MISSOURI TUBERCULOSIS ASSN. INFANT MORTALITY IN MISSOURI. 1924 INFANT MORTALITY IN MISSOURI IN RELATION TO BIRTH CERTIFICATION AND REGISTRATION AND TO TUBERCULOSIS 1911-1923 MISSOURI TUBERCULOSIS ASSOCIATION 306 ODEON BUILDING, ST. LOUIS, MO. ACKNOWLEDGEMENT In presenting this statistical survey of infant mortality in Missouri to the people of the State, bringing to their attention the triumphant achievement made in the reduction of deaths in infancy and from tuberculosis in the State in the past twelve years, we wish to acknowledge that t'he attainment of these beneficent results have been made possible only through the cooperation given the tuberculosis move- ment by the teachers and the pupils of the schools of the State. They have cooperated in the health education program and also have provided largely for the financial support of the movement by the selling of Tuberculosis Christmas Seals, the chief source of the State Associa- tion's financial support throughout the past thirteen years. Particularly to the State superintendent of public schools and to the county and city superintendents of schools are we grateful for the cooperation which they have given us throughout this period, finding culmination in the incorporation of health education in the recently established State course of study. To these and to other friends we take this occasion again to ex- press our gratitude and again to request continuation of their support. MISSOURI TUBERCULOSIS ASSOCIATION -- September 1, 1924. ' ' Executive Secretary. INFANT MORTALITY IN MISSOURI IN RELATION TO BIRTH CERTIFICATION AND REGISTRATION AND TO TUBERCULOSIS 1911-1923 HIGH POINTS 1. Missouri, because of incomplete and inaccurate birth statistics, is not admitted to the United States Census birth registration area. 2. Without reliable birth registration, Missouri cannot establish a permanent effective child health program. 3. Duty of State Health Commissioner, county and municipal health officers and local registrars of vital statistics to enforce birth certification. 4. Infant mortality rates of the thirteen leading cities of Missouri from the year 1911 to 1923, compared. 5. Infant mortality rates of Missouri cities compared with those within and without the birth registration area, in population groups. 6. Reasons for birth certification and registration and their significance to the nation, states, cities, towns, to country people and to the child himself. The child's right. 7. Pungent questions addressed to public officials, health officers, physicians, teachers, preachers, social leaders, and parents of young children. 8. Relative progress in reduction of infant mortality rates of nine Missouri cities in the past thirteen years: Merit and rank. 9. Relation of child health to the control of tuberculosis. 10. To family physicians and pediatricians will pass the professional obligations of the tuberculosis specialist. Let them prepare. Appendix. Missouri vital statistics, 1923: Population mortality, progress. Acknowledgement. MISSOURI TUBERCULOSIS ASSOCIATION 306 ODEON BUILDING, ST. LOUIS, MO. 2 INFANT MORTALITY IN MISSOURI IN RELATION TO BIRTH CERTIFICATION AND REGISTRATION AND TO TUBERCULOSIS YEARS 1911-1923 A statistical report of infant mortality in 665 cities of the United States for the year 1923, published by the American Child Health Association, just received, yields information pertaining to Missouri which is of particular interest to health workers in those cities whose reports of both births and deaths have been supplied by the United States Bureau of the Census or by state or local authorities. Of outstanding interest is the fact that Missouri, because of inaccuracy of birth records, is not admitted to the birth registration area of that bureau. This shortcoming on the part of our state not only wounds state pride but tends to discourage child health work, for without the reliable statistical information which is fundamental to the upbuilding of such health work we never may expect to erect a substantial permanent program for the alleviation of the vicissitudes of child birth and for the control of the diseases of childhood -- both of much significance in the control of tuberculosis and for the health and economic welfare of the state. From the preface of this report we quote: It should be the primary ambition of a State Health Officer to bring his state as promptly as possible into the regis- tration areas (birth and death) so that our country as a whole, and not merely a section of it, may see clearly the course that it is sailing. This admonition to the state health officer should be extended to county and city health officers and to local registrars of vital statistics, so that the states and counties, as well as the entire country, may clearly see the health courses they are sailing. As information pertaining to the infant mortality in the cities of Missouri we submit statistics as tabulated from this report. (See Table I, page 3.) Accepting this report as a basis for comparison, in respect to infant mortality in 1923 the thirteen cities of Missouri from lowest to highest ranked as follows: 1, Carthage; 2, Moberly; 3, Jefferson City; 4, St. Louis; 5, Sedalia; 6, Springfield; 7, Independence; 8, Joplin; 9, St. Joseph; 10, Columbia; 11, Kansas City; 12, Cape Girardeau; 13, Hannibal. Expressed in another and equivalent way, but less exactly than in terms per 1000, in Carthage in the year 1923 one child died in the first year of life to every twenty-seven babies born; in Moberly, one to seventeen; in Jefferson City, one to fifteen; in Sedalia and St. Louis, one to fourteen; in Independence and Springfield, one to thirteen; in Joplin, one to twelve; in Kansas City, Columbia and St. Joseph, one to eleven; in Cape Girardeau, one to ten; in Hannibal, one to seven. 3 TABLE I. INFANT MORTALITY IN THE CITIES OF MISSOURI YEARS 1911-1923 CITIES IN DEATH, BUT NOT IN BIRTH, REGISTRATION AREA INFANT MORTALITY RATE Rank Popu- Death-Rate by Name of City lation All Ages Average Deaths under One Year Age Pop. 1920 per 1 M Pop. 1911 1916 per 1,000 Births Census 1922 1923 -'15 -'20 1918 1919 1920 1921 1922 1923 647 Cape Girardeau * 10,252 19.3 19.9 90 104 662 Carthage * 10,068 13.8 13.1 - - 59 27 640 Columbia * 10,392 18.7 19.4 -- 102 88 349 Hannibal 19,306 13.2 15.9 108 115 117 136 87 83 107 142 559 Independence * 11,686 15.1 15.6 - - 95 78 457 Jefferson City 14,490 14.0 13.2 92 81 70 67 92 90 103 65 234 Joplin 29,902 14.6 16.9 122 97 108 81 84 83 99 86 19 Kansas City 324,410 14.6 14.4 114 107 113 102 123 94 100 92 514 Moberly 12,808 15.1 12.3 101 80 82 75 72 71 84 59 84 St. Joseph ** 77,939 17.4 16.4 97 93 119 93 88 77 82 88 6 St. Louis 772,897 12.5 13.6 100 83 93 73 76 67 59 70 324 Sedalia 21,144 12.2 13.7 97 91 93 62 86 59 85 71 181 Springf ield 39,631 15.2 15.1 115 112 115 99 105 83 77 76 584 cities in death AND birth registration states, infant mortality, year 1923--78.0 81 cities in death, but not in birth, registration states,- (same) 90.4 * Places first listed in 1920 Census as having over 10,000 population. Early statistics often unobtainable. ** Important state institutions are located here which influence the crude death rate. For purpose of comparison, that the reader may know where the cities of Missouri stand with the cities of other states in respect to infant mortality, we submit another table from this report which exhibits the cities of the United States having the highest and lowest infant mortality rates, by population groups. (See Table II, page 4.) We would bring to your attention the status of St. Louis and Kansas City in the population group of cities over 250,000 and of Carthage and Hannibal in the population group of cities between 10,000 and 25,000, population. Further, it will be observed that the infant mortality rates of cities in death and birth registration states are considerably lower than those of cities in death, but not in birth, registration states, namely, 78.0 and 90.4, respectively. These figures exemplify the need of state-wide, yes, nation-wide, birth registration, if the infant mortality rate of any specific local community is to be reduced, which means, if we would save the lives of babies in that community. 4 TABLE II. CITIES IN THE UNITED STATES WITH THE HIGHEST AND LOWEST INFANT MORTALITY RATES IN YEAR 1923 LOWEST HIGHEST POPULATION OVER 250,000 Death and birth registration areas Seattle, Wash. 49 Portland, Ore. 53 Minneapolis, Minn. 54 Death registration area only St. Louis, Mo. 70 Death and birth registration areas Pittsburgh, Pa. 98 Washington, D. C. 92 Buffalo, N. Y. 90 Death registration area only Kansas City,, Mo. 92 POPULATION 100,000-250,000 Death and birth registration areas Spokane, Wash. 48 Yonkers, N. Y. 59 Oakland, Cal. 63 Grand Rapids, Mich. 63 Death registration area only Des Moines, la. 64 Death and birth registration areas Lowell, Mass. 110 Richmond, Va. 110 New Bedford, Mass. 105 Death registration area only Atlanta, Ga. 134 POPULATION 50,000-100,000 Death and birth registration areas Berkely, Cal. 41 Long Beach, Cal. 41 Tacoma, Wash. 48 Death registration area only Davenport, la. 63 Death and birth registration areas Charleston, S. C. 150 Manchester, N. H. 117 East St. Louis, 111. 108 Death registration area only El Paso, Tex. 169 POPULATION 25,000-50,000 Death and birth registration areas Pasadena, Cal. 37 Oak Park, Ill. 37 Almeda, Cal. 40 Death registration area only Cedar Rapids, la._ 53 Death and birth registration areas Winston-Salem, N. C. 142 Asheville, N. C. 134 East Chicago, Ind. 124 Death registration area only Pueblo, Colo. 132 POPULATION 10,000-25,000 Death and birth registration areas Santa Cruz, Cal. 26 Winchestertown, Mass. 26 Huntington, Ind. 30 Death registration area only Carthage, Mo. 27 Death and birth registration areas Goldsboro, N. C. 161 Cairo, Ill. 155 Ogdensburg, N. Y. 142 Death registration area only Hannibal, Mo. 142 5 The rank of the states (covering cities of 10,000 or over, only) which have been admitted to the United States Census birth registration area, with the infant mortality rate for 1923 (death of infants under one year age to 1,000 births) of each, follows: 1, Washington, 51; 2, Oregon, 53; 3, Minnesota, 62; 4, California, 66; 5, Nebraska, 67; 6, New Jersey, 71; 7, New York, 71; 8, Montana, 73; 9, Utah, 74; 10, Ohio, 75; 11, Connecticut, 77; 12, Wisconsin, 77; 13, Kansas, 78; 14, Massachusetts, 78; 15, Indiana, 79; 16, Illinois, 85; 17, Michigan, 85; 18, Maryland, 87; 19, Pennsylvania, 87; 20, Mississippi, 88; 21, Maine, 89; 22, Vermont, 90; 23, Kentucky, 90; 24, Virginia, 99; 25, New Hampshire, 101; 26, Wyoming, 102; 27, North Carolina, 110; 28, South Carolina, 117; All cities, 78. The corresponding information for states admitted to death, not to the birth, registration area is: 1, Iowa, 68; 2, Louisiana, 78; 3, Missouri, 78; 4, Florida, 92; 5, Colorado, 95; 6, Alabama, 96; 7, Texas, 104; 8, Tennessee, 107; 9, Georgia, 122; All cities, 90.4. Missouri with the city infant mortality rate of 78 per 1000 births holds a rank approximately equivalent to those of Kansas and Massachusetts, namely, fourteenth or fifteenth of the twenty-eight states admitted to the birth registration area. The vital statistics law of Missouri requires that a birth certificate made out on a blank to be obtained free of cost from the local registrar of vital statistics shall be made out and be filed with the local registrar within ten days after birth, by the attending doctor or midwife or by the parents, if no doctor or midwife was in professional attendance. Furthermore, it is an obligation of every citizen of the state, especially of health officers, physicians, nurses, school officers, teachers, preachers, members of parent-teachers' association and mothers' clubs and officers and members of all organizations promoting social welfare and health work, to uphold health officers in this enforcement of the law. The Missouri law requiring certification and registration of births should be strictly observed so that the state may be admitted to the United States Census, birth registration area thus removing the stigma of disinterest in child health and public welfare from Missouri, which now is brought so vividly to the attention of the world. Further reasons for the voluntary observance and legal enforcement of birth certification and registration, not only for the public welfare but also for the welfare of the individual, follows: 1. As evidence to prove the age and legitimacy of heirs; 2. As proof of age to determine the validity of a contract entered into by an alleged minor; 3. As evidence to establish age and proof of citizenship and descent in order to vote; 4. As evidence to establish the right of admission to the professions and to many public offices; 5. As evidence of legal age to marry; 6 6. Ab evidence to prove the claims of widows and orphans under the Widows' and Orphans' Pension Law; 7. As evidence to determine the liability of parents for the debts of a minor; 8. As evidence in the administration of estates, the settlement of insurance and pensions; , 9. As evidence in the enforcement of laws relating to education and to chi labor; 10. As evidence to determine the relations of guardians and wards, 11. As proof of citizenship in order to obtain a passport; 12. As evidence in the claim for exemption from or the right to jury and militia service. To the end that every child born in Missouri may be assured his right to the registration of his birth, let every physician practice, teacher teach, preacher preach and parent demand, birth certification and registration. Comparing the average infant mortality rates for the five year period 1916-20 with that of 1911-'15 there was, in round numbers, an increase for Hannibal of 6%, a decrease for Jefferson City of 12%; for Joplin, 20%; for Kansas City, 6%; for Moberly, 21%; for St. Joseph, 4%; for St. Louis, 17%; for Sedalia, 6%; and for Springfield, 3^. A like comparison of the average infant mortality rates of the more recent three year periods 1918-'2O and 1921-'23, in round numbers, yields the following: a decrease for Hannibal of 3%; an increase for Jefferson City of 13%; a decrease xor Jcplin o 2%; for Kansas City, 15%; for Moberly, 7%; for St. Joseph, 18%; for St. Louis, 19%, for Sedalia, 11%; and for Springfield, 26%. While of less significance than for the five or three year periods, because of the usual variations up and down of the death and birth rate from one year to the next, yet yielding information of much significance, a comparison of the mortality rates of the thirteen cities of Missouri for the years 1922 and 1923, in round numbers, yields information as follows: An increase tor Cape Girardeau of 16%; a decrease for Carthage of 54%; for Columbia of 14%; an increase for Hannibal of 33%; a decrease for Independence of 18%; for Jefferson City, 37%; for Joplin, 13%; for Kansas City, 8%; for Moberly, 30%; an increase for St. Joseph of 7%; for St. Louis, 19%; a decrease for Sedalia of 16%; and for Springfield, 1%. What the towns of Missouri having a population of less than 10,000 in the 1920 census and what rural Missouri may be doing for the saving of the lives of babies, must be left to conjecture; for until the certification and registration of births'throughout the state become sufficiently complete and trustworthy to be accepted by the bureau of the Census as worthy of record and publication, what such towns and rural districts of Missouri are doing to save children cannot be known. Of more real significance to a community than its infant mortality rate is whether or not that community is reducing its infant mortality rate as the years pass, and how fast. How is it in this respect with the cities of Missouri? (See Table III, page 7.) 7 TABLE III. EXHIBIT OF PROGRESS IN INFANT HEALTH WELFARE BY THE CITIES OF MISSOURI Years 1911-1923 PER CENT. INCREASE OR DECREASE OF AVERAGE INFANT MORTALITY RATES, BY YEAR-PERIODS Name of City Five Year Periods 1911-15,1916-20 Three Year Periods 1918-20,1921-23 One Year Periods 1922,1923 Relative Progress Merit Rank Per Cent. Rank Per Cent. Rank Per Cent. Rank Cape Girardeau - - -- - - - - - Increase 16% -11 - 9 Carthage -- -- - - - - Decrease 54% - 1 - ? Columbia - - - - - - - . »» 14% - 6 - ? Hannibal Increase 6% 9 Decrease 3% 7 Increase 33% 9 13 - 54 9 Independence - - - -- - • Decrease 18% - 4 - - ? Jefferson City Decrease 12% 4 Increase 13% 9 -I II 37% 1 2 + 58 8 Joplin II 20% 2 Decrease 2% 8 II 13% 4 7 +119 3 Kansas City 6% 6 •1 15% 4 II 8% 5 8 + 83 5 Moberly II 20% 1 II 7% 6 II 30% 2 3 +156 1 St. Joseph II 4% 7 II 18% 3 Increase 7% 7 10 + 67 7 St. Louis II 17% 3 •I 19% 2 II 19% 8 12 +123 2 Sedalia II 6% 5 11% 5 Decrease 16% 3 5 + 79 6 Springfield II 3% 8 26% 1 II 1% 6 9 + 94 4 Avr'g Progress Decrease 9% - Decrease 10% *Decrease 5% - - + 8V * * _ *Excluding Cape Girardeau, Carthage, Columbia and Independence. With these cities included the average is Decrease 9%. **Cities having a ''relative progress merit" of more than +81, average of the nine cities, may be regarded as doing commendable child health work. Let them keep im- proving. Assuming a relative value of +5 to each per cent, decrease and of -5 to each per cent increase in infant mortality for the five year periods; of +3 and -3, respec- tively, for the three year periods; and +1 and -1, respectively, for the one year periods multiplying and taking the sum of the product thus obtained, we may find a basis of relative merit for progress in child health work in these cities. On this basis of comparison the nine cities of Missouri, for which records covering the whole thirteen years 1911-1923 are available, rank and standing in relative progress merit follows: 1, Moberly, +156; 2, St. Louis, +123; 3, Joplin, +119; 4, Spring- field, +94; 5, Kansas City, +83; 6, Sedalia, +79; 7, St. Joseph, +67; 8, Jefferson City, +58; 9, Hannibal, -54. As to their relative deserving of commendation or for condem- nation, we will leave the mayor, public health officer and welfare leaders of each of these cities to judge for themselves. 8 To the readers of its report the American Child Health Association addresses the following pungent questions pertaining to infant mortality and child health welfare: Do you know where your city stands? Do you know why? In your city: Are all births registered? Can all mothers get prenatel care? Are midwives licensed and inspected? Are there child health centers? Is the milk supply pure? Are school children taught health habits? Have you medical school inspection? IF NOT, WHY NOT? Of mothers of infants WE would ask: Do you keep your baby clean? Do you keep your baby cool and in the opn air? Do you keep flies from the baby? Do you keep flies from the baby's food? Do you give your baby fresh fruit juices daily? Do you give your baby clean milk from tuberculosis tested cows? IF NOT, WHY NOT? In justification of the policy of an organization like the Missouri Tuberculosis Association, the function of which is to fight tuberculosis, giving the attention and incurring the expense incident to the preparation and distribution of a bulletin upon infant mortality, such as this, it may be noted that as the years pass it is becoming more and more apparent that the tuberculosis fight is becoming more and more a fight for the health welfare of children. It is in the age-period of childhood that tuberculosis infection most frequently occurs and when, through the establishment of sound health habits, through the correction of bodily defects, through the overcoming of incipient chronic disease, through spontaneous and supervised play and re- creation, the fight against tuberculosis can be carried out most effectively and at the least cost in effort and with the minimum outlay of money. And, too, more and more are we learning that the practice of the tuber culosis specialist is invading the field of the pediatrician, the physician who specialized in practice with children. To this fact we urgently would bring the earnest attention of all pediatricians and family physicians in Missouri, that they may be prepared to meet these professional obligations as they arrive. MISSOURI TUBERCULOSIS ASSOCIATION 306 ODEON BLDG. ST. LOUIS, MISSOURI August 23, 1924. W, McN. Miller. M. D Executive Secretary. 9 APPENDIX MISSOURI VITAL STATISTICS YEARS 1911-1923 A preliminary announcement by the State Board of Health of births and deaths in the whole State for the year 1923, received August 13, tabulated and compared with corresponding data for 1911, with derived information, shows: 1911 1923 Change 1. *Births (exclusive of still births) 74,130 66,691 Dec. 7439 2, *Birth-rate per 1000 population (estimated) 22.4 19.4 ft 13.5% 3. Deaths, all ages, from all causes 43,479 41,853 If 1626 4. Death-rate per 1000 population (estimated) 13.2 12.2 ft 7.5% 5. **Deaths under one year age 7,050 4,933 If 2117 6. 7. Death-rate, under one year age per 100,000 Popula- tion, all ages 213.4 Percent, deaths under one year age of deaths, at all ages 16.2 143.5 11.8 If II 32.7% 27.3% 8. 9. 10. 10a. *Infant mortality rate, i.e., deaths under one year age to 1000 births 95.1 *Population mortality rate, i.e., deaths at all ages to 1000 births 586.5 *Population mortality rate due to deaths under one year age (I.M.R., see No. 8) 95.1 *Percent. of total population mortality rate (see No.7) 16.2 74.0 627.6 74.0 11.8 If Inc. Dec. If 22.2% 7.0% 22.2% 27.3% 10b. 11. *Average percent, for each year Deaths from tuberculosis, all forms, all ages 5,113 2,857 If If 2.3% 2256 12. Tuberculosis death-rate, all forms, per 100,000 Pop. 154.7 83.1 If 46.3% 13. 14. Percent, deaths from tuberculosis, all forms of deaths from all causes 11.8 *Population mortality rate due to tuberculosis 69.0 6.8 42.8 If If 42.0% 37.9% 14a. *Percent. of total population mortality rate 11.8 6.8 If 42.0% 14b. 15. 16. *Average percent, for each year Percent, deaths from tuberculosis under one year age of deaths from all causes in same age period, determined from United States Census Mortality Statistics, 1921 Deaths from tuberculosis under one year age, estimated 52 **54 " 3.5% ***1.2% Inc. 2 17. 18. *Population mortality rate, deaths under one year age and due to tuberculosis, excluding duplication under one year age 163.4 *Percent. of total population rate 27.9 116.0 18.5 Dec. If 29.0% 33.6% 18a. 18b. *Average percent, for each year " Population of Missouri, estimated, year 1911--3,304,407; year 1923--3,437,271 2.8% *It must tie borne in mind that registration of births in Missouri is regarded by the United States Census as too incomplete or too inaccurate to be acceptable for record, i.e., for admission to the birth registration area. The records of births here submitted and the information derived therefrom, must be regarded as untrust- worthy, but as having some value if this be understood. **Estimated. ***Assumed to be the same as in 1921. 10 POPULATION MORTALITY RATES: POPULATION SUICIDE. A matter of interest (to some countries it is of much significance and even of apprehension) is that the population mortality rate, i. e., deaths at all ages to 1000 births, in Missouri has increased from 586.5 in 1911 to 627.6 in 1923, an increase of 7%, seven deaths, all ages, to one hundred births. Had the birth-rate and infant mortality rate of 1911 prevailed in the State in 1923, there would have been 7333 deaths under one year age instead of 4933, a saving of 2400 lives of infants to Missouri in the year. Had the tuberculosis death rate of 1911 prevailed in the State in 1923, there would have been 5317 deaths from that disease instead of 2857, a saving of 2460 lives to Missouri in the year. From both there has been a saving to the State, allowing for deaths of infants under one year age due to tuberculosis, of a total of 4774 lives. But over these rates and the diminished percentage increase, there is cast the shadow of uncertainty which arises from the unacceptable character of birth registration in Missouri. A matter of significance to the business men and to property owners of a state or community is the rate of growth of the population as it is effected relative- ly by births and deaths, a relationship which may be designated by the terms "popu- lation mortality" or "population suicide". "Population suicide" we may say truly, because most deaths under one year of age and all deaths from tuberculosis are pre- ventable . It is as much suicidal for a self-governing people slowly to die out from preventable disease as for a self-killing man quickly to die from willful pistol firing-and more consequential to the welfare of the State. For a people of a democracy not to save children from preventable disease, not to correct physical defects, not to overcome developing chronic disease, not to train them in sound health habits, not to provide them with proper and sufficient food and with suf- ficient sleep in fresh air at proper hours, all, is as reprehensible as not to save a child from a rabid dog. One half, or more, of the deaths under one year age are preventable and not to save the lives of infants by public health service or by personal effort is evidence of a lack of public health consciousness and a conscience, and evidence, too, of personal thoughtlessness, ignorance, indolence, greed. For the term "popu- lation mortality", or "population suicide", as applied to infants under one year age the term "population infanticide" might well within the truth be used. How in the past twelve years have births and deaths, the inherent elements of population growth, affected the population of Missouri? In Missouri in the year 1911 there were, in round figures, 587 deaths to every 1000 births; in the year 1923 there were 628 such deaths, an increase of 41 deaths to the 1000 births; a percentage increase of population mortality of 7.0%, with the corresponding population decrease. Of the 587 deaths at all ages to the 1000 births in the year 1911, 95 (16.2%) were of infants under one year of age; of the 628 such deaths in the year 1923, 74 (11.8%) were under one year of age, a decrease of 21 deaths under one year of age to the 1000 births, a percentage decrease of population mortality of 27.3% in the twelfth year, or an average rate of 2.3% a year. 11 Of the 58? deaths at all ages to the 1000 births in the year 1911, 69 (11.8%) were due to tuberculosis; of the 628 such deaths in the year 1923, 43 (6.8%) were due to tuberculosis, a decrease of 26 deaths due to tuberculosis to the 1000 births, a percentage decrease of population mortality of 42.0% in the twelfth year, or an average rate of 3.5% a year. Of the 587 deaths at all ages to the 1000 births, the population mortal- ity rate (population suicide rate) in the year 1911, 95 (16.2%), were deaths under one year age and 69, (11.8%) were from tuberculosis; of the 628 deaths in the year 1923, 74 (11.8%) were under one year age and 43 (6.8%) were from tuberculosis. This shows a decline in the twelfth year, in round figures, of 21 deaths (22.2%) under one year age and 26 deaths (37.9%) from tuberculosis. This decline in the population mortality rate (population suicide rate) due to deaths under one year age expressed in the percentage was 22.2%; that of tuberculosis 37.9%, or an average rate of 1.9% and 3.2% for each year, respectively. The significant point in this survey of the population mortality in Missouri for the twelve years 1911-1923 is that of the 587 deaths to the 1000 births in the year 1911, allowing for duplication of deaths from tuberculosis in the first year of life, 94 deaths (16.0%) were of infants under one year age and 69 deaths (11.8%) were due to tuberculosis, a total of 163 deaths (27.8%) out of the 587 such deaths, or twenty-eight out of one hundred. And of the 628 such deaths, in the year 1923, 73 deaths (11.6%) were of infants under one year age and 43 deaths (6.9%) were due to tuberculosis, a total of 116 deaths (18.5%) out of the 628 deaths, or nineteen out of one hundred such deaths; that is in the twelfth year following the year 1911, there was a falling off of 47 such deaths (8.0%) or eight out of one hundred such deaths. Again, had the birth-rate in 1923 been the same as it was in 1911, namely, 22.4 per thousand population instead of 19.4 and the death-rate under one year age the same as heretofore given for 1923, namely, 144 per 100,000, there would have been 64 such deaths (10.1%) per 1000 births, population mortality rate of infants under one year age, instead of 74 deaths (11.6%), out of the would be 635 deaths at all ages in the year 1923; and there would have been 37 such deaths (5.9%) due to tuberculosis to 1000 births, population mortality rate due to tuberculosis, instead of 43 deaths (6.7%), out of the would be 635 deaths at all ages, seven out of one hundred such deaths or one out of fourteen. Such would be deaths under one year age plus such deaths due to tuberculosis at the 1911 birth-rate, in 1923, would have numbered 101 instead of 116 per 1000 births in the year. On this basis in 1923 there were 15 such deaths fewer (12.9%) to the 1000 births than in 1911, showing a saving of one life to every eight births. Lives saved which, but for the work done in the care of infants and in the prevention of tuberculosis by public health service and volunteer health organizations in the State in the twelve intervening years, would have been claimed by death. 12 However, over all of this that implies trustworthy birth registra- tion, be it remembered, there rests the cloud of uncertainty; not so, though, as to that which pertains to tuberculosis, which shows a saving of 2460 lives in the year 1923, provided the tuberculosis death-rate of 1911 still prevailed. Let each of us do his utmost to attain a birth registration in Missouri that will deserve the recognition of the State's worthiness for admission into the birth registration area. You can help by buying, selling, using, Tuberculosis Christmas Seals. W.McN.M. - oo ACKNOWLEDGEMENT In presenting this survey of infant mortality in Missouri to the people of the State, bringing to their attention the triumphant achievement made in the reduction of deaths in infancy and from tuber- culosis in the State in the past twelve years, we wish to acknowledge that the attainment of these benificent results have been made possible only through the cooperation given this movement by the teachers and the pupils of the schools of the State. They have cooperated in the health education program and also have provided largely for the financial support of the movement by the selling of Tuberculosis Christmas Seals, practically the sole source of the State Association's financial support throughout the past dozen years. Particularly to the State superintendent of public schools and to the county and city superintendents of schools are we grateful for the cooperation which they have given us throughout this period, finding culmination in the incorporation of health education in the recently established State course of study. To these and to other friends we take this occasion again to ex- press our gratitude and again to request continuation of their support. MISSOURI TUBERCULOSIS ASSOCIATION (Dr. Walter McNab Miller) Executive Secretary. Missouri Tuberculosis Association 306 Odeon Bldg., St. Louis, Mo. ANNOUNCEMENT. We are pleased to announce that Mr. D. W. Clayton, former Missouri county superintendent of schools, later a high school inspector of the State Department of Public Schools, more recently engaged in the thrift work of the United States Treasury De- partment, and for the last three years the superin- tendent of city schools of Aurora, has entered into the service of the Missouri Tuberculosis Association. For the present Mr. Clayton will be engaged in field work for the Association in connection with health education work and the Christmas seal sale. This announcement is made in the belief that the teachers of Missouri will be pleased to know that Mr. Clayton again is to come into professional relationship with them in their work. MISSOURI TUBERCULOSIS ASSOCIATION Sept. 11,'24. (Dr. Walter McNab Miller) Executive Secretary. AUTOMOBILE vs. TUBERCULOSIS In Missouri in the year 1923 automobile accidents accounted for 398 deaths; tuberculosis for 3186 - one to eight. The death-rate from automobile accidents was 11.6 to 100,000 popu- lation; from tuberculosis, 92.2. The prevalence of automobile accidents is alarming; that of tuberculosis, by the same token, is frightful. Aside from the personal distress of the estimated 28,674 living cases of tuberculosis and the great wastage of human lives caused by the disease in the year 1923, there still was the tremendous economic loss to the State -- estimated to be $25,500,000. Death from automobile accident usually is sudden oi' follows after a few days; death from tuberculosis always is slow, from a few months to many years, usually a slow consuming wastage - CONSUMPTION. Death from automobile accident is not alto- gether preventable, tuberculosis is wholly so. Will you help prevent tuberculosis? You can do so by selling or by buying and by using, Tubercu- losis Christmas Seals. MISSOURI TUBERCULOSIS ASSOCIATION 306 ODEON BUILDING, ST. LOUIS, MO.