupled with 
high birth rate), tuberculosis and typhoid mortality rates* 
2* Lack of chlorination of public water supplies, except in Pocoraokej 
existence of many private water supplies which present potential hazards. 
3* Need for treatment of sewage at Snow Hill and Pocoraoke City and 
for more effective treatment measures at Ocean City* 
4. Existence of many insanitary privies and of other problems of 
general sanitation. 
5, Inadequate provision for supervision of food handling establishments* 
6, Low proportion of pasteurized milk used in most areas in the Cppnt^, 
7, Low proportion of preschool children protected from diphtheria. 8, High incidence of cases of tuberculosis associated with complex 
social problems. 
9, Need for earlier discovery and treatment of cases of syphilis, 
especially of instances of the disease among prenatal cases. 
10. Need for more comprehensive program of child health conferences, 
11. Incomplete school health service program, 
12. Delay and difficulty at times in securing medical and hospital 
care of needy patients including colored, especially in securing hospital 
care when needed for obstetrical and other types of cases, 
13. Lack of provision for bedside nursing service* 
14. Shortage of trained public health nurses, 
15. Lack of an experienced public health nursing supervisor. APPRAISAL SCORE FOR PUBLIC HEALTH SERVICES 
WORCESTER COUNTY, MARYLAND, 1939 
Sections 
Percentage Attainment 
Vital Statistics 80 
Communicable disease control 60 
Syphilis and gonorrhea control 65 
Tuberculosis control 74 
Maternity hygiene 69 
Infant and preschool hygiene 45 
School hygiene 30 
General sanitation 45 
Food and milk control 51 
Total, all sections 52 Major Recommendations 
In considering the future development of the public health program 
in Worcester County during the next five years, the following major recom- 
mendations are suggested: 
1* That early provision be made for the employment of a well trained 
and experienced public health nursing supervisor. 
2. That special effort, as outlined in this report, be directed to the 
reduction of the excessive morbidity and death rates from tuberculosis and 
typhoid, as well as from diarrhea and enteritis and other conditions related 
to the high infant mortality. 
3. That as emphasized in the report, the program of sanitation and food 
control be gradually strengthened and include the stimulation of the use of 
pasteurized milk. 
4, That consideration be given to the appointment of a health 
education supervisor to work under a joint program to be developed by the 
County Health Department, the County Department of Education, and the County 
Tuberculosis Association. 
5. That as early as possible more adequate housing facilities for the 
health department be provided, including the establishment of central head- 
quarters on a rent-free basis by the County at Snow Hill. Origin and Purpose of Survey. The public health survey of Vorcester 
County was conducted at the request of the 
County Health Officer and the County Commissioners, with the approval and 
full cooperation of the Maryland State Board of Health. The appraisal 
was launched early in June and completed in September, 1940. Most of the 
data regarding services are for the year 1939, although the births, deaths 
and cases of diseases reported in the County have been analyzed for several 
years in order to determine general trends. 
An effort has been made to ascertain outstanding characteristics 
and circumstances which bear upon the health of the population, to deter- 
mine the status of health conditions in the population, and to obtain a 
reasonably accurate picture of health services performed in the County as 
evidenced by selected typical activities. The chief purpose of the study 
has been to make an inventory of existing problems, resources and services 
as a basis for considering plans for future development during the next 
five years. 
We wish to express our appreciation of the valuable cooperation 
received from many individuals and organizations in the County and in the 
State and to express the hope that this survey and report may be helpful 
in future program planning. G-eneral Characteristics 
Worcester County, located on the Eastern Shore of Maryland, 
consists of four incorporated communities besides a large unincorporated 
area* The thirteenth to be formed in Maryland, the County was estab- 
lished as a governmental unit in 1742 and was named after the Earl of 
Worcester# It is bounded on the north by Sussex County, Delaware, on 
the east by the Atlantic Ocean, on the south by Accomac County, Virginia, 
and on the west by Somerset and Wicomico Counties* The surface of the 
county is flat, has an area of 491,5 square miles, and nearly all lies 
within 40 feet of sea level# 
Aside from the Pocomoke River, which crosses the western half 
of the county and forms part of its western boundary, the surface streams 
are few in number and small in*size# The Pocomoke is sluggish, full of 
suspended and vegetable matter and partially tidal, and furnishes neither 
water power nor potable waters# Most of the smaller streams in the county 
are tidal estuaries and likewise unsuitable for domestic use# 
The mean annual temperature at Snow Hill, the county town, is 
58°F., and the annual precipitation is about 36 inches. 
Worcester County is served by the Delmarva Division of the 
Pennsylvania Railroad, and is crossed from north to south by Federal 
Highway No, 13, There are no commercial airlines operating in the 
district, Financial Factors: Affairs of the county are administered by a Board of 
County Commissioners of three members who also serve 
as the Board of Health. In 1939, the per capita tax valuation was approx- 
imately $1016. The tax levy in that year amounted to $1.25 on each one 
hundred dollars of property subject to taxation for county purposes, and 
to $.2335 on each one hundred dollars of property subject to taxation for 
State purposes, making a total of $1.4835, On the basis of income derived 
from taxes, appropriations amounted to $315,829 of which $5950 or 1,9 per- 
cent were appropriated for the health department. The approproation for 
the health department was approximately one-half of the amount appro- 
priated for the care of the physically and mentally ill patients in the 
county. As another index of economic status,* it is noted that on the 
first of January, 1940, a little over one-quarter of the households were 
equipped with telephones, there being 1957 telephones in the county* 
Professional Services. There are no hospitals in the county, patients 
needing hospital care being taken usually to 
Salisbury or to Baltimore, There are 13 resident physicians, 7 dentists, 
and one nurse registered or licensed:-to practice in the county. Several 
physicians in adjoining counties or state practice in the county. There 
are perhaps half a dozen practical nurses with either no or little train- 
* Some 450 families receive Old Age Assistance averaging $15 per month, 
while 118 families receive Aid for Dependent Children for 279 children; 
or about 3,7 percent of the children under 16 receive some form of re- 
lief aid. Eleven persons receive Aid for the Blind. ing in nursing. There seems to be a serious problem related to the pro- 
vision promptly of medical and hospital services for needy cases, es- 
pecially for colored persons. 
The People 
The population of the county in 1930 was 21,624, of whom 31 per 
cent were colored. The population, showing only a slight increase during 
the past four decades, is largely native-born as shown by the following: 
Native-born white 68.4 percent; foreign-born white 0.6 percent, and Negro 
31.0 percent. The age distribution in comparison with that for Maryland 
and for the United States as a whole was as follows in 1930 - 
Percentage Age Distribution, 
1930 
Age Group 
Worcester County 
Maryland 
U.S.Total 
U.S.Rural 
Under 1 
year 
1.7 
1.6 
1.8 
2.1 
Under 5 
years 
9.1 
8.9 
9.3 
10.8 
5 - 
9 
10.9 
10.0 
10.3 
11.9 
10 - 
14 
11.0 
9.4 
9.8 
11.2 
15 - 
24 
17.5 
17.8 
18.3 
18.6 
25 - 
34 
12.5 
15.7 
15.4 
13.0 
35 - 
44 
12 .2 
14.2 
14.0 
12.1 
45 - 
64 
18.9 
18.1 
17*4. 
16.6 
65 and over 
7.9 
5.9 
5.5 
5.8 
Total 
100.0 
100.0 
100.0 
100*0 
Source: 
U.S. Bureau of the Census; Population 
, Vol.III, 1930 Census 
From the above data it is seen that the county, for several 
disease conditions, has a less favorable age distribution than the state 
with a slightly larger proportion than the state under 15 years of age 
and a much larger proportion than the state and the United States over 
45 years of age. The large proportion of Negro population is likely to 5 
be associated with pupils health problems of special importance to be 
discussed later. 
The occupational status of the population in 1930, which was 
fairly comparable with that at present, is shown in the following tabula- 
tion adapted from Volume III of the 1930 Census - 
Percentage Distribution of Gainfully Occupied Persons 
Industries 
Male 
Female 
Agriculture 
52.3 
12.3 
Forestry and fishing 
4.8 
0.1 
Extraction of minerals 
0.01 
0.0 
Manufacturing and mechanical 
16 .4 
15.3 
Transportation and communication 
7.4 
2.7 
Trade 
10..2 
10.4 
Public Service 
1.1 
0.6 
Professional Service 
2.3 
15.9 
Domestic .and personal 
2 .3 
41.8 
Not specified 
3.2 
0.9 
Total 
100.0 
L 
100.0 
From the above tabulation, it is noted that this is largely an agrr 
cultural area,* thus confirming the impression which one obtains from driving 
over the county and observing many apparently prosperous farms and attractive 
homes* 
Public Health Administration 
Public health work in Worcester County is carried on largely by the 
County Health Department, The health officer is appointed on a full-time 
basis by the County Commissioners with the approval of the State Board of 
Health. The county is fortunate in having as health officer a physician 
who is also a graduate in public health and otherwise ably equipped to serve 
10,213 persons live on 2103 farms; about two-thirds of the farms ere oper- 
ated by their owners. There are some 88,000 acres in cultivation, 104,000 
in pasture and woods. Thirty-five farmers have herds of cattle. in this important position. The staff consists of 4 clinic or conference 
physicians, part-time, a part-time dentist, 4 public health nurses, a 
sanitary inspector, one clerk, full-time, and one clerk, part-time. 
The budget of the health department in 1939 was about one dollar and a 
quarter per capita, representing an increase of 17 cents per capita 
over the previous year. 
The State Board of Health, through several staff members, 
renders advisory and educational services and provides considerable 
financial aid (84 percent in 1938; 80 percent in 1939) from state and 
federal funds, the latter being derived from the U.S, Public Health 
Service and the U.S, Children’s Bureau, The Maryland Tuberculosis 
Association and The Maryland Society for Mental Hygiene are the prin- 
ciple state voluntary agencies rendering services in the county, A 
County Public Health Association and a County Tuberculosis Association 
affiliated with the Maryland Tuberculosis Association have recently 
been organized. The County Chapter of the American Rod Cross devotes 
its activities largely to first aid instruction and relief, with 
classes conducted a year ago in home hygiene and care of the sick. 
There are several Parent-Teacher Associations interested in the public 
health program, besides a Home Demonstration Agent, Approximate Expenditures for Worcester County, Fiscal Year 1938, 1939 
1938 
1939 
Source of Funds, 
;939 
Local 
State 
Federal 
Voluntary 
Salaries 
$12,536 
$15,136 
$3650 
$4684 
$6622 
$180 
Travel and Trans- 
portation 
3,006 
3,273 
800 
1815 
658 
- 
Office & Clinic 
2,016 
1,963 
484 
1479 
- 
Clinic supplies 
and equipment 
1,253 
975 
— 
975 
- 
- 
Vaccine, Toxoid 
and Sera 
373 
271 
- 
271 
- 
- 
Dental Clinics 
775 
725 
650 
75 
- 
- 
Tuberculosis Con- 
trol 
191 
600 
- 
- 
- 
600 
Crippled Children 
Hospitalization 
Other 
2,844 
168 
3,803 
116 
- 
- 
3803 
116 
- 
Miscellaneous 
120 
241 
- 
241 
- 
- 
Registration of 
Vital Statistics 
240 
239 
239 
- 
- 
- 
Total 
$23,522 
$27,342 
$5823* 
$9540 
$1U99 
$780 
1939 
Percentage 1938 
- 
- 
21.3 
14.4 
34.9 
40.9 
40.9 
43.6 
2.9 
1.1 
Per Capita 
$1.09 
$1.26 
- 
- 
- 
* Increase of $2423 over previous year. Vital Statistics 
During the year 1939, there were 413 live births, 18 stillbirths, 
and 315 deaths from all causes reported for Worcester County, A comparison 
of selected rates for the County and the State for the year is of interest 
Birth and Death Rates from Selected Causes, 1939 
Birth Rate* 
Stillbirth Rate** 
General Death Rate* 
Infant Mortality Rate** 
Tuberculosis Death Rate*** 
Typhoid Death Rate*** 
Worcester County 
Maryland (Provisional) 
White 
Colored 
Total 
White 
Colored 
Total 
16,2 
24.9 
12.8 
74.7 
73.8 
0 
25.6 
69.8 
18,5 
157.0 
134.1 
29.8 
19,1 
43.6 
14.6 
108,9 
92.5 
9.2 
14.9 
39.5 
10.9 
40.5 
44.4 
0.6 
20,1 
74.2 
15.1 
84.1 
207,1 
2.9 
15.8 
47.0 
11.6 
50.0 
72.2 
1.0 
Per 1,000 population, 
** Per 1,000 live births, 
*** Per 100,000 population. 
From the above data, chosen as indices, it appears that birth 
rates and death rates from several important causes in the county are much 
higher than the average for the state, for both white and colored persons. 
Particularly striking are the infant mortality and tuberculosis death 
rates. 
The mortality experience for selected causes for the year 1939 
is compared with a five year average, and the rates ore give® for the five- 
year period in the following table - Total Deaths 
from Selected Causes 
Period 
1935-1939 
Cause 
Year 
1939 
Annual 
Total 
Rate* 
Average 
Typhoid and Paratyphoid 
2 
2.4 
12 
11.1 
Scarlet Fever 
0 
0.6 
3 
2.8 
Whooping cough 
0 
1.8 
14 
8.3 
Diphtheria 
0 
0.2 
1 
0.9 
Influenza 
7 
5.4 
27 
25,0 
Tuberculosis 
20 
27.8 
139 
128.6 
Syphilis 
1 
3.8 
19 
17.6 
Cancer 
25 
22.8 
119 
105.4 
Heart Disease 
61 
52.6 
265 
243.2 
Pneumonia 
15 
27.6 
138 
127.6 
Diarrhea and enteritis 
10 
10.4 
52 
48.1 
Puerperal causes 
1 
4,0 
20 
10.5** 
Automobile Accidents 
4 
8.4 
42 
38.8 
* Per 100,000 population. 
** Per 1,000 live births. 
In contrast with the high rates from certain important causes, 
emphasis should be given to the fact that there have been no cases nor 
deaths in the county from smallpox in many years, and only one death from 
diphtheria (1938) in the past five years. Active measures of vaccination 
and immunization have been taken to protect the public from these unneces- 
sary diseases, and the results have been commendable. 
The registration and analysis of records of births and deaths by 
the County Health Officer and the Bureau of Vital Statistics of the State 
Board of Health conform in general to modern practices. Pressure of many 
duties prevents the health officer and his staff from carrying out routinely 
certain of the tabulations and graphic presentations of data vtfiich would 
prove helpful currently in analyzing the local problems for administnative 
purposes. Environmental Sanitation 
Health departments have a primary responsibility in carrying out 
one of the principal functions of government - the provisions of a safe and 
healthy environment. Many communicable diseases may be largely controlled 
by applying proper technics to eliminate environmental hazards. For example, 
the control of typhoid fever, the dysenteries, malaria, septic sore throat, 
undulant fever, and trichinosis is largely a problem in environmental sani- 
tation, Other diseases also may be prevented in part at least by the wide 
application of sanitary measures. 
One of the most sensitive indices of the health status of a com- 
munity is its infant mortality rate, When diarrhea and enteritis is a fre- 
quent cause of death, it is almost axiomatic that serious environmental 
hazards exist. 
Typhoid fever and bacillary dysentery also occur most frequently 
in communities which have difficult environmental problems. The elim- 
ination of typhoid fever has in large measure been accomplished in those 
districts where there is adequate control over water, food and milk supplies 
coupled with systematic measures for the discovery and supervision of 
carriers. 
Control of the environment is difficult to obtain in a rural area 
where the population is widely scattered, Hov/ever, it is possible to 
achieve a considerable measure of success if a sufficient staff of trained 
workers is provided and if all available facilities are properly utilized 
for the benefit of the entire community. CASES REPORTED OF 
TYPHOID FEVER- 
PER 100,000 POPULATION 
WORCESTER COUNTY 
AND 
STATE OF MARYLAND, 
1919 1° 19S9 Inclusive. 
. - . o -'Y>*r 
KEY 
WORCESTER COUNTY 
STATE OF MARYLAND 
1£4 0 In Worcester County there are several indices which point to a 
need for more emphasis on the sanitation program. The relatively high 
typhoid fever mortality rate (11*1 per 100,000 population compared with a 
state rate of 1.8) for the five-year period ending in 1939, and the high 
diarrhea and enteritis death rate for the same period both indicate a need 
for careful analysis of the sanitation problems in the county* In an ap- 
praisal of this type, it is impossible to discover the exact reasons for 
such unfavorable rates as have long been experienced local ly, but careful 
epidemiological study of all cases of enteric disease should reveal much 
of interest for local control officials. 
On the basis of the American Public Health Association Appraisal 
Form, Worcester County scores 45$ for general sanitation activities in- 
cluding water supply and wastes disposal, and 51$ for food and milk sani- 
tation, With slight revision of the sanitarian’s program and after mak- 
ing a few relatively inexpensive capital improvements, these scores could 
be raised to 78$ and 7S$ respectively. 
For this county, the problems of sanitation may be advantageously 
divided into four large groups: (1) water supply and waste disposal; 
(2) domestic, school, and recreational sanitation; (3) food, milk, and 
shellfish sanitation; and (4) industrial hygiene. That there must be 
considerable overlapping from one group to another is obvious, but for 
purposes of discussion these arbitrary separations will suffice. 11 
Water Supply, There are four public water supplies in the county serving 
87$ of the urban residents living in Berlin,..,Ocean City, 
Pocomoke City and Snow Hill. All of the supplies are derived from ground- 
water sources. The only supply that is chlorinated is that serving Poco- 
moke City. 
Most sanitary engineers and health officers believe that every 
public water supply should be properly protected against contamination by 
the use of chlorination. There are two advantages to the chlorine-treatment 
of water: (1} any pollution that may exist at the source is rendered 
harmless; and (2) there is a safety factor present in the distribution 
system in case back-siphonage through a faulty plumbing fixture should 
cause contamination. There are in reality no serious disadvantages or 
objections to the use of chlorine for treating public water supplies. 
It is also widely believed that no home in a community served 
by a public water supply should be permitted to use water coming from a 
private source. Wherever possible, there should be full utilization of the 
public supply by all residents of the district. 
It is therefore suggested: (1) that the Mayor and Council of 
Berlin, Ocean City and Snow Hill, respectively, give early consideration 
to the need for chlorinating the public water supplies of each of these 
towns; and (2) that it be required that as soon as practical all residences 
in communities having public water supplies be required to abandon private 
supplies and use only water from the urban supply* 
One of the most serious defects from the standpoint of water supply 
in Worcester County is the large number of pitcher pumps \iilch are used by residents throughout the entire county. Although the pitcher pump may be 
convenient for the person who uses it, sanitarians recognize the potential 
hazard of its being primed with polluted water resulting in the contamina- 
tion of the entire supply. 
Whenever new domestic wells are developed in the future, it is 
suggested that a modern type of pump be installed. There are many such 
pumps on the market which cost but little more than the pitcher pumps. 
Sewage Disposal* All of the towns in Worcester County are sewered, and 
there are treatment plants at Berlin and Ocean City* 
The needs for urban sewage are reasonably well met, but there are rela- 
tively serious defects in the ultimate disposal of the sewage from all 
communities except Berlin* 
At Pocomoke City one of the sanitary sewers has its outfall in a 
creek which empties into the Potomac River at a point near the center of 
town and upstreams from it; most of the outfalls empty directly into the 
Pocomoke River. Septic conditions prevail at the sewer outlets, and there 
is abundant evidence that a treatment plant is needed. Many disease 
hazards exist where raw sewage discharges into a brook, river or harbor 
in addition to other nuisances created* 
At Snow Hill, the sewer outfall is located where it, also, is 
a nuisance. The available dilution water is relatively inadequate, and 
indications are that treatment should be provided at an early date. 
The Ocean City sewage treatment plant is designed to comminute 
solids and chlorinate the effluent which ultimately reaches "The Inlet" 
on the South side of the town. Unfortunately,. the chloiinator works only when the sewage pumps are operating with the result that the chloii ne de- 
tention period is relatively brief (5 or 6 minutes). This means that there 
probably is no sterilization of the effluent. 
The Berlin sewage treatment plant lacks toilet and lavatory 
facilities; the need for handwashing equipment at a sewage works is obvious. 
The Resident Engineer at Salisbury, representing tho State Department of 
Health, has already brought this defect to the attention of local officials, 
and it should be corrected as soon as possible. 
Despite the nearly universal use of privies for sewage disposal 
in the smaller communities and rural areas of the County, some places utilize 
cesspools or septic tanks. The design and construction of satisfactory 
water-carried sewage disposal units is a technical job, and the require- 
ments in certain sections of the county are particularly exacting. The 
State Sanitary Engineer is required by law to approve tho plans for new 
installations of sewage disposal units for camps and other public places. 
Inasmuch as the more difficult problems are often associated vdth tourist 
places, it is suggested that the County Hoalth Department require that 
builders submit plans to the state office for approval before construction 
bogins. 
Some years ago a successful privy program was conducted in Wor- 
cester County, Thors is again a real need for a community sanitation pro- 
gram in the county. Although W.P,A, labor is not now available to resume 
operations on the community sanitation project, it may be possible to 
re-open the project when labor is to be had once more, and a representative 
of the United States Public Health Service has been detailed to Maryland to assist in developing local programs. A successful privy-building 
campaign might well pay dividends by lowering the infant mortality rate, 
and reducing the number of typhoid cases. 
The disposal of sewage under a scavenger system at Taylor’s 
Landing and George’s Island Landing seems to be the most logical method 
of handling those local problems. The health department might designate 
sites for the disposal of the excreta .collected by the scavenger. 
In general, the sewage disposal problem resolves itself into 
three stages: (1) that pertaining to urban sewerage and sewage disposal; 
(2) the problem of rural disposal units; and (3) the few special problems 
such as exist in connection with the shellfish industry. The State De- 
partment of Health is best equipped to direct the first phase, and can 
furnish important assistance to the local unit in carrying out the de- 
tails of the second and third phases* 
Refuse Disposal, Refuse consists of garbage, rubbish and ashes, and is 
frequently offensive. The disposal of refuse is a prob- 
lem in municipal housekeeping which can most frequently be solved by the 
department of public works or by the town engineer. The disposal problem 
is frequently most acute in small incorporated communities which have plenty 
of available space for disposal* The reasons for this include: (1) high 
unit cost of handling relatively small amountsof refuse; (2) lack of ad- 
ministrative (or service) departments in the local government; and (3) reluc- 
tance of local officials to invade a new field. 
There are tw plans for providing adequate refuse collection 
services in small communities: (1) directly by the town; or (2) privately under contract with the town. In many respects the second alternative is 
preferable in that it frequently costs the community less money. Suitable 
provisions for equipment and mode of handling should be set up in the con- 
tract, and the collector should be required to adhere closely to these 
requirements. Trucks with non-leaking bodies are essential for. carting 
garbage, 
Insofar as the ultimate disposal of refuse from towns is con- 
cerned, probably dumping of rubbish and ashes, and hog-feeding of garbage 
provide the cheapest available methods, While incineration may bo more 
sanitary if a proper incinerator with adequate personnel is provided, the 
process is likely to be much more expensive. Dumps should be located where 
they will not bo nuisances, and they must be properly maintained. This 
usually means that they should be well away from nearby homes, on land that 
is not likely to be us -d for building purposes* Often land-fill can be 
used for eliminating mosquito-breeding places. Hog farms should be well 
drained; the garbage should be cooked before being fed; concrete feeding 
platforms should be provided; hogs should be vaccinated against hog 
cholera; and there should be sufficient piped water available for washing 
down all buildings associated with the process. 
The Worcester County Health Department has advised local officials 
from time to time concerning the collection and disposal of refuse despite 
the fact that the problem has few health implications. The advice which 
has been given has been sound, and, if followed, the problem would almost 
inevitably ?/ork itself out without further nuisance. For reference, the note prepared by the County Health Officer and addressed to the Mayor of 
Ocean City on January 11, 1939, covers the essential points in a satisfac- 
tory program for any town in Worcester County* 
General Sanitation, The sanitarian must always balance costs against re- 
sults to be obtained. This is obviously good business, 
requiring careful planning, and involving consideration of all environmental 
problems in the community. There are numerous problems of general sanita- 
tion which could be worked out were the necessary funds available. For 
instance, inadequate water supply and sewage disposal facilities for houses 
within areas serviced by public water supplies and sewers are quite 
untenable, but must exist in many instances because the costs of providing 
satisfactory facilities are in excess of the value of the property involved. 
Such a situation, however, may indicate the need of a housing program. 
Residential Sanitation* In Worcester County there are problems of resi- 
dential and school sanitation which require care- 
ful consideration. One of the more important problems in home sanitation 
has already been pointed out - the need for a privy sanitation program. 
Many homes in Pocoiroke City, as well as in the smaller communities of the 
area, are badly in need of decent sanitary facilities. Primarily it is a 
need for sewage disposal units, but the extensive use of pitcher pumps is 
fraught with considerable danger to the health of families throughout the 
county. There is also a problem related to the lack of water supplies -of 
any kind for many homos except from a "community" pump. During 1939 the County Health Department made 172 inspections of 
private premises in the County,* This represents about 3.4 visits per 
week spent on residential sanitation. It is questionable whether enough 
time is spent on this phase of the work when the magnitude of the problem 
is considered. At least one-third of the time of the sanitarian should be 
spent on sanitary problems until some of the more serious conditions are 
impro ved. 
School Sanitation, The Worcester County Health Department has not taken 
an active interest in school sanitation heretofore, 
although nearly every school was provided with sanitary privies during the 
last community sanitation program. Present plans include a thorough in- 
spection of every school in the county to be made during the Autumn of 1940, 
and routine supervision of all buildings thereafter* It would be desirable 
to have water samples taken annually at all schools not served by public 
supplies. Pitcher pump installations at schools should be replaced by 
more satisfactory equipment* 
The abandonment of many one-room schools and the construction of 
modern, well-equipped consolidated schools throughout the county has been 
of benefit from the sanitary standpoint. Extension of this program would 
eliminate many of the kss satisfactory buildings, and result in giving 
every Worcester County school child the opportunity of practicing health 
teachings during school hours. 
* In addition, 87 nuisance and garbage complaints were investigated. Camp Sanitation. There are numerous camp sites in the county, and 
regular inspections of these places are made by the 
sanitary inspector. During 1939, he visited 9 camp sites 48 times for 
various purposes. 
All camps are licensed to operate, by the State Department of 
Health, only after they have been inspected and approved by the county san- 
itary officer. This is a sound policy which should be continued. 
It will be helpful locally if the sanitarian requires 
contractors to submit their plans for camp sewage disposal systems to the 
Bureau of Sanitary Engineering of the State Health Department for approval 
before construction begins. This policy, if followed routinely, would 
in large measure avoid creating such difficulties (e.g. drainage problems) 
as have arisen in the lowlands north of Ocean City, 
Nuisances and Complaints. It has frequently been found useful to maintain 
spot-maps in health department offices to record 
the location of complaints and of special public health problems. The 
sanitarian, by appropriate use of this device, may often save considerable 
time and effort by making routine inspections and eliminating the onuses 
of complaints before the nuisance becomes serious. 
Food Sanitation 
Although health departments everywhere feel a responsibility in 
supervising the food industry, the problems are so diverse and so highly 
technical that most organizations for various reasons have been unable to devise a soundly conceived plan of food sanitation. Obviously routine in- 
spections of food establishments, although helpful, cannot insure the safe- 
ty of products coming from these places. Too many people and too many opera- 
tions are involved in the food industry to allow of such a simple solution 
as would obtain under mere routine inspection. 
Possibly the most important thing that the average health depart- 
ment can do at the present time in this field is to secure the application 
of the principles of satisfactory food handling wherever possible. This 
has been accomplished reasonably well in some areas thruugh training pro- 
grams for food handlers conducted by health departments* 
In Worcester County, agriculture and the canning industry play 
important roles in the economic life of the community. There are health 
problems of considerable magnitude associated with each, and the County 
Health Department has the responsibility of providing supervision over those 
aspects which affect the welfare of the consumer. 
One of the important health aspects of food-harvesting relates 
to sewage disposal for the itinerant laborers employed in the fields during 
the various seasons* Provision for the disposal of body wastes from all 
field-workers is essential. Either permanent or portable privies should 
be provided at convenient locations in those areas where large numbers of 
workers are employed. 
The inspection of tho 17 canneries, formerly carried out by the 
State Department of Health which licenses these places, is. a duty of the 
local sanitary officer. The shellfish industry, which presents many interesting public 
health problems, is discussed at length elsewhere in this report*. 
Eating Establishments* A program of licensing for eating establishments 
throughout the county is needed* A satisfactory 
start has been made at Ocean City, but further legislation must be enacted 
before a county-wide plan can operate. 
The interest shown by the local health department in eating and 
drinking utensil sanitization is commendable, although in some of the com- 
munities the major need is for additional emphasis on the basic sanitation 
of eating places* For instance, primitive means for sewage disposal were 
observed in one or two places in Pocomoke City, and the indications are 
that similar conditions exist elsewhere in the county* 
There are state laws covering the cleansing of food containers 
so that unsatisfactory conditions need not necessarily exist in any com- 
munity** A system of routine inspections of all eating establishments 
with emphasis on the proper storing and handling of food, the provision 
of adequate toilet and lavatory facilities, and the cleanliness of equip- 
ment, should prove to be of considerable value in Worcester County* 
There were 410 inspections of 74 eating establishments in the 
county during 1939* There arc many more eating places which are not sub- 
ject to inspection although they should be included in the list* 
* Adopted July 15, 1938. Shellfish Sanitation 
In recent years the United States Public Health Service in 
cooperation with the Food and Drug Administration has supervised the 
shellfish industry insofar as interstate commerce in--oysters is concerned. 
The work done by the Service has consisted essentially of setting standards 
and accepting certification by State health departments -of shellfish 
shippers from the various states. For instance, the Service has set cer- 
tain standards of purity for waters from which oysters may be taken for 
shipment in interstate commerce. Local health officials are required 
to certify shippers on the basis of these standards. There are spot 
checks made by engineers from the U. S. Public Health Service from time 
to time, and standards are constantly being raised* 
Because of the inherent dangers existing in untreated raw oysters, 
sanitarians have searched for a method of controlling this hazard, A few 
years ago a scheme for purifying oysters was tried on a laboratory scale, 
and the experiment was so successful that large-scale conditioning plants 
using chlorine have been built in England, and in certain American states. 
In nearly every instance, the plants have been constructed in order to 
purify shellfish coming from heavily polluted waters. The success of this 
purification scheme has been demonstrated both here and abroad; few com- 
plaints have been registered once the plants have been put in operation; 
and veteran oystermen realize the advertising value of this protective 
measure. Worcester County Shellfish. There are approximately 22,000 barrels of 
oysters shipped from Stockton and Girdletree 
annually, and an additional 4,500 bags of clams are sent out each year. 
These shipments represent a large industry, and Sinepuxent Bay Oysters 
are known throughout the East. 
The shellfish harvested at Stockton and Girdletree are taken from 
clean waters, covering muddy bottoms, are allowed to stand on floats until 
the shells are clean, and then are packed ready for shipment. There are a 
few opportunities for contamination of these shellfish, and these hazards 
should not be minimized. 
Among the dangers are: (1) boating over or adjacent to the beds; 
(2) contamination from land surface wash onto the floats; and (3) handlers 
who suffer from or are carriers of enteric disease. Each of these hazards 
potentially exists, and none can be eliminated completely. This is true of 
the oyster industry everywhere, and is not specific for Worcester County. 
Similar hazards exist in the milk industry, and pasteurization 
has been used to obviate the dangers. Chlorination of oysters is similar 
to pasteurization of milk: it renders the product safe without altering 
its essential characteristics. 
The Public Health Service has tried informally to interest the 
local oystermen enough to agree to the construction of a conditioning plant 
somewhere in the county, but there has been some hesitancy on the part of 
the shellfish producers to accept such a new procedure without further 
study of the effect of conditioning on shell oysters. The Maryland State 
Department of Health has also advocated a conditioning plant to be built 
somewhere on the shores of Sinepuxent Bay, Both of these agencies are familiar with the board aspects of 
the shellfish sanitation problem, and their advice should be carefully 
considered. Inasmuch as a definite problem exists in Worcester County, it 
would seem desirable for the County Commissioners to cooperate with the State 
Department of Health and the oystermen in building a treatment plant for 
washing all oysters sold in interstate commerce. Obviously a central plant, 
well located, would be more economical to build and operate than a series of 
smaller installations. The costs of treatment per barrel of oysters are 
modest, and should not prove to be a burden on the industry. An oyster- 
borne epidemic traceable to local products would be infinitely more costly. 
Supervision* Up until the pa'csent, one of the real difficulties of the 
shellfish sanitation program locally has been the apparent 
duplication of services reaching the various oystermen. For instance, the 
local health department has been interested in the health of handlers and 
has been instrumental in arranging for scavenger services at the water- 
front establishments, Tho Bureau f Sanitary Engineering in the State 
Department of Health has been studying tho waters of Sinopuxont Bay, has 
discussed a conditioning plant, and has worked with the Public Health 
Service in connection with the local industry. The Food and Drug Division 
is interested in the quality of the product, and inspects packing plants 
as well as the shucking house at Stockton, Finally, the U.S. Public Health 
Service representatives make periodic inspections Titiich apparently seldom 
meet with the favor of the local oystermen. 
It is questionable whether the Worcester County Health Department 
should have any routine contact with the industry, and, because of lack 
of trained personnel for this type of work locally, it is suggested that the county health unit act only on special occasions as the direct repre- 
sentative of the State Department of Health** 
Milk Sanitation 
Milk as one of the most favored foods found in Nature, is poten- 
tially one of the most dangerous to the public health. Containing, as it 
does, most of the dietary essentials of mankind, it is also an excellent 
medium for the growth of disease-producing bacteria. Hence, it must be 
handled carefully efter being taken from disease-free cows* 
Pasteurization has been developed to assist in making milk a safe 
food to consume* It is not a panacea for the production of dirty milk, nor 
is it alone a guarantee against infection, but it is a potent weapon to be 
used against the milk borne diseases. Coupled with careful handling, pasteur- 
ization results in a product which is safe for human consumption. None of 
the important food values of raw milk is destroyed by pasteurization, nor 
is the taste or appearance of the product altered if the method is correctly 
applied* 
Milk sanitation programs include at least three essential stages: 
(1) inspection of dairy farms including examinations of animals and of milk 
handlers; (2) inspection of pasteurizing and bottling plants; and (3) laboratory 
examination of raw and market milk, and milk products. No satisfactory program 
of milk control can be arranged unless all of these phases are taken into 
consideration* One of the administra- 
* This report would be incomplete without reference to the chronic typhoid 
carrier who periodically works at Stockton. If he refuses to stay away from 
the industry he might well be institutionalized. Ho is an excellent reason 
why the present practice of floating should be abandoned in favor of a 
treatment plant* tive problems is to plan a milk sanitation program in which the proper amount 
of emphasis is given to each aspect* 
Worcester County Milk. There were at least 32 dairy farms producing milk 
for sale in Worcester County during 1939, This 
group does not include many one- and two-cow dairies operating throughout 
the county, and over which the health department exercises little control. 
All but three of the farms under supervision were visited at 
least once during the year, and each of 18 farms were inspected at least ten 
times. It is questionable, especially in view of other pressing inspection 
problems, if there need be more than semi-annual routine inspections of farms 
producing milk for pasteurization, yet there were 99 inspections of 10 farms 
selling their milk to i)asteurizing plants during 1939• 
There were, in addition, 155 inspections of 22 retail raw milk 
establishments, or an average of seven visits per farm* However, 10 of these 
22 farms had 115 inspections or an average of 11,5 visits per farm,while the 
remaining 12 farms averaged less than 2 visits for the year. It is believed 
to be good practice to make an average of 6 visits per year to each raw milk 
producing farm.on a milkshed* 
There were 22 inspections made of the two pasteurizing plants in 
the County, although modern practice calls for weekly inspections of these 
establishments* 
The local sanitarian regularly takes milk samples to the branch 
laboratory at Salisbury, and duplicate reports are distributed to the var- 
ious dealers by the inspector. It would save time and effort if these were 
mailed out from Pocomoke City, Only those reports which indicate serious 
problems need necessarily be followed up immediately by a special visit of 
this nature. During 1939 there were 33 samples of pasteurized milk, 150 of 
raw milk previous to pasteurization, and 211 samples of retail raw milk 
examined in the Salisbury laboratory. Indications are that the pasteurized 
milk in Worcester County is of uniformly satisfactory quality* On the other 
hand, but 75$ of the samples of raw milk met the bacterial standards usually 
set by health officials for retail raw milk. Apparently the majority of the 
unsatisfactory samples were taken during the summer, and a frequent source 
of trouble on some farms was a lack of adequate cooling facilities* 
The Raw Milk Problem* Although approximately 100$ of the milk going into 
Ocean City is pasteurized, there is too much raw 
milk being consumed in Worcester County for the dafety of the population from 
unnecessary diseases which might be spread* Only 50$ of the milk sold in 
Pocomoke City is pasteurized, and less than 5$ of that sold in Berlin and 
Snow Hill has been so treated. Throughout the rest of the county, only raw 
market milk is available* 
The hazards of raw milk are widely known: septic sore throat, diph 
theria, scarlet fever, typhoid, and undulant fever are diseases spread by raw 
milk or milk products* There is much preventable illness, some fatal, each 
year in this country due to the continued use of a potentially dangerous 
foodstuff that could be made safe. 
Because of the facts cited above, it is suggested that the help of 
all community organizations be enlisted in stressing the importance of pas- 
teurized milk in order that dealers will be stimulated to invest in pasteur- 
izing equipment and that consumers will desire increasinly to purchase only past eurized milk, so that the health of the citizens of Worcester County- 
may be better protected* What is needed more than anything else is a wider 
understanding by the public of the dangers of raw milk and the advantages 
of pasteurized products. 
The Health Department*3 Milk Program. Considerable emphasis apparently is 
placed on routine inspection of farms 
by the sanitarian. This is essentially non-technical work, and relatively 
ineffective insofar as the quality of the product is concerned. While 
routine inspections are necessary, advantage should be taken of the fact 
that the present county sanitarian has had technical training in dairying. 
It is suggested, therefore, that, with the cooperation of the Bureau of 
Laboratories of the State Department of Health, the local department insti- 
tute a program of field laboratory supervision of pasteurization by making 
direct microscopic examinations of producers’ samples collected at the two 
pasteurizing plants, and by making routine phosphatase tests on pasteurized 
milk. Such a plan would be in addition to the present routine sampling 
procedure which should be continued. 
The direct microscopic examination is a rapid test for indicating 
the quality of raw (or pasteurized) milk. The phosphatase test indicates 
whether or not milk has been properly pasteurized. 
It is suggested that these examinations by the sanitarian be used 
to guide his inspection procedure. Considerable time may be saved by doing 
no more than two inspections per year per farm producing milk for pasteuriza- 
tion unless the direct microscopic count indicates a need for special in- 
vestigation of a certain producer. The total time spent on the additional laboratory work by the sanitarian should be kept at a minimum, and any time 
saved through eliminating unnecessary Inspections can be used to advantage 
by increasing the number of visits to pasteurizing plants. 
Industrial Hygiene 
One of the newer fields of public health, and one which shows 
considerable promise is industrial hygiene. The control of accidents and 
diseases caused by exposure to occupational hazards has cone to be recog- 
nized as an outstanding responsibility of health departments. 
Obviously the problems of industrial hygiene are widely diversi- 
fied, and their solution depends on many factors. In urban areas, exposure 
to industrial dusts and poisons are of prime importance as causes of dis- 
ability, hut in rural communities the farm accident problem is predominant. 
In Worcester County there has been little industrial hygiene work 
done. Although the health department has many other problems to study, con- 
sideration should be given occasionally to the farm accident problem. At 
present there is no real basis for action, but a study of accident statistics 
from the county would reveal the extent of the problem and its local character- 
istics* Possibly an educational program in connection with the County Fair 
each year would be of benefit to the many agricultural workers in the area. 
Control of Diseases 
The program of the County Health Department, in addition to the 
work connected with vital statistics and environmental sanitation previously 
discussed, includes activities for the control of the acute communicable 
diseases, syphilis, gonorrhea, and tuberculosis, and the promotion of mater- 
nal and child health* Acute Communicable Diseases, In the performance of his official duties, 
the health officer acts under authorization of 
the health laws of the State, or the rules and regulations of the State Board 
of Health, In addition to the law requiring physicians to report all cases 
of occupational disease, the rules and regulations of the State Board of 
Health list 46 notifiable diseases. Provision is also made for communicable 
diseases not specifically enumerated to be controlled in accordance with orders 
and directions of the local health officer. 
Cases of major communicable diseases are visited by the health offi- 
cer for the purpose of confirming the diagnosis, of investigating the source 
of infection, and of instituting measures to prevent further spread of the 
disease. Epidemiological studies are made of cases of such diseases as typhoid 
fever, diphtheria,scarlet fever,poliomyelitis, and undulant fever. Cases 
of communicable diseases are required to be reported by physicians, teachers, 
neighbors and members of families* Placarding ia not done. Efforts are made 
to safeguard the public from spread of disease through the channels of water 
and milk supplies. 
The prevention of disease is regarded as of outstanding importance 
in the program of the health department* Through the State Department of Health 
the County Health Officer is kept informed in regard to the births, deaths, 
and causes of deaths and sickness throughout the State, He also must be in- 
formed at all times of conditions in the County if ha and his staff are to keep 
communicable diseases down to a minimum with the least possible interference 
with community activities. This is done through his relations with physicians, 
schools, householders, milk dealers, the press, and the members of the de- partmont, The reporting of communicable diseases has a twofold function: 
first, to acquaint the health department with the prevalence of the disease, 
and, second, to enable the department to take such steps in the control and 
study of the disease as are indicated. 
The number of cases of communicable diseases reported to the health 
department during the past five years is shown below - 
Number of Cases Beported, 1935-1939 
Disease 
1935 
1936 
1937 
1938 
1939 
Annual 
Average 
Typhoid & Paratyphoid 
20 
8 
10 
11 
10 
11.8 
Measles 
8 
151 
76 
23 
2 
52,0 
Scarlet fever 
19 
57 
46 
29 
54 
41.0 
Whooping cough 
2 
22 
2 
3 
9 
5.8 
Diphtheria 
4 
0 
0 
2 
1 
1.4 
Typhus Fever 
0 
1 
0 
0 
0 
0.2 
Poliomyelitis 
0 
0 
0 
1 
0 
0.2 
Meningitis 
0 
0 
1 
1 
4 
1*2 
Ophthalmia Neonatorum 
0 
0 
3 
2 
1 
1.2 
Pneumonia 
28 
45 
60 
65 
58 
51.2 
Streptococcic sore 
throat 
8 
1 
1 
0 
2 
2.4 
In Worcester County, the completeness of reporting of the more com- 
mon, and important, communicable diseases, such as typhoid, measles, scarlet 
fever and whooping cough, falls far short of accepted ratios based on gen- 
eral experience throughout the country. 
While there has beon only one death from diphtheria in the past 
five years, and there were no cases reported in 1936 and 1937, there were 
four cases reported in 1935, two in 1938 and one in 1939, With slightly 
less than a quarter of the preschool ago children protected from this unnec- 
cessary disease, the need for active educational measures to stimulate 
the parents to have their babies and young children immunized is 
indicated. Although 75 percent of the children in the first and Number, Of Diphtheria Deaths 
Worcester County 
1906tol939 Ind. second grades of school, and over 60 percent of all school pupils have been 
immuniz'ed or are not susceptible to the disease as shown by Schick tests, 
the age group where protective measures are most essential has only been 
partially reached. ’While parents should be encouraged to go to their own 
physicians for such protective measures so far as practicable, experience 
elsewhere indicates that most of this work must be done by the health'depart 
ment if a sufficiently large proportion of the children, to insure general 
safety of the public, is to be protected. During 1939, there were 264 child 
ren of 5 years of age or younger, besides 306 school pupils given toxoid, 
in addition to 760 pupils given Schick tests. 
Measures for the control of typhoid fever correspond in general 
with accepted practices. In 1940, a plan was developed whereby typhoid 
carriers, when discovered, are required to sign an agreement with the health 
department regarding their occupation and to abide by the instructions of 
the department regarding their personal There are 4 carriers on 
the register, one having been found in 1939. Typhoid vaccine is freely 
available, and 172 persons were given typhoid inoculations in 1939. This 
number is about half of the desirable quota in relation to the typhoid 
death rate. 
Worcester County has a commendable record of freedom from smallpox 
for many years. Fortunately, vaccination of school children is compulsory. 
The County is participating in the special state-wide pneumonia 
control program, and progress is apparently being made in securing early 
diagnosis and more prompt treatment of cases than heretofore. 
Laboratory service to assist physicians in the diagnosis of cases 
of communicable diseases and to facilitate the work of the health department 
* See footnote Page 24. is provided in a branch laboratory of the State Department of Health located 
at Salisbury, In 1939, there were 254 specimens examined for typhoid and 
paratyphoid fever, 50 for diphtheria (389 nose and throat cultures chiefly 
for streptococci), 44 for undulant fever, 33 for typhus fever, 7 for tularemia, 
beside 24 specimens for pneumonia typing* 
The public health nurses, working on a district basis, render 
valuable services in the educational and follow-up work associated with the 
control of communicable diseases* In 1939, there were 184 home visits made 
for this purpose besides 117 visits made in behalf of the families in which 
communicable disease was a problem* Nurses also carry a heavy responsibility 
in the supervision of cases of ophthalmia neonatorum, especially in view of 
the lack of accessible hospital facilities for caring for such cases. The 
nursing staff is inadequate to provide for routine home visits in behalf of 
cases of measles and whooping cough, although such services are desirable, 
especially for educational purposes and for emphasis regarding the proper care 
of cases and the prevention of serious after effects of these diseases* 
Three of the 10 cases of typhoid fever occurring in the County in 
1939 were hospitalized in Salisbury, These were the only known cases of 
communicable disease given, hospital care. 
A program of community health instruction in regard to communicable 
diseases is gradually being developed, A total of 47 lectures and talks on 
public health were given in 1939, Newspapers cooperate in publishing arti- 
cles dealing with this problem, and 10 or more such articles were published in local papers last year. In addition to information released locally, 
several articles from the State Department of Health were published* 
In summary it may be stated that practices for the control of 
communicable diseases in the county receive a rating on the Appraisal Form 
of the American Public Health Association of 60 percent. The chief losses 
are due to the incompleteness of reporting, to the lack of spot maps and 
chronological tabulations showing the current prevalence of diseases, to the 
low proportion of preschool children immunized against diphtheria, and to 
the lack of nursing follow-up service for cases of measles and whooping 
cough. Commendable progress is being made, however, in the development of 
facilities and services to meet most of these needs. This is only one of 
the several problems which indicate the need for an increase in trained 
public health nursing service. 
Syphilis and Gonorrhea* Reporting of cases of syphilis and gonorrhea has 
gradually improved during the past two years as 
shown by the following figures - 
Reported Cases 
of Syphilis and Gonorrhea 
1937 
1938 
1939 
Syphilis 
184 
282 
307 
Gonorrhea 
21 
32 
40 
These cases are reported by name and address to the local or the 
State Health Department* It is obvious that reports of cases of gonorrhea 
are still quite incomplete* Furthermore, it is also found that the propor- 
tion of the cases of syphilis reported in the early stages of the disease, 
although higgler than in most parts of the state, is much lower than is de- 
sirable* The principal activities for the prevention and control of syphilis 
and gonorrhea are the venereal disease clinics, with follow-up service, con- 
ducted jointly by the State and the County Health Department, the provision 
of free drugs for all patients including cases of private physicians, the 
treatment of indigent eases with drugs supplied free by the State Department 
of Health, the provision for blood tests and other examinations in the branch 
State Laboratory, and the provision of transportation for many cases receiv- 
ing treatment. Three evening clinics are held each week in the county, one 
in Pocomoke City, one in Snow Hill, and one in Berlin. During 1939, a clinic 
was also conducted in Stockton. In view of the serious problem of transpor- 
tation, a bus service has been provided for this purpose. Epidemiological 
investigations of cases and contacts are carried out. Lapsed clinic cases 
are reported to the health officer, who also assists the physicians employed 
on a part-time basis for clinic work, and cards are sent out requesting them 
to return for treatment. Cases who do not respond are visited by the nurse. 
In private practice, relatively few reports are made to the health depart- 
ment of potentially infectious cases who discontinue treatment. 
There were 208 clinic sessions held in 1939, with 385 cases accepted 
for treatment and 7892 visits made to all clinics. Of the 241 new cases of 
syphilis admitted, 4.5 percent were diagnosed as congenital, while 19.5 were 
in the primary or secondary stage of disease, the remaining 76 percent being 
classed as latent and tertiary cases. A study was made of 302 syphilis pa- 
tients who became inactive in the clinics during the calendar years 1938-39. 
Of this number, however, 74, or 25 percent, had attended for a reasonably 
desirable period of 40 weeks or longer. Of the remainder, 39, or 12 percent, 
were cases classed in the primary or secondary stages of the disease upon admission; twenty-five of these cases attended clinic for a period of less 
than 20 weeks. Follow-up service for delinquent cases is especially im- 
portant for early cases, and the health department is rendering active ser- 
vice in this regard* 
The following tabulation indicates the services rendered in 1939 - 
Treatment Services by Clinics, 1939 
Pocomoke City 
Stockton 
Snow Hill 
Berlin 
Total 
Number of old Cases Accepted 
Syphilis 
79 
47 
84 
149 
359 
Gonorrhea 
7 
1 
3 
10 
21 
Chancroid 
1 
0 
4 
0 
5 
New Cases Accepted 
Syphilis 
47 
42 
61 
91 
241 
Gonorrhea 
7 
1 
3 
10 
21 
Chancroid 
1 
0 
4 
0 
5 
Total Clinic Visits 
2206 
1378 
1629 
2579 
7892 
The number of treatments per case of syphilis during the year 
averaged 18, while the number of treatments per case of gonorrhea averaged 
nearly 4* 
Personnel and equipment are available for making darkfield examine' 
tions at the clinic and 29 such examinations were made in 1939. Facilities 
are also available for making spinal fluid examinations* 
When a patient moves out of the district, insofar as possible, a 
complete record of treatment provided to clinic cases is sent to the health 
officer in the area to which the patient goes in order that treatment may be 
satisfactorily continued* This is a highly desirable practice. 
Among 236 patients beginning treatment in 1939, there were 178 
familial contacts reported. Of these, 79 were located and examined and 50 
of the 55 found to be infected were placed under treatment. In addition, there were 133 extra-familial contacts reported during the year, of whom 75 
were examined; 62 were found to be infected and 58 of them were placed under 
treatment. This is a very important section of the work to facilitate con- 
trol measures as early and successfully as possible. 
In the Stats Laboratory, during 1959, there were 1749 blood tests 
made for diagnosis of syphilis, and 100 smears examined for gonorrhea. 
Community health instruction in regard to these diseases has only 
been partially developed. Three talks on this subject were given during the 
year with an attendance of 185, Five newspaper articles were printed local- 
ly, While many pamphlets dealing with syphilis and gonorrhea were distributed 
there may be an opportunity to extend this educational service in a timely 
manner. 
During three months in the first quarter of 1940, an epidemiologist 
from the State Department of Health spent a large portion of his time in the 
county and rendered valuable assistance in the further development of this 
program and in the analysis of results. 
In summary, it may be said that the county is fortunate in having 
a well developed program with three active clinics, while a large amount of 
follow-up service is provided. The rating of 63 out of a possible 100 points 
on the Appraisal Form for the services rendered in 1939 fails to indicate 
the large amount of constructive v/ork required for the development of the 
well organized program being provided in 1940, Special credit is also duo the 
health officer for the largo amount of time spent in the development of the 
effective clinic program, staffed by local physicians, health department 
nurses and clerks, in addition to his many other duties. Tuberculosis. Tuberculosis, in Worcester County, is a major cause of death, 
of incapacity, of family breakdown, and of social dependency. 
As a cause of death, this disease, on the average, during each of the past 
five years was exceeded only by heart disease, nephritis, and cerebral hemorr 
hage. Of new cases reported in 1939, numbering 45, tuberculosis was exceeded 
by scarlet fever (54), pneumonia (58), and syphilis (307), There were five 
cases of pulmonary tuberculosis and 2 of other forms reported after death* 
There are 77 known living cases of tuberculosis among Worcester County resi- 
dents on the active register maintained by the health department. Judging 
from experience elsewhere, however, it may be conservatively estimated that 
there are over 100 active cases and mors than 300 contacts of the disease in 
the county. In 1939 there wore 90 contacts of new cases reported to have 
been examined, or about two-thirds of the desirable number according to ex- 
perience over the country. On the basis of data obtained from studies of 
costs of this disease, it may be estimated that the cases of tuberculosis 
in the county will eventually cost someone over $400,000, 
There is systematic reporting to the health department of cases 
returned to the area from state or other sanatoria* Epidemiological investi- 
gations is made of reported cases; but many cases come to professional atten- 
tion or are reported late in the stage of the disease. 
One of the essential elements of a county tuberculosis program is 
the clinic service. Tuberculosis clinics are held in the forenoon once a 
month, usually on a rotation basis, in Pocomoke City, Snow Hill, and Berlin, 
by the Superintendent of the Maryland State Sanatorium, located at Pine Bluff, 
He is paid on a clinic fee basis by the Maryland Tuberculosis Association, 
This arrangement for clinic service seems practical, especially as a large pro 
portion of the white cases from the county arc cared for in this sanatorium. TUBERCULOSIS DEATH RATE 
1906+o 1939 Inc), 
Worcester County 
State oP Maryland 38- 
There were 205 cases registered at clinics in 1939 as having made 298 clinic 
visits. While the number of cases registered is reasonably satisfactory, the 
frequency of visits is low, perhaps due in part to the acute problem of trans- 
portation for clinic cases. X-ray examinations, one of the most important 
factors in case finding and early diagnosis, last year numbered 247. It is 
gratifying to note that a quarter of the clinic cases were classed in the 
minimal stage of disease when diagnosed. The number of cases of tuberculosis 
among the colored population is very high in relation to the proportion of 
colored in the total population. Hence it is important to provide adequate 
nursing, clinic, and institutional facilities, coupled with vigorous case 
finding measures, for this group in the county. 
A study of 38 recently diagnosed cases of active tuberculosis carried 
by the health department shows that 37 were visited within one month of the 
date of report, while the other patient was visited within two months. This 
is a good record of service. Physicians do not always wish the health depart- 
ment to visit a case, and it has been the practice to leave responsibility 
for educational work and other necessary provisions in such cases to the at- 
tending physician. 
In 1939, the nurses registered 104 cases and made 518 home visits 
to cases of tuberculosis in addition to 324 visits of various kinds in behalf 
of patients. Because of the pressure of other duties, many cases discharged 
from sanatoria are not visited within one month of discharge, although this 
is a desirable practice. 
The total hospital patient days for cases from Worcester County 
numbered 8181 in 1939,-a high and favorable experience. Fourteen of the 
22 cases admitted to institutions went to Pine Bluff, four to Henryton (colored), three to Sabillasville, and one to Mt. Wilson Sanatoria, Seven of these cases 
were classed as minimal at the time of admission. Ten of the cases 7/ere hos- 
pitalized within two months of the time they were reported to the health de- 
partment. Of 24 cases discharged, 5 left the institution against advice. In 
1939, there were 44 different patients from the county in sanatoria. 
Laboratory services are provided in the branch of the State Labor- 
atory located in Salisbury, where 337 specimens for tuberculosis diagnosis 
were examined in 1939, 
Community health instruction in regard to the problem of tuberculosis 
in addition to the personal contacts of physicians and nurses, is gradually 
being developed. In local newspapers, 37 articles were published last year, 
and many pamphlets supplied by the Maryland Tuberculosis Association were 
distributed. There is a local tuberculosis association, affiliated with the 
Maryland Tuberculosis Association, which assumes, with the aid of the health 
officer, responsibility for the Seal Sale, In 1959, the amount of the Seal 
Sale, of $1058, was $185 more than in 1938; and the gradual increase in this 
activity is gratifying. Some $600 were available for direct tuberculosis 
control work in the county in addition to the clinic service. Excellent 
cooperation exists between the State and County Tuberculosis Association and 
the County Health Department, 
In summary, the tuberculosis control activities in Worcester County 
have been extended during the past two years, and in 1939 received a rating of 74 percent on the Appraisal Form, The chief losses in appraisal point 
to the need for: (a) increased case finding activities, especially 
among contacts, (b) for finding some way to stimulate more frequent attend- 
ance at clinics (although it is recognized that a large proportion of cases 
are hospitalized shortly after diagnosis is established), and (c) for ex- 
tending public health nursing services as soon as the staff can bo increased* 
Tuberculosis mortality in this county is excessive and the control of this 
disease requires vigorous measures with the cooperation of all individuals 
and agencies (educational, health and welfare) in the county and with as- 
sistance from appropriate state agencies. 41- 
Mat ernal and Child Health 
Historically, health departments turned their attention to the 
hygiene of the individual as the control of communicable diseases became 
less pressing. They began with an attack on infant mortality* Programs 
for school health were developed as problems of nutrition, dental care and the 
extent of physical defects were discovered in the school age group* Programs 
were later developed to improve the health conditions of pregnant women to 
prevent maternal mortality, and to foster the health and well-being of the 
unborn child and the growing family* Four activities are thus common to most 
health departments: promotion of the hygiene of the mother, the infant, the 
preschool child, and the school age child* 
In 1939, there were 413 live births and 18 stillbirths, 54 or 12,5 
percent occurring in hospitals - outside of the County, While the hospitals 
in which most of these deliveries occurred are registered, they are not on 
the approved list of the American Medical Association Council of Medical 
Education and Hospitals, Not only is there no hospital in the County, but 
there is also no organized nursing service at time of delivery. Those fac- 
tors are likely to throw additional burdens and demands on the already over- 
burdened staff of the health department, 
Records indicate that 135 births were attended by licensed midwives 
and 11 by others. The percentage of deliveries by midwives is over three 
times as high as the average for the counties of the State and five times as 
high as the average for the State if Baltimore is included. Midwives are 
registered in the County and are given field supervision by nurses, including 
midwife classes and check-up of equipment and methods. Actual Number. Of Puerperal Deaths 
Worcester. County 
1906 to 1939 Incl. A consulting nurse-midwife is provided by the State Health De- 
partment on request. Early in 1940, she spent a month in the area, dividing 
her time between Wicomico and Worcester Counties, 
Three afternoon clinics for prenatal care are held monthly, one 
each in Pocomoke City, Snow Hill, and Berlin, and one was held less regularly 
in 1939 in Stockton, The location of these clinics is central, but unfor- 
tunately the clinic in Pocomoke City, which is one of the best equipped, is 
located on the third floor of a building without an elevator. An obstetrical 
consultant from Johns Hopkins Hospital now visits the county every two months 
always attending the prenatal clinic in Snow Hill, 
The 175 cases registered in prenatal clinics during 1939, the larg- 
est number being in Berlin, made 434 visits - or averaging 2.5 visits per 
case, about half of the desirable average number of visits. Eight percent 
of the cases were registered before the fourth month, and an additional 51 
percent before the sixth month. The taking of blood tests is a routine 
procedure in these clinics, and 32 percent were found positive for S3qphilis, 
This is a high proportion of cases having syphilis. It is unfortunate that 
11 of these cases found to have syphilis could not have been bought under 
the efficient treatment given in the venereal disease clinics. Early treat- 
ment of syphilitic pregnant women is effective in preventing congenital 
syphilis. In December of 1939, prenatal dental service was begun for needy 
cases by the school dentist employed by the State Health Department and 
partly financed by the county. Nineteen dental examinations were made in 
1939; treatments were given to all but five who refused to benefit from this 
care. This service will be available only half of the year - the time the 
school dentist is in the county. Field nursing service was rendered to 160 prenatal cases in 1939, 
representing 37 percent of those in the county, A total of 493 home visits 
besides 297 visits elsewhere in behalf of the cases were made. Thirty-seven 
percent cf these cases were registered before the sixth month of pregnancy. 
Blood pressure readings, in accordance with generally accepted good 
practice, are taken by the nurses upon home visits, and urinalyses are 
made. In addition, these examinations and tests are routinely made in 
the clinics. 
There were 185 postpartum cases registered with the nurses in 1939 
as having received 275 home visits. While the number registered is reason- 
ably satisfactory, the frequency of visits is lower than desirable on the 
average. Only twenty percent of these cases were visited within 48 hours 
after delivery, and about the same proportion received two visits within 
10 days. 
The health officer and the nurses have analyzed the infant deaths 
and stillbirths occurring in 1939 as one index of the extent of medical and 
nursing supervision of the families which the health department was able to 
render. Only 19 percent of the mothers experiencing stillbirths or deaths 
of the infant during the first month of life attended prenatal clinic; only 
14 percent of the mothers in the latter group received home nursing visits, 
and then to only a very limited extent. Of mothers whose babies died after 
the first month of life, 39 percent were visited, but less than half of the 
cases received as many as two visits. On the other hand, one of these 
families received thirteen and another eighteen visits. The need for 
wider prenatal nursing supervision is indicated. 
Another study of records of 346 infants born in the county, not 
including those who died, shows that 55 percent of these infants were visited INFANT MORTALITY 
- Worcester County 
State Of Maryland 
1906 to 1Q38 Incl. and received an average of 4*14 visits per infant* Furthermore, it is grati- 
fying that 47 percent of these infants who were visited were seen during the 
first week of life; 80 percent being visited during the first month. A fairly 
intensive service, with early supervision, is thus rendered the infents whom 
the nurses are able to reach* 
During the year 1939 there were 131 infants registerd at child 
health conferences as having made 227 visits. In view especially of tho high 
infant mortality rate, there is apparent need for a more comprehensive pro- 
gram of child health conferences in the county. This fact is again emphasized 
when it is observed that only 247 preschool age children (15 percent) wore 
registered as having made 312 visits to conferences, The Hoalthmobilo of 
the State Health Department spent 8 days in the county in 1939, and examined 
275 children. No defects were reported for 135 of these children. The re- 
mainder were followed up by the nurses to secure corrective work* 
There were 314 infants registered with the nurses in 1939, as hav- 
ing received 1227 home visits and 174 reference visits. This is an invaluable 
service, but the frequency of visits averages only about two-thirds of the 
desirable number. In addition, 108 preschool age children (but less than 7 
percent of those in the county) received 367 home visits and 171 other (refer- 
ence) visits in behalf of the children under supervision. The medical con- 
sultant on infant and child health of the State Department of Health is avail- 
able upon request to aid with special problems, A nutrition advisor from the 
State Department is also available and spends several days in the county each 
year. The county is also fortunate in having as health officer a physician 
with considerable experience and training in pediatrics. There has been considerable activity in the county in community 
health instruction as related to maternity and infancy; pamphlets have been 
distributed, talks have bean given, and the newspapers have cooperated. The 
visit of the Healthmobile is also a useful seasonal educational measure. 
The low appraisal scores of 69 percent for maternity hygiene and 
45 percent for infant and preschool care are due to the lack of personnel 
and facilities in the county to do as extensive a job as would be desirable 
and highly fruitful in view of the excessive infant mortality rate. The 
high incidence of diarrhea and enteritis is an illustration of one of the 
important problems. The work that is being done is on a high level of ef- 
fectiveness, but it needs extension as indicated, especially for increased 
nursing service and for active development of child health conference ser- 
vices. Even recognizing that a fairly large volume of child health service 
may be rendered by physicians, there remains a very large number not reached 
by doctors or nurses until an acute emergency arises. There are certain 
sections in the county needing special study because of the unusual incidence 
of infant disease problems among both white and colored. Seventy percent 
of the stillbirths and 61 percent of the infant deaths were among colored 
persons, although the proportion of the colored population is roughly half 
of these ratios. The State Department of Health, Bureau of Child Hygiene 
has recognized that the problems of the county in maternity and infancy care 
need vigorous measures and lias consequently given more aid in personnel than 
is usually provided in comparision with the amount of responsibility assumed 
by a county. Under the present able leadership, and with increasing county 
support, this major burden should soon begin to grow lighter to the satis- 
faction of the citizens, taxpayers, and professional workers alike. school Health* In a previous section were discussed the factors relating to 
school sanitation. It is our purpose here to consider those 
aspects of the school program which relate primarily to the physical status 
of pupils and teachers. All of these factors naturally bear an. important re- 
lationship to the mental hygiene atmosphere of the schools, which naturally 
influences the mental growth and development of the children* 
According to data kindly furnished by the Superintendent of Schools, 
there are some 4031 school pupils enrolled in the county, classified as follows 
Public Schools 
Elementary 
High 
Total 
White 
1816 
771 
2587 
Negro 
1181 
263 
1444 
Total 
2997 
1034 
4031 
While there is no organized program for the health examination 
of pupils of selected grades each year, 301 pupils were given medical exam- 
inations, and 450 were given dental examinations in 1939• However, it should 
be pointed out that provision has been made for testing of vision and of 
hearing, annually, according to modern procedures, and including in the near 
future for hearing tests the use of the audiometer, A study of loss of hear- 
ing among school pupils in 1940, showed that 533 out of 697 tested, or 77 
percent, had normal hearing; 154 showed loss of hearing of less than 15 percent, 
and 10 showed a loss of hearing above 15 percent. In one of the school dis- 
tricts where the nurse supervised vision testing of 590 pupils, using the 
Snellen Test, 90 children, or 17 percent were found to have defective vision 
in marked degree and should be examined by an ophthalmologist. These tests 
are needed for all school pupils* If the child is to benefit from the regular educational facilities, 
he needs to see and to hear as well as possible; and furthermore, handicapping 
defects, if present, should be discovered and corrected as early as possible 
and before they may pass a stage which may lead to permanent handicaps* 
There is also needed a health program for high school pupils* 
Dental examinations are made of children in the first three grades* 
State records indicate that 53 clinics were held in the county when 116 child- 
ren were treated in 1939. It should be noted that the 1938-39 program was 
completed in February and the 1939-40 program began in December of 1939* 
Parents sign a permit for such work, and a charge of one dollar is made for 
the service rendered each child. The dentist is authorized to do the work 
free if the local Parent-Teacher Association or a responsible group indicates 
that the child comes from an indigent family. Not all colored schools are 
served, however. Some work has been accomplished for preschool children on 
Saturday mornings. And, as previously indicated, with the help of the State 
Bureau of Child Hygiene, a prenatal dental program has been launched. 
Three orthopedic clinics a year are conducted by a clinician employed 
by the State Department of Health. In 1939 a total of 30 new cases of crippled 
children were reported, 5 were brought under treatment; 32 were admitted to 
nursing service and received 53 home visits besides the 59 visits made by 
the children to diagnostic clinics. 
Data kindly furnished by the Maryland League for Crippled Children 
show the registration of known cases as of May 1, 1940 - 
Crippled 
Children in Worcester County 
Age Groups: 
1 to 5 yra. 
6 to 10 yrs. 
11 to 15 yrs* 
l6 to 21 yrs. 
Total 
White 
15 
21 
19 
16 
71 
Colored 
10 
2 
9 
5 
26 
Total 
25 
23 
28 
21 
97 Crippled Children in Worcester County 
Location 
and Color 
Location 
Whit e 
Colored 
Girdletree 
3 
0 
Newark 
1 
5 
Snow Hill 
13 
2 
Berlin 
20 
7 
Stockton 
3 
2 
Pocomoke 
25 
3 
Bishop 
1 
1 
Whaleysville 
4 
2 
Showell 
0 
3 
Johnson’s Neck 
0 
1 
Ocean City 
1 
0 
Records of the State Department of Health show that 14 patients were 
hospitalized in 1939 at a cost of $3803, plus $115 for appliances* 
Mental hygiene clinics, largely for vrork with children, were 
re-established in 1940 by the Maryland Society of Mental Hygiene, with a 
psychiatrist and a psychiatric social worker in attendance* The psycholo- 
gist of the Society occasionally also participates in the work. This is a 
valuable service which should be extended with the participation of the 
education, health and welfare agencies participating in a joint plan. 
A very interesting and constructive study of nutrition problems in 
schools has been conducted, through the cooperation of the schools, the health 
department, and the "Parent-Teacher Association, The final results of this study- 
should be useful in planning the future program of health education and nutri- 
tion. Already, the preliminary results have been used in a constructive 
manner for the benefit of pupils and the interest of teachers and other pro- 
fessional workers. There are many problems of nutrition in the county Which need continuing attention. These place considerable responsibility on the 
public health nurses, the welfare workers, arid school personnel. 
Previous reference has been made to the work of the health depart- 
ment for the control of communicable diseases among school pupils, including 
diphtheria immunization and smallpox vaccination. Public health nurses made 
161 home visits and 338 reference visits in behalf of school pupils. 
Classroom teachers in all schools do not have access to cumulative 
health record cards showing the child’s health history since entering school. 
Nor do the classroom teachers have records of causes of absence. New health 
record cards have been prepared for the high schools. The teachers are sup- 
plied with a booklet of Instructions for the Control of Communicable Diseases 
supplied by the State Department of Health, Several of both the white and 
colored schools have active parent organizations. 
In considering the future development of the school health program, 
which now scores 30 percent on the Appraisal Form, consideration may well be 
given to closer integration of school health services and health education, 
to increased health education work in high schools, and to a more comprehensive 
program of health examinations and follow-up service. The close working re- 
lationships between the school department and the health department are com- 
mendable , 
Problems of Medical Service 
As previously noted at the beginning of this report, there is an 
important problem in the county of securing necessary medical and especially 
hospital services promptly for certain types of cases. Inasmuch as the health department is an official county agency which must assume responsibility 
for certain indigent cases, including several prenatal and obstetrical 
cases and communicable disease cases, the county health department should 
be given authority to secure the necessary medical and hospital care for 
a case when indicated. The present plan often involves delay because of 
the time required in clearing cases with the County Commissioners and 
places the health officer in a very unfortunate and discouraging position. 
Furthermore, the basis of arrangement for medical care by the welfare de- 
partment involving the payment of medical services through the patient 
has often proved unsatisfactory* 
Public- Health Nursin 
In previous sections, the valuable work of tte four public health 
nurses in the county has been discussed. There are 4 nurses for a popu- 
lation of some 22,000 people, or one nurse to 5500. This ratio gives each 
nurse a task almost three times as large as an ideal. Furthermore, it 
should be pointed out that there is no trained and experienced nursing 
supervisor to assist the staff nurses in correlating and planning the work 
on a comprehensive basis or to serve as a consultant always at hand. Con- 
sulting service is rendered so far as practicable by the director of nurses 
of the State Department of Health, but this does not take the place of a 
supervising staff member who is constantly available, Tno provision of a 
well equipped supervising nurse is perhaps the greatest need in the county 
for strengthening the public health program* 
Public health nursing has come to be recognized not as an expense 
but as an investment that pays large dividends in the saving of human lives and the prevention of suffering. It has been well said that no community 
can afford not to spend the money for this type of health worker. One 
of the functions of a public health nursing program is instruction in 
the techniques of nursing care of the sick in the home, and the giving 
or securing of such care when necessary in accordance with the medical 
instructions of the attending physician; with assistance in securing special 
care for patients having special types of disease, such as orthopedic, 
arthritic, and cardiac conditions, diabetes and cancer, and in securing 
convalescent care. The nursing load in the county is too great to permit 
of the bedside nursing care needed. This is a very important problem in 
the county. 
Enormous credit is due the staff nurses for the program being 
actively carried on, A time study conducted by the nurses in November of 
1939, showed that on the average, 34 percent of the tine was spent in home 
visits, 27 percent in travel, 16 percent in clinics, 17 percent in office 
work, and the remainder in miscellaneous duties. The study also revealed 
that overtime is not uncommon. Were there more clerical assistance, per- 
haps the office time could be slightly reduced, although this figure is 
not out of line with general experience elsewhere. In a county of this 
size, much time is required for travel, 'To meet the large problems 
many of them greater than the average, (e,g, infant mortality and tuber- 
culosis), efforts should be made to increase the nursing staff, and divi- 
dends would be returned many times in the reduction of unnecessary illness. 52 
Furthermore, attention should be called to the lack of bedside nursing 
care and to care of cases at the time of delivery* 
The nursing time study also showed the distribtuion of nursing 
visits by types of services as follows: 
Service visits 
Percent of time 
Communicable diseases 
6.5 
Syphilis and gonorrhea 
8.9 
Tuberculos is 
7,7 
Maternity 
12.3 
Child Hygiene 
28.5 
School 
18.7 
Morbidity 
10,2 
Crippled Children 
4.1 
Collection of specimens 
3.0 
99.9 
Although there are variations, to be expected, between the various 
services of the different nurses, the average distribution of services cor- 
responds with what would seem desirable in general. Increased emphasis on 
maternity visits would seem worthy of consideration. But it is difficult 
to suggest any point which might be curtailed. Continuing study of this 
problem by each nurse, bearing in mind the individual needs of cases under 
supervision and their relative importance, seems to be the only immediate 
answer. 
The nurses are relieved of much of the social service work which 
sometimes presses for attention, because there are 5 social workers in the 
county. Cooperation between tha nurses and the social workers, with occa- 
sional conferences is essential. Because of the important problem of trans- 
portation, the nurses are unable to carry on as much group instruction as 
is sometimes feasible. Heme visits are essential even though time consuming* The county and the state are making a sound investment in the public health 
nursing in the county, but the county should plan for the gradual assumption 
of increasing responsibility in the provision of this essential service 
for the benefit of the citizens and the taxpaj'ers. 
Summary and Conclusions 
Worcester County has a well organized and ably administered county 
health department wEth a loyal and energetic staff. The county has gradually 
assumed increasing responsibility for the conservation of the health of its 
people during recent years. Enormous progress has been made during the past 
two years, A large proportion of the health department budget is derived 
from State and Federal funds. The county should plan to assume a much larger 
share of this budget in the not far distant future, and to secure as soon 
as possible a well qualified supervising nurse, at least one more staff nurse, 
an additional cleric, part-time, and some increase in medical assistance for 
the health officer. The sanitation program should be strengthened, Tho 
county also should plan for more adequate housing facilities for the depart- 
ment, In view of the fact that the success of tho public health program and 
tho advancement of the school health and nutrition programs depends so much 
on the participation of the public in various aspects of these programs, the 
extension of activities of public health education should be early considered. 
To cassist in this important work, there is needed a supervisor of health 
education who has had considerable training and experience in education and 
public health. 
This report has endeavored to outline existing health problems, to 
emphasize certain gaps, and to suggest some of the future lines of develop- 
ment, It is hoped that this critical review may be helpful in future program 
planning during the next five years.