PUBLIC HEALTH BULLETIN No. 258 A STUDY OF MEDICAL PROBLEMS ASSOCIATED WITH TRANSIENTS FEDERAL SECURITY AGENCY U. S. PUBLIC HEALTH SERVICE WASHINGTON, D. C. Federal Security Agency U. S. PUBLIC HEALTH SERVICE Public Health Bulletin No. 258 A STUDY OF MEDICAL PROBLEMS ASSOCIATED WITH TRANSIENTS By CHARLES F. BLANKENSHIP Passed Assistant Surgeon and FRED SAFIER Associate Social Science Analyst United States Public Health Service From the Division of Domestic Quarantine in cooperation with The Divisionof Public Health Methods, National Institute of Health PREPARED BY DIRECTION OF THE SURGEON GENERAL UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON : 1940 For sale by the Superintendent of Documents, Washington, D. C. ------- Price 25 cents FEDERAL SECURITY AGENCY UNITED STATES PUBLIC HEALTH SERVICE Thomas Parran, Surgeon General Joseph W. MolntiN, Assistant Surgeon General, Chief of Division DIVISION OF DOMESTIC QUARANTINE ACKNOWLEDGMENTS All original data collected during this study were secured in and by the cooperation of agencies, both public and private, that give assistance to transients. In the Transient Case Study alone, approxi- mately 200 such agencies in 20 towns and cities gave office space and many types of help so that transients might be interviewed at the time of application for assistance. This cooperation often entailed considerable rearranging of worker time, office space, and method of handling beneficiaries. The United States Public Health Service hereby expresses its appreciation to all individuals and agencies that cooperated in mak- ing the study. The list of persons and agencies is too long for enumeration, but it may be said that almost without exception it includes all such agencies in the study cities. The administrators of several national organizations, both official and private, made available the resources of their respective field offices. Among these organizations are the Farm Security Administration, the American lied Cross, the Salvation Army, and the Volunteers of America. The State health officers in the States in which the Transient Case Study was conducted made the greatest single contribution by sup- plying interviewers needed to carry out the field work. Without this assistance, a study of this character could scarcely have been prosecuted. Field data of the syphilis study were collected by Dr. E. B. Brandes, Supervisor of the Shelter Care Division Hospital in Cincinnati; and Senior Surgeon John F. Mahoney, Medical Officer in Charge, Venereal Disease Research Laboratory, U. S. Marine Hospital, Stapleton, New York, performed the serological tests. Dr, J. D. Dunshee, of the Arizona State Board of Health, made all ar- rangements, actively supervised, and carried out the study of tuber- culosis among migratory agricultural workers in Maricopa County, Arizona, using equipment furnished by the State Board of Health. The Louisville City Hospital Study was made possible by Dr. Hugh Rodman Leaved, City Health Officer, who made the records avail- able, and Dr. P. E. Blackerby, Assistant State Health Officer, who supplied the clerical assistance to copy them. Assistance in the preparation of these materials was furnished by the personnel of Work Projects Administration Official Project No. 765-23-3-2. Finally, the authors wish to express their appreciation to the vari- ous members on the staff of the Division of Public Health Methods of the National Institute of Health for the advice and assistance given in the conduct of the study. CONTENTS Page Introduction 1 Summary and conclusions 5 Recommendations 16 PART I Migration and transiency 18 Mobility of the United States population 18 Social costs of migration 19 Volume of transiency 21 Family attachment 22 Size of the transient family 22 Age 23 Place of origin 24 Motives for migration 25 Rationale of migration 29 PART II Statutory limitations on public assistance to transients 33 Settlement law 34 History and development 34 Acquisition of settlement 36 Loss of settlement 39 Statutory provisions for relief to nonresidents 41 Statutory provisions for the burial of nonresidents 43 PART 111 Administrative practices of agencies giving public assistance to transients. _ 44 Agencies giving public assistance to transients 44 General function 45 Agency control 48 Restrictions on the type of medical care available to transients 50 Use of settlement restrictions against the transient 53 In out-patient departments 58 In tuberculosis hospitals 59 PART IV Illness and medical care 63 Volume of disabling illness 64 Disabling illness by diagnosis groups 71 Extent of medical care received by transients 74 Medical services operated specifically for transients 84 PART V Influence of transients on community health 87 Sanitation and housing 87 Diet and malnutrition 94 VI Page Influence of transients on community health—Continued. Effect of transients on existing communicable disease 96 Tuberculosis 97 Syphilis 109 Typhoid fever and dysentery 115 Smallpox 118 Meningococcic meningitis 120 Introduction of new communicable diseases 120 Creation of unusual and inconstant demands on public medical facilities 123 References 128 Transients building a home in California. A STUDY OF MEDICAL PROBLEMS ASSOCIATED WITH TRANSIENTS Introduction This study, initiated with the specific objective of investigating the public health problems that exist in or are caused by migration and transiency, consists of an analysis of available published material and a field study of case data collected in 20 cities in 15 States. The public health aspects of transiency have been recognized in general for a great many years. Previous studies were concerned very largely with specific problems as, for example, those carried out by the United States Public Health Service as early as 1913.1 The present study is intended to cover the major phases of the transient health problem, but for purposes of orientation, reference is made to the predisposing or exciting causes of migration or transiency, the problems occurring as a result of migration, and those arising from unusual or variable demands on medical facilities. Among the specific questions which the study will attempt to answer are the following: 1. What factors are associated in the causation of transiency, and how important is the desire for health as one of them? 2. What statutory provisions serve to discriminate against transients? 3. What are the administrative practices of agencies giving public as- sistance to transients? 4. What are the definite medical needs of transients, and how completely are those needs met? 5. What influence do transients have on community health? 6. How can the medical problems associated with transients and transiency best be solved? It is a matter of common knowledge that throughout the United States nonresidents or transients are treated differently from resi- dents in many of their contacts either with private social agencies or with governmental bureaus, departments, and local authorities. Recognizing the complexity of the requirements for eligibility for public assistance, as well as of the laws, regulations, and adminis- trative policies by which such requirements are put into operation, certain highlights of these social practices have been analyzed in the study, a discussion of which will be found in Parts I and 11. 1 See references (19), (75), and (110). 2 Even a cursory examination of the transient problem leads one to the conclusion that transiency is “the pathology of migration.” Hence, an understanding of the complex of migration is a pre- requisite to any practical solution of the problems associated with transiency. The term “transient,” as used in this study, may prove confusing unless it is understood at the outset that the word, although in common usage, has various connotations not only in the different geographical areas of the country but also in legal and administrative contexts. The term “transient,” as it is interpreted in this discus- sion, designates any needy person in any community who is dis- criminated against in that community’s program of material aid or medical care by the adoption of residence and technically related requirements. Putting it into the simplest possible terms, the group of persons referred to here as “transients” is made up of those persons “on the road” who are unable to maintain themselves insofar as the necessities of life are concerned. Among the necessities which these individuals find themselves unable to secure through their own resources is medical assistance of all kinds. It was there- fore with specific reference to the availability of medical assistance and the transients' need for it that this study was initiated. Sources of data.—ln the bibliography attached there will be found a list of available documentary or previously published material con- sulted in the course of the preparation of this bulletin. Citations and reference sources are noted throughout the text. TRANSIENT CASE STUDY In the spring of 1938, a total of 1,893 transient families and 9,040 unattached transients were interviewed by trained case workers in 20 cities distributed over 15 States of the United States. The data on each case had to be secured in one interview, inasmuch as there was no certainty that the same individual or case could be reached again. Persons interviewed were those applying to social or medical agencies for assistance of some kind. In each instance the interview was con- ducted after it had been determined that the applicant was a “tran- sient” or nonresident. The interview was conducted before any decision on the application had been made. Inasmuch as the transients interviewed for this study constituted a mechanically controlled random sample of all transient applicants in the city at that time, and since each individual interviewed was automatically a transient because he had been so classified by an official of some public assistance agency, the sample is believed to be representative and of sufficient size to merit detailed analysis. In 3 this connection it might be noted that in some States the act of classi- fication by an official of some agency as a nonresident is virtually the only one necessary to determine transiency. In the selection of towns and cities to be studied,2 care was taken to include representative parts of the country, towns and cities show- ing the greatest concentration of transients, and various types of transients. The last-named consideration is thought quite important in a survey of the entire transient problem. Within the selected towns and cities, every organization rendering any type of assistance to transients was included in a preliminary survey. Based on estimates of the number of transients seen by the several agencies, a selection of agencies to be studied was made so that approximately 90 percent of the current flow was represented. Furthermore, the selection gave equal consideration to those of all types, social and medical, case-work and mass-care, handling either families or unattached cases. In all, about 200 agencies were selected for study. Sampling within the agency was controlled so that the same pro- portion of all applicants was interviewed in each of the types of agencies. Interviewing was conducted over a period of 6 weeks and simultaneously a count was taken of all applicants to the selected agencies so that the flow was measured and the sampling periodically adjusted. trained case workers under both local and regional supervision completed the interviews. The case data thus collected are based on depositions made by individual transients. While it is not possible to verify these data, they are believed to be as reliable as any information secured by the interview technique. STUDY OF AGENCY PRACTICE In order to determine the manner in which public assistance of the several types is given to transients, the restrictions placed upon aid to this group of persons, and the administrative practices of agencies giving aid to transients, as compared with their statutory provisions, schedule data were collected by interviewing the responsible heads of the several medical and social agencies in the 20 cities included in the Transient Case Study. Data were compiled on the 432 agencies that had given' some type of assistance to one or more transients during the month preceding the interview. Agencies refusing free care to transients were not included in the analysis. 2 Phoenix and Tucson, Ariz.; Hot Springs, Ark.; El Centro, Los Angeles, and Stockton, Calif.; Denver, Colo.; Jacksonville, Fla.; Atlanta, Ga.; Boise, Idaho ; New Orleans, La.; Minneapolis, Minn.; Albuquerque and Roswell, N. Mex.; Cincinnati, Ohio ; Philadelphia, Pa.; El Paso and San Antonio, Tex.; Ogden, Utah ; and Seattle, Wash. 4 TUBERCULOSIS STUDY An additional body of data on the incidence of pulmonary tuber- culosis among transients was secured through collecting chest roent- genograms of migratory agricultural workers in 19 cotton camps in Maricopa County, Ariz. For this purpose a mobile X-ray unit was used. All cotton camp tenants over 14 years of age and within a reasonable radius of the unit were invited to come in for examination. A total of 583 persons responded and were given the X-ray exami- nation. The films thus collected were interpreted independently by two roentgenologists, one from the staff of a local tuberculosis diag- nostic clinic and the other from the United States Public Health Service. When interpretation of the films was made, one or both of the roentgenologists occasionally classed the film as “suspicious” insofar as the presence or absence of “active pulmonary tuberculosis” was concerned. When the interpretations of the two roentgenologists were different, the case was tabulated as “negative” in preference to “suspicious” or “active.” Similarly a case was called “suspicious” in preference to “active” if both interpretations appeared on a single film. In this way the cases tabulated as “active” represent only those on which there was complete agreement. TRANSIENT SYPHILIS STUDY In order to investigate the incidence of syphilis among transients, beneficiaries of the Shelter Care Division Hospital of the Cincinnati Department of Safety were chosen as the population to be studied. The institution handles a relatively large number of transients and requires that each beneficiary have a physical examination by the medical staff soon after admission and once a week thereafter. In every case, on admission the applicant is classified by a trained social- service worker as “local homeless,” “State transient,” or “nonresident.” This classification made possible a comparative study of the several groups. Blood specimens from 1,170 beneficiaries of the hospital were examined by the Kahn and Kolmer techniques in the United States Public Health Service Venereal Disease Research Laboratory at Stapleton, New York. LOUISVILLE CITY HOSPITAL STUDY As a measure of illness experience and of the frequency with which transients are accepted or rejected at large city hospitals, a study was made of the records of 1,488 applications to the Department of Ad- missions at Louisville (Ky.) City Hospital. This group of applicants 5 is essentially similar to those considered as “transients” throughout this study. It is recognized that a few of the applicants may not have been needy and in that sense not transients, but it is not believed that the number is large enough to prejudice the validity of the group as a transient group. CALIFORNIA GENERAL HOSPITAL STUDY In March 1939, a questionnaire was sent to each of the 66 general hospital in California, under county or nonprofit association control, listed in the 1939 Hospital Number of the Journal of the American Medical Association. The responsible authority of each hospital was asked to supply data on the number of transients admitted to in- patient service during 1938, on either a free or part-pay status. Re- plies were received from 42 hospitals. The resulting data on the num- ber of transients hospitalized during the year are believed to consti- tute a satisfactory sample on which to base some conclusions as to the cost of hospitalization of transients in an area where the problem is particularly acute. Summary and Conclusions There is in the United States a large but fluctuating number of needy individuals, variously estimated at 200,000 to 1,000.000, who are discriminated against in programs of material aid and public medical care by the application of residence and technically related require- ments. Such persons are called “transients” in this study. The study is limited to the continental United States and is con- cerned with the health of transients as it is affected by their mode of life and social opportunities. It attempts to determine: (1) The origin of transiency from migration and the importance of lack of health as a cause; (2) the statutory limitations on public assistance to transients; (3) the administrative practices of agencies giving as- sistance to transients; (4) the medical needs of transients; (5) the influence of transients on community health; and (6) the most equi- table and practical solution of the medical problems of transients and transiency. Original and documentary data related to this subject are presented. Sources of published material used are given in the references. Orig- inal data collected and used include: («) About 11,000 schedules re- corded by trained workers in 20 cities of 15 States, containing the migration history, personal characteristics, and disabling illness and medical care history during a 3-month survey period of some 16,000 transients who were applying for public assistance; (6) 432 schedules on the admission policies of public assistance agencies in the same cities; (c) records of application of 1,488 transients for in-patient 6 care at a large charity hospital; {d) serological reactions of 1,170 inmates of a large municipal shelter for homeless men; (e) results of chest X-ray examinations of transients in 19 cotton camps in a south- western State; and (/) replies from 42 local governmental and non- profit association general hospitals in California to a questionnaire concerning the number of transients hospitalized during 1938. MIGRATION AND TRANSIENCY Migration lias been an outstanding characteristic of the people of the United States. Students of migration in this country are convinced that, since the forces causing it are still operative, it will continue and may increase in the future. It produces not only demographic effects, in that the age, sex, and race compositions of populations are materi- ally influenced, but also a number of effects on social organization in general and community, family, and individual adjustment in par- ticular. It is in the failure of individuals to orient themselves prop- erly to new environments, especially in their failure to maintain or secure economic self-sufficiency, that transiency arises. It seems indisputable that, if migration is to continue, and some proportion of the migrants may be expected to fail in their attempts at rehabilitation, social planning should be directed toward guiding the streams of migration and relieving the destitution of the unsuc- cessful. These functions can be carried out successfully only by coop- erative Federal and State action. Interstate migration is motivated largely by economic need, and only a small part of the whole is caused by ill health. Practically all the pathological conditions for which transients move across State lines are pulmonary, usually tuberculosis, and most migration of this type is directed toward the Southwest. It is estimated that there are now in the southwestern States at least 10,000 tuberculous transients who are unable to pay for needed sanatorium care. The highest pro- portion of individuals who became migrants because of health was found among transients interviewed in Hot Springs, Ark., followed in order of importance by Tucson, Ariz,; El Paso and San Antonio, Tex.; Denver, Colo.; and Los Angeles, Calif. By place of origin the highest proportion of health migrants was found among transients from the* eastern States. One part of migration, usually not recognized, is that which was started because of economic conditions but turned toward the Southwest because of ill health. Another large part of the transient problem that has been ignored in most studies and writings is intrastate migration. It is princi- pally rural-urban and a considerable proportion of the individuals move in search of medical care—a factor found to be almost negligi- ble in interstate migration. 7 No exact census of transients in the United States has ever been possible because of the very nature of migration and transiency. An estimate, based on data collected during the first quarter of 1938, indicates that some 400,000 transients applied for public assistance in 1 year throughout the country. Data on transient cases in 1934 and 1938 indicate that families make up about one-fifth of the total cases, although the percentage probably is much higher in some cities. The transient family seems definitely to be increasing in size, particularly among transients from the States furnishing the greatest part of the transient popula- tion. There is also some evidence that the largest families are the least mobile. In general, transients are younger than residents on the relief rolls. As between interstate and intrastate transient family heads, the in- terstate group contains the smaller proportion of persons 55 years of age and over and of youths under 25 years of age, while among the unattached the interstate group shows the smaller proportion of aged but a greater proportion of youths. If classified according to the last State in which they had lived for as long as 1 year, practically half of the family transients inter- viewed came from 4 States, Oklahoma, Arkansas, Missouri, and Texas, and half the unattached interstate transients came from 11 States. About TO percent of the families and 77 percent of the unattached had been migrants for less than 1 year, while among those who had been migrants for as long as 2 years practically all of the family cases and more than nine-tenths of the unattached had lived in the State of interview 1 year or more. These data indicate that the transient population is not, as is often stated, made up largely of a group of individuals who have chosen a life of migration. While some few do follow a pattern of seasonal movement or just wander from place to place as oppor- tunity for economic improvement presents itself, it is believed that approximately three-fourths of the interstate transient group is made up of families and individuals who are in the process of relocation. STATUTORY LIMITATIONS ON PUBLIC ASSISTANCE TO TRANSIENTS The majority of States have among their statutes so-called “poor laws,” “pauper laws,” “public assistance laws,” or “public welfare laws.” In these laws the State imposes upon itself or its political subdivisions the obligation to relieve the destitute. Provision for public medical care usually is embodied in these laws—hence relief for the sick-poor is set within the framework for relieving destitu- tion. 8 In 39 States the “poor laws” include other sections called “settle- ment laws” in which, with few exceptions, it is provided that the benefits of relief to the destitute are to apply only to persons defined by law as residents of the State or certain of its political subdivisions or both. There may or may not be further provision for the medical relief of nonresidents. The history of settlement law may be traced to the feudal era in England. The English influence in this country is partly due to the legal concepts inherited and brought from England by the first colonists who, if not always racially identical, were culturally sim- ilar to the English. Settlement laws of the original colonies have served as models for subsequent State settlement laws. Another reason for the adoption in the United States of settlement laws closely resembling those of England during the seventeenth century is found in the similarity of social and economic conditions existing in the original colonies and England at that time. In both countries the chief occupations were agricultural and, with a relatively limited labor supply, the laboring classes were surrounded by a series of restrictions designed to attach them, as far as possible, to the locale where they happened to be settled. However, the most important reason for the existence of settlement laws, and the most important consideration in discrimination against the transient today, is the attempt of the individual communities to protect themselves from persons likely to become dependent. “Commorancy" or residence, as such, in a given locality and over a stipulated period of time is a common prerequisite to settlement in the laws of all States, and the list of conditions under which residence must be accomplished in the various States is a long one. On the subject of where a person must have lived to acquire resi- dence, the 39 States having settlement laws have 13 different provi- sions. This confusion alone has contributed a great deal to the difficulties involved in dealing with transients. Provisions in regard to the length of residence required for settle- ment are more complex. Time required varies not only between States, from (i months to 5 years, but often between political subdi- visions within States, according to the person's financial status, his property ownership, or his state of health or that of members of his family. Analysis of the provisions of the settlement laws over a period of 25 years shows that during that time one-third of the States have increased the period of residence required for settlement. Settle- ment laws in all but seven of the States having such laws make restrictive provisions that bear on either the continuity of residence or its chronological precedence to application for public assistance. 9 Sixteen States void the entire period of residence if it is interrupted by a period during which the person is not self-supporting and, in others, provisions change the period required if the individual re- ceives specific kinds of support. Citizenship is a prerequisite to settlement in one State and in one county of another State. In three States persons may be prevented from acquiring settlement in a town or county by a formal warning from the authorities to depart. Several States provide that employ- ees and patients of State institutions either may not gain settlement or may do so only after a relatively prolonged period. Statutory enactments on loss of settlement may be as effective in barring transients from public assistance as those relating to acquiring settlement. The situation regarding loss of settlement is less complex only because fewer States have statutes on the subject. Three States provide for loss of settlement solely on acquisition of any new settlement, six on acquisition of a new settlement in another State, and nine on acquisition of a new settlement within the same State. Eighteen States provide for loss of settlement by absence for a specified period which varies from 1 month to 5 years. In six States, the stipulated period for loss of settlement is less than is that for acquisition, and one State voids settlement after assistance as a pauper for 5 years. Thirty-nine States make provision in their poor-laws for the relief of nonresidents. In 32 States it is mandatory, in 2 it is mandatory for certain cases only, and in the other 5 the statutes are only per- missive. In 24 States responsibility for the relief rests on local political units, in 3 States the State alone is responsible, while in 10 States there is joint responsibility. Relief to nonresidents in some States is available only to those who are sick; in other States it depends on funds being available. Several States limit such relief to those “who have been committed to jail,” “have been injured on the State highways,” or “who are indigent by reason of physical or mental infirmity.” Others specify “State paupers” (undefined) or “those who are not residents of any individual township.” Probably the most important restriction on assistance to nonresidents is the stipulation, made by 19 States, that such aid be temporary or emergency only. The settlement laws are the embodiment of a discrimination which most States and communities exercise against persons who have be- come or who are likely to become dependent on the community for assistance. Formulated originally both to protect the poor-funds of the community and to restrict the movement of needed workers, they have been handed down to a society in which the free movement 10 of labor is essential and economic distress in local governments is almost universal. The result of such a combination is easily predicted. Many migrants have lost all rights to assistance in any State. Others are entitled to receive only “emergency” assistance, and the majority have no governmental organization to which they can turn for aid. It should be emphasized, however, that the settlement law per se is not the cause but only the statutory method through which transients are made the object of discrimination. Discrimination is equally definite where no such statute exists. ADMINISTRATIVE PRACTICES OF AGENCIES GIVING PUBLIC ASSISTANCE TO TRANSIENTS Three-fourths of the 432 agencies that assist transients in the 20 study cities are social, i. e., their primary function is to dispense gen- eral relief; and one-fourth are primarily medical. Medical agen- cies, however, handle only 13.1 percent of all applications from transient families and 7 percent of those from unattached transients. A count of transient applications in 1938 indicated that, in addition to the applications for aid at medical agencies, 2.7 percent of those rd social agencies were also for medical care. In the 20 cities there are the same number of hospitals that give assistance to transients as there are clinics (or out-patient departments). General hospitals represent almost 63 percent of such hospitals, and maternity hospitals about 20 percent. Of the 324 social agencies, 57 percent are mass-care agencies and they handle two-thirds of all applicants to social agencies. The remaining 43 percent are case-work agencies and handle one-third of the cases. Thirty-two percent of agencies providing medical care to transients are under governmental control, while among those not giving medi- cal attention to transients the percentage is only 13.3. However, the governmental-agency applications included three-fourths of all persons who applied to medical agencies and one-third of all who applied to social agencies. Of all agencies giving medical care to transients, more than one-third restricted the care to emergency service only; another third gave ordinary care to selected cases only; and less than a third had no restrictions upon the type of medical attention furnished. Of the 146 general hospitals in the 20 cities, only 30 gave any medical care to transients and only 7 gave it without restrictions. Data on residence requirements of out-patient departments in general hospitals of the United States were available in studies from 11 the National Healtli Inventory. These show that while only slightly more than half of all out-patient departments, both free and other, make residence requirements for eligibility for care, 91 percent of local governmental and 73 percent of State out-patient departments do so. Regardless of location with reference to settlement law and of the organization in control, discrimination against the transient in public assistance agencies is the rule, and public assistance agencies that treat transients on the same basis as residents are the exception. The findings (1) that governmental agencies handle the greater part of applications to medical agencies, (2) that a higher proportion of governmental than of nongovernmental general hospitals give free care to transients, and (3) that a greater proportion of them adhere to the settlement restrictions, were to be expected. That almost half of all governmental as well as nongovernmental agencies ill States with settlement laws have stricter settlement requirements than the law provides is not so well known. This seems to indicate that it is not entirely the settlement law that deprives the transient of relief. The analysis of agencies in the 20 cities by restrictions upon type of care given is probably a representative picture of the provision of medical care to transients. When it is seen that almost two-thirds of the agencies giving medical care to transients restrict the care to either emergency or selected cases, the difficulties facing the transient who requires medical care are at once apparent. ILLNESS EXPERIENCE AND MEDICAL CARE OF TRANSIENTS COMPARED WITH THOSE OF RESIDENTS It was found that 13.6 percent of the 9,040 unattached transients who were interviewed and 21.7 percent of the 7,105 transients in interviewed family cases had had disabling illness during the 3-month survey period. Interstate family transients had a 74 percent higher disabling illness rate than did residents, and the rate for interstate unattached transients was 45 percent higher than that for residents of comparable age and sex. Transients not only had a higher dis- abling illness rate than all residents considered in the Health and Depression Study, but higher even than the “poor” residents. On the basis of mobility, transients who have been migrants less than 2 years have less disabling illness than those who have been migrants a longer period of time, and as the period of stay in the State of interview increases, the disabling illness rate becomes higher. In any comparison of disabling illness rates between interstate and intrastate transients, if only the individual making the application for 12 public assistance is considered, the intrastate group exhibits a higher rate of disabling illness, and makes a considerably higher proportion of applications for assistance to medical agencies. Analysis of disabling illness by diagnosis groups shows that inter- state transients have, like residents, the highest disabling illness rate from the respiratory diseases. In the unattached, this diagnosis group is followed, in order of importance as a cause of disability, by accidents, puerperal conditions, communicable diseases, and diges- tive diseases. Degenerative and nervous conditions and rheumatism fall at the end of the six most important groups. Among family interstate transients, communicable diseases, puerperal conditions, digestive diseases, degenerative diseases, and accidents follow res- piratory conditions in order of importance. The disabling illness rates of all interstate transients exceed those of residents for all conditions except degenerative, nervous, and rheumatic diseases. The greatest excess of disabling illness among interstate transients, as compared with residents, appears in the un- attached who seem to have more than seven times as much disability from communicable diseases and almost five times as much from accidents, as do residents of comparable age. From these data it is seen that transients, either interstate or intrastate, have considerably more disabling illness than persons who have resided in communities long enough and under such conditions as to have the status of residents. Intrastate transients have even higher disabling illness rates than do the interstate. It is believed that this difference is due to the greater proportionate migration of intrastate transients to cities in search of public medical care which they do not believe is available to them at home in smaller communities. That a larger proportion of intrastate than of interstate transients’ applications were to medi- cal agencies is a corollary of their search for medical care. Data on disabling illness rates by degrees of mobility definitely suggest a health selection in migration. The pattern appears to be as follows: Among all interstate transients the most recent migrants have the least number of disabling illnesses, and as migration con- tinues the incidence of disabling illness increases. However, as ill- ness strikes more frequently, the result seems to be that migration is delayed and often the migrant settles down in some community and eventually becomes a resident. This tendency may be respon- sible for the high rate of illness and disease found in cities among the local homeless, many of whom may well be former interstate tran- sients disabled for migration by chronic or recurring diseases. There are several reasons why transients exhibit a very high rate of disabling illness. First, they are more likely than residents to suffer 13 accidents while traveling from place to place. They are exposed to the risk of communicable disease to a much greater extent than are residents, who do not often live in the insanitary conditions found in camps, shelters, and other forms of temporary habitation, A second and more important reason for a high disabling illness rate among transients is that they are “marginal” individuals. A majority of them start migration because they are unable to support themselves at home, and it has been shown repeatedly that the poorest fraction of the population has the highest illness rates. Third, some of those found as transients have migrated because they are ill, and finally the very fact that they receive less medical care than needy resident groups may well tend to increase their illness rates. One-ninth of all disabling illness experienced by members of transient families (but excluding families headed by persons eligible for Federal hospitalization) was hospital- ized, less than a third received only the attention of a physician, and almost three-fifths did not come to medical attention. For similar illnesses residents received 3.2 percent more hospitalization, 21.4 per- cent more attention by physicians, and some type of care in 24.5 percent more of the illnesses reported. A considerable proportion of the unattached interstate transients interviewed are eligible for Federal hospitalization. One-ninth of all unattached transients were beneficiaries of this service as United States veterans, and 3.4 percent were eligible for medical care as merchant sea- men. These two groups received some kind of medical attention for 83 percent and 96.4 percent of their disabilities, respectively, while only 66.2 percent of those experienced by other unattached transients were given medical attention. Veterans were hospitalized for 50.2 percent of their reported disabilities, seamen for 40.3 percent, and other unat- tached transients for only 28,3 percent. Data on 1,444 nonresident applications for in-patient care at Louis- ville City Hospital show that those by Kentuckians constitute more than half of the total. About three-fourths were made by white per- sons and slightly more than half by females, the excess of females over males occurring principally in the age group 15-24. The greatest num- ber of intrastate applicants (Kentuckians) in relation to the population of the place of residence came from counties touching Jefferson, the county in which Louisville lies. Disposition of the transient applicants at this hospital was as fol- lows: (a) 43.7 percent were admitted; (b) 11.6 percent were referred to other hospitals; (c) 3.6 percent were referred to practicing physi- cians; and (d) for 41.1 percent no provision for medical care was made. The proportion by place of residence of applicants accepted for bed care at Louisville City Hospital was between 40 and 50 percent for all nonresidents except those from Jefferson County, only 8.6 percent of whom were admitted. 14 Discrimination against transients was discussed from the viewpoints of cause, history, trends, and modus operandi. Data on medical care received by transients show the results of this discrimination. No class or type of transient, except special beneficiaries of the Federal health services, receives as much medical care as even the poor in resident groups. Although most students of the subject agree that care re- ceived by many residents is not adequate for the maintenance of health,, transients receive even less care than do residents. THE INFLUENCE OF TRANSIENTS ON COMMUNITY HEALTH Transients may be found living under all kinds of sanitary condi- tions. While some transients resemble, in their hygienic surround- ings, residents of the same economic status, a greater proportion are forced to exist under almost every imaginable variety of insanitary condition. Wretched housing among transients is found in every State, but more frequently in the Southwest since transients are found there in the greatest numbers. The majority of transients live in temporary shelters that range downward in degrees of sanitation from the Farm Security Administration camps and the better grower camps, through the worst of grower camps and the poorer tourist camps to the most insanitary of all, the squatter camps or jungles. In the latter are often found all conceivable violations of hygienic standards in excreta disposal. The water supply even for drinking purposes is often the nearest stream, pool, or irrigation ditch. Seri- ous overcrowding in the shelters is almost universal even in the grower camps. As a result of these conditions a high incidence of typhoid fever and, particularly, of dysentery, occurs among transients, especially among the migratory agricultural workers. On the basis of dis- abling illnesses reported by transients in interviewed cases, the inci- dence of typhoid fever was approximately 34 times as high as among all residents of the United States in 1938. Various organizations have been vitally concerned with this aspect of transient life, and there is some evidence that housing conditions in general are improving. Both the Farm Security Administration camps and those grower camps built and maintained under the juris- diction of competent health authorities have done a great deal to im- prove the living conditions of transients. It remains to be seen whether good camps can be provided in sufficient number to raise the standard of sanitation for any significant number of transients. No thorough studies of the diets of transients have been made, but a partial one showed that on the basis of milk consumption the diets of transient children are very inadequate. Since the majority of migratory agricultural transients in the Southwest come from the 15 West South Central States, their diet is very likely to be that of the poorer residents of those States, made even more inadequate by the financial distress into which the transients have fallen. It is believed by all competent observers that their diets fall far short of minimum requirements in total calories, vitamin and mineral content, and digestibility. As evidence of the results of inadequate diets among these tran- sients it was found in one study of the children of migratory agri- cultural workers that 27.9 percent of them had nutritional and dietary defects, not including dental caries and decalcification. Dur- ing the Transient Case Study 6 transients were interviewed who had been disabled by pellagra, a deficiency disease, during the 3-month survey period. The cumulative effect on future health in the western States of allowing children to subsist on very inadequate diets is one that should be given serious consideration by health authorities. The incidence of active pulmonary tuberculosis among all tran- sients who apply for public assistance is probably around 2 percent for the country as a whole and somewhat higher in the Southwest. In some cities to which there is considerable migration because of pulmonary conditions and in which migratory labor is not in very great demand, the incidence of active pulmonary tuberculosis among transients may be as high as 9 percent. Almost without exception the nonresident or transient tuberculous person is excluded from the sanatorium or must spend a long time in residence before hospitalization. This can mean only that he is forced to continue spreading the infection to nontuberculous indi- viduals. According to a survey of unattached homeless men in one city, the incidence of serologically detectable syphilis appears to be about 8 percent for white interstate unattached transients and about 29 per- cent for colored. This is approximately 2 percent less than the rates determined for the corresponding local homeless groups in the same city. As in tuberculosis, the transient with syphilis is usually “in- eligible” for public treatment, despite the fact that one of the most important public health considerations in the treatment of syphilis is the protection of the rest of the population by making each case noninfectious. Smallpox is not only occurring at a high rate among transients but is being spread by them from one community to another and from State to State; meningococcus meningitis epidemics also seem to be encouraged by the housing of transients in congregate shelters. A very great danger to the health of communities exists in the possibility of the introduction by transients of relatively unknown diseases. For example, all the known requirements for the intro- duction of malaria into a number of States exist in the transient 16 situation today. This disease and trachoma are probably now being carried to California and other parts of the West by transients from the South Central States. A very important effect of interstate transients on communities is the cost of public medical care given to them. For hospitalization alone it has been estimated that transients cost Los Angeles County (Calif.) $170,000 annually. From the records of admissions of inter- state transients to 16 county hospitals in California, an annual cost per county of $26,000 was estimated. The Louisville (Ky.) City Hospital Department of Admissions estimates that the hospitaliza- tion of nonresidents in this institution cost Louisville taxpayers about $14,000 in 1937 and around $9,000 in 1938. It is of interest to note that more than half the applicants and transients admitted to this institution were intrastate transients. The effect of transients on community health is to increase the hazard of ill health to residents and to raise the incidence of most of the communicable diseases. The incidence of tuberculosis, syphilis, gonorrhea, and malaria almost certainly is increased in a community by adding transients to the resident population. This is partly due to the higher rate of these conditions among transients; but it results chiefly from the fact that transients are not given equal considera- tion in community programs of sanitation, preventive medicine, and isolation of infectious cases of communicable disease. The discrimination noted against diseased transients in hospitals, sanatoria, and clinics undoubtedly has an economic basis. The cost of hospitalization for the average long period of institutionalization in pulmonary tuberculosis is so high that no community feels willing to provide facilities or pay for hospitalizing nonresidents with this condition. Hence there result the settlement laws with their special restrictions against persons with pulmonary tuberculosis. The States have felt that if nonresidents were admitted to State tuberculosis sanatoria it would serve only to attract more indigent tuberculous persons from areas where free hospitalization for this disease is not available to all persons suffering from it. The data presented on the cost of public hospitalization now being supplied to transients in general hospitals seem to show that an enor- mous load from this cause is being carried by some communities, in spite of the fact that transients generally receive considerably less medical care and hospitalization than do residents. Recommendations The conclusions expressed in this report have resulted from the anal- ysis of original data collected during the course of the study, from the various studies, books, and articles published on transiency and related subjects, and from the advice and counsel of various authorities. 17 Specific recommendations as to the most equitable and practical solution of the medical problems associated with transients are: (1) In any plans formulated, the basic consideration that migration and transiency are permanent characteristics of American society and economy must be given a prominent place. (2) There should be a national policy on migration, and an.organization to direct and influ- ence migration should be created on the Federal level. (3) There should be instituted a program of hospital and sanatorium construc- tion and maintenance and of public medical care for the medically needy, through the combined efforts of the Federal Government and the States, that would make available in every State adequate medical care and a public institution bed for each needy individual who re- quired it. These services should be similarly available to all needy persons regardless of residence status. In the case of transients with pulmonary tuberculosis and other chronic debilitating conditions, pro- vision should be made for returning these cases to the last State in which they had legal settlement if it is certain that proper medical care, including hospitalization, is immediately available there and if if is not more important socially that they be hospitalized as transients. (4) The presence of a considerable number of interstate transients in any State should be recognized as a special health problem in the allot- ment of Federal funds to States for the maintenance and improvement of local public health facilities. (5) The Federal Government should neither formulate nor contribute funds to a health program organized exclusively for transients. Determination of the transient’s settle- ment status, the investigation of his financial need, and his certification for any needed medical care should be handled by such public social organizations and personnel in each community as carry out similar functions for residents. Determination of medical need and adminis- tration of all public medical care given to the transient should be allo- cated to that public medical agency in each community charged with similar responsibilities for needy residents. Part I MIGRATION AND TRANSIENCY MOBILITY OF THE UNITED STATES POPULATION The extraordinary geographic mobility of the American people lias been a subject for comment by a host of both native and foreign observers. The whole development of the civilization of this conti- nent is, directly or indirectly, associated with migration. Immigra- tion settled these shores; internal migration peopled the continent. The westward trek of the nineteenth century is still in our memories. In fact, there is even now a significant east-to-west trend in migration. Since the end of the nineteenth century, however, there has been a simultaneous and parallel migration from west to east, as well as a significant, if less well defined, movement between the north and the south. These are the currents that would appear heaviest if a flow map were drawn to scale showing the numbers of migrants concerned. Three other migrational tendencies, however, have contributed and are at present more than ever contributing to the phenomenon of our tremendous mobility. One is the classic rural-urban pulsation, which, in contrast to the other movements mentioned, is not peculiarly American but is characteristic of all countries or regions that are in the process of industrialization.1 This has, in general, taken the form of migration from the farms and rural communities to the city. Recently, however, as a result of the depression, there has been a city-to-farm movement as well.2 Still another migration pat- tern is that incidental to the seasonality of certain trades and indus- tries, preeminently in agriculture. Finally, there is the migration caused by trades in which, seasonally or otherwise, the labor demand has varied so much from week to week, or from day to day, that it lias brought about a certain shifting labor supply known as casual labor. Migration is a phenomenon of both the past and the present and may be expected to continue. That it will be a problem in the future is suggested by three considerations: (1) The factors conducive to migration are still operative; (2) in the opinion of a number of 1 There is attached a composite reference list covering what are believed to be the significant publications bearing on the subjects discussed. If specific citation is made, publications are referred to by number, e.g. (-}•}). 2 See especially (51) and (113). 19 authorities, sound economic policy will, in the future, demand addi- tional migration particularly from certain problem areas that are harboring a larger population than they can support;3 and (3) there is evidence that the mobility of Americans is increasing. The Na- tional Resources Committee has pointed out that the proportion of the native population living outside the State of birth has increased steadily since 1890.4 Migration must, therefore, be accepted as a social phenomenon that will continue. Its effects must be reckoned with in all social planning. Since it is obviously impossible to ignore migration and futile for social agencies and the law to discourage it, an examination of some of its social costs becomes pertinent so that transiency, one of the problems, may be considered in proper perspective. SOCIAL COSTS OF MIGRATION Although it has been contended that the social interrelations af- fected by migration are fewer in modern society than in a more primi- tive one, the effects of present-day migration are, nevertheless, evident and. in view of the greater population involved, more intense. First are the demographic effects, many of which are so well recognized that they are considered part of social law.5 Migration may well have direct relationship, for example, to the differences in birth rates between city and rural communities. The trend of migration from rural communities with high birth rates to cities with low birth rates undoubtedly exerts a negative influence on population growth, especially since the effect of the newcomer’s need for economic adjustment in the city is further accentuated if he belongs to one of the racial minority groups. Migration may also influence birth and death rates by changing the age and sex composition of whole communities, if not by more subtle changes in social attitudes and characteristics. Migration may have an even more direct demographic influence either in the area from which it originates or that to which it is directed. Certain regions attract the aged and are correspondingly affected by the change in the age composition of their populations.6 Cities ordinarily attract the able-bodied at their most productive age, but farm-to-city migration, just as migration in general, is said to be sex-selective and to contribute further to the disproportion of women over men usually present in cities.7 There is some indi- cation that women are more migratory than men and predominate 3 See (51), (113), and (7), 4 See ( Persons included in the selected sample of transients applying for public assistance in 20 cities covered by the Transient Case Study. The Study extended over a 6-week period between March 8, 1938, and May 7,1938. 2 The Southwestern resort States include Arizona, Colorado, and New Mexico. Table 54.—Distribution of a selected sample1 of unattached interstate transients and of adults in interstate transient families with history of tuberculosis, according to area of interview and family attachment All per- sons in eases inter- viewed Persons with history of tuberculosis Area of interview and family attachment Number Percent of total per- sons in cases inter- viewed 12,182 284 2.3 3,064 90 2.9 1,614 1,460 9,118 2,280 6,838 50 3.1 40 2.8 194 2.1 50 2.2 144 2.1 2 Persons included in the selected sample of transients applying for public assistance in 20 cities covered by the Transient Case Study. The Study extended over a 6-week period between March 8, 1938, and May 7,1938. 2 The Southwestern resort States include Arizona, Colorado, and New Mexico. Considering the difference between the percentages of all transients with a history of tuberculosis in the two areas, as shown in table 53. and the size of the transient population in relation to the total popula- tion of the two areas, it is apparent that the load from tuberculosis in transients falls much more heavily on the cities of the resort States. In table 55 this unequal distribution is shown on an annual basis in terms of transients with a history of tuberculosis per 100,000 population. Still another way of showing the proportion of tuberculous persons among transients in the cities of the Southwest is illustrated by table 56 which lists certain causes of migration. It will be seen that more than 1 percent of all unattached transients started migration specifi- 107 cally because of tuberculosis. When asthma, hay fever, chronic bron- chitis, and other pulmonary conditions are included, the figure for “pulmonary migrants” becomes 3.8 percent. The corresponding rates for family interstate transients (based on one possible case to the family) are 0.9 percent and 2.2 percent. Table 55.—Distribution of total transients1 applying for public assistance in 20 cities and of transients with history of tuberculosis, according to location of city Location of city Estimated annual num- ber of tran- sients in all cases apply- ing to all agencies 1 Estimated annual num- ber of tran- sients with history of tuberculosis Population 1930 (in thousands) Number of transients with history of tubercu- losis per 100,000 popu- lation Total 348,000 7,000 6,213 113 Cities in resort area 2 113.000 2, 500 406 616 Cities in rest of United States 235,000 4, 500 5.807 77 1 Estimated for 1 year. In arriving at the estimated number of transient applications for the entire year, use was made of data from the records of the Federal Emergency Relief Administration Transient Bureau in 1935 on the flow of transients by month by States, and of data from the Transient Case Study. This method is believed to be sufficiently accurate for an estimate of the total annual transient flow. The sea- sonal fluctuations in the size of the transient population in the Southwest are influenced largely by the matur- ing date of the local crops and by prevailing weather conditions, neither of which have changed materially during the 3-year interval, 1935-38. 2 Southwestern resort States include Arizona, Colorado, and New Mexico. Table 56.—Distribution of a selected sample1 of interstate transients in the resort States2 with different motives for migration, according to family attachment Motive for migration Health All transients Condition for which migration began Non- health Family attachment Total2 Pulmonary Total Tubercu- losis Other pul- monary Other Number Total 3,865 2,772 1,093 173 102 37 65 71 3, 692 Family transients 2 105 61 25 36 44 2,667 1,025 Unattached transients . 68 41 12 29 27 Percent Total 100.0 4.5 2. 6 1.0 1. 6 1.8 95 5 100.0 3.8 2. 2 .9 1. 3 1. 6 96 2 Unattached transients 100.0 6. 2 3.8 1.1 2.7 2.5 93.8 1 Persons included in the selected sample of transients applying for public assistance in 20 cities covered by the Transient Case Study. The Study extended over a 6-week period between March 8,1938, and May 7, 1938. 2 The Southwestern resort States include Arizona, Colorado, and New Mexico. 3 Data on health migrants and health conditions in family cases relate to only one person per family. 108 The validity of these rates is supported by the results of X-ray examinations of a number of adult migratory cotton workers46 in Maricopa County, Ariz., carried out in the spring of 1938. Table 57 shows the results of interpretation of the films. Table 57.—Distribution of a selected sample1 of adult migratory cotton workers examined by X-ray, according to interpretation of roentgenograms for active tuberculosis Interpretation of roentgenograms W orkers examined Number Percent 583 100.0 566 97.1 8 1.4 9 1.5 i The study was carried out by the Arizona State Board of Health in cooperation with the U. S. Public Health Service during the late winter and spring of 1938 in 19 cotton camps in Maricopa County, Ariz. The incidence of definite active tuberculosis in this group was found to be 1.5 percent. The group was not transient in the sense used in the Transient Case Study, inasmuch as the persons concerned were not, at the time of examination, applying for public assistance. They were, however, migrants and probably had not acquired legal settlement under Arizona’s 3-year residence ruling inasmuch as they were selected because of residence in cotton camps. Brown,47 who studied the same group of people at the same time, has shown them to be “needy.” California does not have a particularly acute problem from tuber- culosis among transients, as indicated by the relative incidence of the disease among transients and residents, according to the Depart- ment of Public Health of the State. In July 1937, the Department began a statistical study of “the incidence of positive tuberculins and active tuberculosis among * * * the migratory population of the State.” 48 A summary of the results of tuberculin tests is shown in table 58. The Department comments on the findings of the study to the effect that it was of particular interest to note that the total percentage of positive tuberculin tests among whites was 26.9 and only 18.2 among adolescent (ages 15 to 19) whites. It was noted that among California residents in comparable age groups about 32 percent show positive tuberculin tests. In all, 1,808 X-rays were made. Of all migrants examined, less than 1 percent showed active tuberculosis.49 49 See “Tuberculosis Study,” in the Introduction. 47 See (11). 48 From (U)- 49 From (ii). Figure 14.—Tuberculous daughter of a transient living in a camp near Sacramento, Calif. Figure 15.—A transient with tuberculosis “takes the cure” in a southwestern State. 109 Table 58.—Distribution of tuberculin tests given migratory agricultural work- ers of specified race, according to results of tests 1 Results of tests All tests Tests given workers of specified race White Mexican Japanese Filipino Negro Total tests given 2,511 1,526 806 60 98 21 Number read 2, 324 1,410 735 60 98 21 Number positive- 798 380 338 19 48 13 Percent positive 34.3 26.9 45.9 31.6 49.0 62.0 1 Data supplied by Dr. S. F. Farnsworth of the California Department of Public Health. By way of summary, it may be said that in the resort States the incidence of pulmonary tuberculosis among transients is very proba- bly 2to 3 percent. There are approximately 3,000 tuberculous transi- ent persons annually requesting public assistance in the procurement of the ordinary necessities of life in the 5 study cities of these States. If all the towns and cities of these States are included, the number requesting public assistance during 1 year would be nearer 5,000. A considerable number of tuberculous transients have undoubtedly not been included in any of the data presented. The Transient Case Study was concerned only with persons applying for public assistance; therefore, the whole group of nonresident tuberculous persons able to secure ordinary necessities but unable to secure institutional care were not appreciably sampled in the Study. Because of various factors tending to keep tuberculous persons who need assistance only in securing hospitalization from applying for it, the proportion of tuberculous transients among applicants for public assistance must be lower than that among the entire transient population. In the absence of more definite data, it is estimated that the resort area con- tains 10,000 needy tuberculous persons who have not fulfilled the requirements for legal settlement in the respective States. Syphilis.—ln the discussion of tuberculosis the theoretical approach of estimating and evaluating dilution effects, that is, the effect of mixing two populations with dissimilar incidence rates of tuberculosis, was given consideration. This approach was appropriate in connec- tion with tuberculosis inasmuch as the disease is often, perhaps most often, transferred from one person to another without physical con- tact and without knowledge of the transfer. The tuberculous parent with a positive sputum usually cannot prevent infecting and rein- fecting his children so long as he remains in the household with them, since he cannot easily avoid the dissemination of tubercle bacilli in conversation, sneezing, or coughing, nor can he avoid some transfer of infection as he mingles with his fellow townsmen and neighbors. Society has recognized the probability of effective contact of the tuberculous with other persons through the necessary activities of ordinary life and has endorsed isolation of the tuberculous in hospitals. The situation is not the same with respect to syphilis. Effective contact in syphilis is, in most cases, the result of sexual or erotic physical contact. There is not an intermingling of all persons within a community in such a manner that syphilis transfer might be as likely from one person as another. Environmental influences, such as education, social and economic status, moral views, and personal habits, are so important that there is a decided tendency for syphilis in a given social or economic group to spread within that group more rapidly than into others. The theoretical approach of evaluating dilution effects on the general population would have little meaning in a discussion of syphilis. The important consideration in a discussion of syphilis seems to be the extent of the danger to resident contacts from transients with infectious syphilis and how it compares with the similar danger from residents who are likely to have the same contacts. The data on syphilis incidence to be presented in this section relate to unattached male transients. The resident group most likely to have the same sexual contacts as male unattached transients are the local homeless males who most nearly resemble them so far as social, economic, and habit patterns are concerned. Several factors on which the propagation of existing communicable disease depends may be disregarded in this discussion. Factors which in syphilis are probably not significantly influenced in a community by the presence of transients are: The susceptibility of the population, the virulence of the organism, and the rate of transfer of infection per case. A careful study of the incidence of syphilis among indigent transient men applying for residence in camps under the Federal Emergency Relief Administration Transient Program in Minnesota in 1934-35 has been made by Dukelow. The examinations comprising the study were made in conjunction with the routine physical examination re- quired of all such applicants and were made on 6,534 white men and 728 Negro men. Data presented include history of syphilis, evidence of congenital syphilis, primary syphilis, or secondary syphilis, and serological reactions by the Kline and Kolmer techniques.50 Three out of 2.419 white and 2 out of 350 Negro transient men were diagnosed as having either primary or secondary syphilis, a rate for the two groups of 0.124 percent and 0.571 percent respectively,51 Although these examinations were carefully done on a comparatively large number of transient men, the rates established are not signifi- cantly above zero and, accordingly, are of limited usefulness. In order to overcome this objection it would be necessary to examine a much 50 See (37) and (38). B1 See (37) and (38). larger group than was done under the Federal Emergency Relief Ad- ministration Transient Program or was possible during the present study. A great deal of data on this subject can be compiled from the records of routine examinations of transients during 193T-35, but in almost no instances, other than the study in Minnesota, was the work done with sufficient exactitude for the results to have statistical value. Syphilis incidence will be discussed as determined by serological reactions. In table 59 are shown percentages of the 6,508 white transient men and 727 Negro transient men, over 15 years of age, by 10-year age groups, whose tests were interpreted as “serological reaction positive” in the study by Dukelow. It will be seen that among Negro transients there were higher percentages of tests in all ages interpreted as “positive” than among white transients, but the greatest difference occurs in the two youngest groups, and differences decrease as the age of those tested increases. Table 59.—Distribution of positive serological reactions of 6,508 white and 727 Negro transients 1 examined in Minnesota in 1934-35, according to the age of the individuals 2 White Negro Age group Total examined Percent serological reaction positive Total examined Percent serological reaction positive Total s 6,508 7.4 4 727 18.8 15-24 1,233 2.11 235 14.0 25-34 1,707 6. 80 241 25.3 35-44 1,578 8.81 168 17.9 45-54 . „ 1.225 9.88 56 17.9 55-64 65 and over. ... _ .. 565 200 11.86 7.00 •27 11.1 1 According to Federal Emergency Relief Administration definition of the term 2 Data from (38). 3 Excluding 26 of unknown age. * Excluding 1 of unknown age. 5 Including all of known age, 55 years of age and over. Because of the very common practice of using the designations “local homeless,” “intrastate transients,” and “interstate transients,” it was believed important in the present study to compare syphilis incidence among these three classes of homeless persons. An opportunity to make such a study was offered in the Cincinnati Shelter Care Division Hospital which serves all three types of homeless persons and, further- more, has both the medical and social facilities necessary for such a study.52 Table 60 shows the results of the serological tests on white interstate transients in this institution, with the combined interpretation of the sa Refer to the Introduction for further description of the study. 112 two tests by the Kahn and Kolmer techniques.53 It will be noted that, while 7.9 percent of the total had serology positive for syphilis, the percentage varied from 3.5 percent in the age group 15-24 to 11.1 per- cent in the age groups 55-64 and 65 and over. This seems to indicate a direct relationship in these transients between age and probability of having positive serology. There is also a remarkable similarity be- tween the rates determined in Minnesota in 1934-35 and those found in Cincinnati 3 years later. Table 60.—Distribution of 596 white interstate transient males of different age groups examined l)y serological reaction, according to technique of test and interpretation of combined results1 Technique of test and interpretation of com- bined results All tran- sients Age group 15-24 25-34 35-44 45-54 55-64 65 and over Kahn Kolmer Number Total- _ 596 173 173 139 75 27 Serology Negative negative 540 635 1 4 9 5 4 0 47 0 39 8 167 167 0 0 0 0 0 0 6 0 6 0 154 152 1 1 3 3 0 0 16 0 15 1 123 122 0 1 3 1 2 0 13 0 10 3 64 63 0 1 3 1 2 0 8 0 5 3 24 23 0 1 0 0 0 0 3 0 2 1 8 8 0 0 0 0 0 0 1 0 1 0 Negative Doubtful Serology c Negative ioubtful Positive Negative.-. Doubtful Serology { Positive >ositive. Positive Doubtful Total Percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Serology n Negative egative 90.6 89.8 .2 .7 1.5 .8 .7 96.5 96.6 89.0 87.9 .6 .6 1.7 1.7 88.5 87.8 85.3 84.0 88.9 85.2 88.9 88.9 Negative Doubtful Doubtful Negative. _ ... ... .7 2.2 .7 1.4 1.3 4.0 1.3 2.7 3.7 Serology doubtful-. . Negative Positive Positive Negative Doubtful- Doubtful Serology r Positive ositive. Doubtful 7.9 3.5 9.2 9.3 10.7 11.1 11.1 Positive. 6.5 1.3 3.5 8.7 .6 7.2 2.2 6.7 4.0 7.4 3.7 11.1 Doubtful Positive 1 The blood specimens were collected in the spring of 1938 at the Cincinnati, Ohio, Shelter Care Division Hospital of the Department of Safety, under the direction of Dr. E. B. Brandes. The serological exam- mations were made at the U. S. Public Health Service Venereal Disease Research Laboratory, Stapleton, N. Y. Tables 61 and 62 present data on the percentage of positive sero- logical reactions in the homeless men studied in Cincinnati by race, 63 Similar tables for the two other classes of white cases and all classes of Negro cases are on file in the Division of Public Health Methods, National Institute of Health. 113 age group, and legal settlement status. Since there was considerable difference in the age distribution of those tests in the three categories by legal settlement status, adjustment to a standard population within each race has been made so that a comparison between the groups is more meaningful. There was no particular difference between the age distribution of white and Negro homeless males in the same legal settlement groups; hence age adjustment was made within the two races and not between them. Table 61.—Distribution of 914 homeless white men of different settlement status according to age, and percentage of each group serologically positive for syphilis1 All men examined Percent serologically positive Age group Total Local homeless Intrastate transients Interstate transients Local homeless Intrastate transients Interstate transients Total. 914 195 123 596 13.3 8.1 7.9 15-24- 207 6 28 173 3.6 3.5 25-34 232 25 34 173 12.0 17.6 9.2 35-44-..- 217 45 33 139 17.8 3.0 9.3 45-54 151 52 24 75 5.8 8.3 10.7 55-64 82 51 4 27 13.7 11.1 65 and over 25 16 0 9 31.2 11.1 1 The blood specimens were collected in the spring of 1938 at the Cincinnati, Ohio, Shelter Care Division Hospital of the Department of Safety, under the direction of Dr. E. B. Brandes. The serological examina- tions were made at the U. S. Public Health Service Venereal Disease Research Laboratory, Stapleton, N. Y. Table 62.—Distribution of 256 homeless Negro men of different settlement status according to age, and percentage of each group serologically positive for syphilis 1 Age group All men examined Percent serologically positive Total Local homeless Intrastate transients Interstate transients Local homeless Intrastate transients Interstate transients Total 256 106 24 126 38.7 37.5 29.4 15-24 57 5 6 46 20.0 21.7 25-34 80 30 8 42 26.7 50.6 33.3 35-44 56 26 8 22 50.0 50.0 18.2 45-54 42 25 2 15 44.0 50.0 60.0 65-64 15 15 0 0 46.7 6 5 0 1 20.0 1 The blood specimens were collected in the spring of 1938 at the Cincinnati, Ohio, Shelter Care Division Hospital of the Department of Safety, under the direction of Dr. E. B. Brandes. The serological examina- tions were made at the U. S. Public Health Service Venerea IDisease Research Laboratory, Stapleton, N.Y. The expected percentages in each group, if all groups had been similar in age distribution, are summarized in table 63, arranged by color and legal settlement status. It will be noted that, in all categories, white men have a considerably lower incidence of positive serology than do Negroes. In both races interstate transient males showed a lower percentage of positive sera than did the local home- less. This is believed to be an important consideration. 114 In conclusion it may be said that, from the consideration of inci- dence on the basis of serology only, unattached males in Cincinnati constitute, to their contacts, a considerable danger from syphilis and that, of the three groups by legal settlement, the local homeless has the highest incidence rate and consequently is most dangerous. Table 63.—Expected percentage1 of persons of different legal status, serologi- cally positive, among homeless men in a population adjusted for age within a race,, according to race Kace Legal settlement status Local home- less Intrastate transient Interstate transient • 10.4 33.6 7.4 34.8 8.3 28.9 1 Based on data from a study of the serological reactions for syphilis of homeless men. The blood speci- mens were collected in the spring of 1938 at the Cincinnati, Ohio, Shelter Care Division Hospital of the De- partment of Safety, under the direction of Dr. E. B. Brandes. The serological examinations were made at the U. S. Public Health Service Venereal Disease Research Laboratory, Stapleton, N. Y. The type of syphilis among transients is probably identical in every way with that found in resident groups. Contracted in the same man- ner, it has the same incubation period, symptoms, and objective signs, and, without treatment, will remain infectious for the same length of time. However, an infectious case of syphilis will become noninfec- tious much more quickly if treated adequately; hence the question be- comes, uUo transients receive treatment for syphilis as early as com- parable residents and are they equally likely to continue treatment?” Early and continuous treatment for syphilis in the needy depends on a number of factors and, in the light of existing knowledge about these factors, a reasonably correct judgment can be made. Treatment of an individual case of infectious syphilis depends initially on the patient’s realization that his symptoms or lesions are a manifestation of disease for which he should have medical advice. There is no reason to assume any difference between transients and comparable residents in this respect. The individual must also know of available medical care and be willing to avail himself of it. In this respect the transient is at a dis- tinct disadvantage. In many cities treatment is not available to the transient. Even where clinics will accept him. he is less likely than the resident to know of treatment centers or physicians that will treat him free or at reduced rates. Also, he is probably more averse to admitting his condition to public officials than a local man would be. The transient usually thinks of himself as definitely a stranger in the community. He knows that residents think he does not belong. He 115 lias learned early in his transiency that a request for assistance is often granted only as he promises to leave the jurisdiction of the agency to which he applies. It would be very surprising if he were not more reluctant than the resident to request public medical care for syphilis. Fortunately, it seems very probable that the ill effects of the tran- sient’s ineligibility for treatment, or at least the discrimination against him when he seeks it. will soon be mitigated. Paragraph 5, Section XV, of the “Regulations governing allotments and payments to States for venereal disease control activities for the fiscal year 1910” states: “To receive funds under this Act, diagnostic and treatment services shall be as freely available to infected residents of other States and counties as to people who reside in the governmental unit providing the services.” 54 As the funds provided for this purpose increase and as the numbers of clinics receiving financial aid under the Act become more numerous, there should be less discrimination against the tran- sient with syphilis, and he should be more likely to avail himself of known facilities; as a consequence, his danger to residents will be lessened. TypJwid fever and dysentery.—ln these two diseases one would expect the greatest difference in incidence between transients and residents. The deplorable sanitary conditions under which many transients live have been widely discussed. Transients who live in crowded camps without a safe water and food supply and without proper sewage disposal would be expected to have a higher incidence of these diseases than would residents of towns and cities with adequate sanitary facilities or rural people living in well-ordered individual homes. Morbidity reports on these diseases are, unfortunately, not avail- able by residence status. However, health workers and most social workers who have had any experience with transients testify to the high prevalence of this type of disease among them. Dr. Lee A. Stone, Director of the Madera County (Calif.) Health Department, tells of one migratory agricultural family: “The Dozier clan * * * began presenting the county with cases of typhoid fever. A total of 11 cases of typhoid fever occurred out of the 42 (individuals) in the clan.” 53 Only 3 cases of typhoid fever occurred in Madera County in 1938, all of them among migratory agricultural workers from Oklahoma.66 Dr. Ellis D. Sox, Health Officer of Tulare County (Calif.),says: “Of the 12 cases of typhoid fever occurring in Tulare County during the 54 See (121). 65 See (109), p. 3. 08 From (53). 116 last 6 months of 1938, all but 2 were in camps and directly in our migratory population. Forty-three cases occurred during the last 6 months of 1937,” His comments on the work being done to combat the situation are: “The control of typhoid fever has been largely through immunization and education until the present health depart- ment was estabished [July 1938] and since then the control of typhoid fever has been primarily through cleaning up of insanitary condi- tions.” 57 The Agricultural Experiment Station of the University of Wash- ington reports that in the hop camps of that State, “Sickness, particu- larly dysentery, was found in nearly all camps. In one large camp the nurse on duty said that in 2 weeks she had dispensed 3 gallons of dysentery medicine. In no other camp was this service pro- vided * * 58 Dr. J. D. Dunshee, of the Arizona State Board of Health, says: “Typhoid fever has been found existent with 4 cases in one camp and 3 additional suspicious ones in the same camp. Dysentery is common * * 50 In a report by the Children’s Bureau several instances of small localized epidemics of both typhoid fever and dysen- tery are cited.60 During the Transient Case Study all persons interviewed were ques- tioned on immunity to typhoid fever. Presumptive immunity was based on (1) having had typhoid fever at any time; or (2) having had three inoculations against typhoid fever at weekly intervals within the last 3 years. In table 64 the data from these questions are shown. It is believed that the transient groups studied contain a relatively high proportion of presumptive immunes as compared with either a predominantly rural or an urban population, and that this is true largely as a result of the intensive campaign of immunization carried out by the departments of health of some of the western States, par- ticularly Arizona, California, and Washington. Dr. Walter M. Dickie of California reports on September 4, 1937, that “Up to August 27, almost 24,000 injections of typhoid vaccine have been administered to migrants.” 61 The Maricopa County (Ariz.) Health Department had placed emphasis on this campaign during the year prior to the Tran- sient Case Study, and the California State Department of Health had done likewise throughout the counties with any considerable transient agricultural problem. 67 From (53). 68 See (122), p. 20. 69 See (S9). 00 See (7J,). 61 See (S2), p. 127. 117 Table 64.—Distribution of transients with presumptive immunity to typhoid fever interviewed in 20 study cities, according to family attachment1 Family attachment All persons in cases interviewed Persons with presumptive immunity to typhoid fever Number Percent of total per- sons in cases interviewed Total 16,145 5,305 mm Family transients 7,105 1,849 26.0 Unattached transients 9,040 3,456 38.0 1 Persons included in the selected sample of transients applying for public assistance in 20 cities covered by the Transient Case Study. The Study extended over a 6-week period between March 8, 1938, and May 7, 1938. The interval for which disabling illnesses were reported by transients includes the 3 months pre- ceding the date of interview. Six cases of typhoid fever were reported as having occurred during the 3-month survey period among the 6,560 transients in interviewed cases in Arizona and California. Expressed as an an- nual incidence rate, this is 367 cases per year per 100,000 transients, although the annual rate of typhoid and paratyphoid fever reported for the entire United States was 11 per 100,000 in 1938.62 It is doubtful whether or not the rate determined for transients is as high as the one actually occurring among these people. For example, although roughly one-fourth of the 6,560 transients inter- viewed in Arizona and California were unattached transients, no case of typhoid was reported as having occurred among this group within 3 months. The factor of health selection probably operated to eliminate from the unattached transient group studied those who had had typhoid fever during the 3 months just prior to the Transient Case Study. It is a debilitating disease and one with a compara- tively long period of convalescence. Few unattached transients who had had typhoid fever in the preceding 3 months would be found by the method of study used since the majority of those who had suffered from the disease had probably either merged into the resi- dent population by returning to their States of legal settlement or had remained in the hospital as convalescents. Another reason for suspecting that the number of cases reported was fewer than actually occurred is that so few of the cases were diagnosed by physicians. An illustration is the “R” family, inter- viewed in California. The family consisted of a grandmother, two of her daughters, her son and daughter-in-law and their five children. The family migrated from Oklahoma to California in January 1938 for the health of one of the daughters who suffered from “asthma.” None of them had presumptive immunity to typhoid fever. On KSee (120). 118 February 14. one of the grandchildren became ill with symptoms of “fever and diarrhea.” Of two physicians who saw the child inde- pendently, one thought it had measles, the other diagnosed the condition as scarlet fever. Forty-three days later, at the time of the interview, the child was still ill. On the tenth or eleventh day of March, six other members of the family became ill. Of the six, two were considered typhoid fever cases by physicians and hospitalized; another had “diarrhea and stomach pain” but was not seen by a physician and was still ill at the time of interview; two others, aged 10 and 3 years, had “fever and headache” and were seen by a physician but no diagnosis was made; and the last, a baby of 10 months, had been seen by a physician and the case diagnosed as “measles.” The grandmother was of the opinion that some of those not hospitalized had typhoid fever also, since “they acted like Robert and Lucille did.” She could very well be correct. Smallpox.—The incidence of smallpox among transients has be«n, and still is. very high. Dr, Lee A. Stone, of Madera County, Calif., reported 44 cases of smallpox in one camp in a period of about 4 months in 1938.03 Dr. A. N. Crain, Director of the Maricopa County (Ariz.) Health Unit, reports: “We have had and are still having [March 1939] an epidemic of smallpox, brought into the State by transients. There have been 150 cases from such contacts and new cases are yet being found.”64 Dr. Warren F. Fox, health officer of Imperial County, Calif., reports: “During the past few months [spring 1939] we have had 10 cases of smallpox imported * * * from Arizona. One case crossed the State line in the eruptive stage via a freight car!”65 Dr. Ellis D. S'ox, Health Officer of Tulare County, Calif., reports in March 1939: “We are in the midst of a small epidemic [of smallpox] at the present time which has been brought into this county by migratory workers from the northern part of the State and * * * from Buckeye, Ariz. The county has had 360 cases of smallpox during the last 12 months.” 66 Dr. John J. Sippy, District Health Officer, San Joaquin County, Calif., reports 62 cases of smallpox in the county during 1938, 15 of which were in migratory agricultural workers. Up to March 1939, 3 cases of smallpox had occurred in San Joaquin County. 2 of which were exposed in Maricopa County, Ariz., and rode by auto to California.67 On one day in the field the author of this study saw 5 cases diag- nosed as smallpox and traceable to cotton workers in Arizona. *» See (109). 61 See (53). 66 See (53). 68 See (53). 67 See (53). 119 The percentage of transients having presumptive immunity against smallpox either because they have been vaccinated or have had the dis- ease is somewhat higher than for immunity against typhoid fever. Table 65 shows the number and percentage of transient persons who “had had smallpox or had a. vaccination scar and had been vaccinated within the past 7 years.” The higher percentage of presumptive im- munity against smallpox does not. however, mean that transients neces- sarily have better protection against smallpox than against typhoid fever. Individual protection against the latter, in present-day prac- tice, is predicated on avoidance of exposure, chiefly through food and water, and on artificial active immunization if exposure is believed unavoidable. This is not the case with smallpox. No person is con- sidered reasonably protected against this disease unless he has had a successful vaccination against the disease within the last few years. Table 65.—Distribution of transients with presumptive immunity to smallpox interviewed in 20 study cities, according to family attachment1 Family attachment All persons in cases interviewed Persons with presumptive immunity to smallpox Number Percent of total persons incases inter- viewed Total-. 16,145 7,105 9,040 7,554 2,915 4,639 41.0 51.3 Family transients. Unattached transients 1 Persons included in the selected sample of transients applying for public assistance in 20 cities covered by the Transient Case Study. The Study extended over a 6-week period between March 8,1938, and May 7, 1938. The interval for which disabling illnesses were reported by transients includes the 3 months preceding the date of interview. Along with the program of inoculation against typhoid which has been cited, many local and State health departments are giving a great deal of attention to seeing that all migratory agricultural workers are protected against smallpox. In Tulare County alone, 18,000 individuals were vaccinated against smallpox during 1938 by the County Health Department,68 Equally heroic efforts are being made by other health departments in California and Arizona. How- ever, it is not likely that any such departments, under their present budgets, will be able to approximate 100 percent vaccination of the transients under their jurisdiction without serious neglect of other duties. Even in the Farm Security Administration camps where 68 See (SS). 120 health workers are assigned full time, only 864, or 80 percent, of the 1,083 family individuals in interviewed transient cases had presump- tive immunity to smallpox. Meningococcic meningitis.—ln the case of meningococcic menin- gitis, transients are perhaps more likely than any other class to give rise to an epidemic. It is a matter of general epidemiological knowl- edge that when a number of adults, not previously accustomed to such conditions, are quartered in congregate shelters, the probability of epidemic meningitis occurring among them is greater than among groups not so constituted. Cook,69 studying enlisted men in the United States Navy, has shown that the attack rates of this condition are in inverse ratio to length of exposure to congregate living; and further, that men entering “barracks” life during the fall and winter months had a much higher attack rate than those whose service life began during the spring and summer. Congregate shelters for homeless men have many of the charac- teristics necessary for an outbreak of meningitis, and epidemics of the condition have occurred in them. One such epidemic was re- ported as arising in a municipal lodging for homeless men in Cin- cinnati when 20 cases occurred during the spring of 1935.70 INTRODUCTION OF NEW COMMUNICABLE DISEASES The spread of most communicable diseases from one country to another or from one community to another depends primarily on the movement of human carriers. There are a few exceptions such as plague, yellow fever, and tularaemia, in which animal hosts may transport the condition to new territories, but the majority of com- municable diseases are dependent on man for introduction into new populations. Whether syphilis was introduced into Europe from the Western Hemisphere or from the Orient, it was nevertheless seen in Europe only after there had been a movement of people from those areas to Europe. The history of epidemic diseases among the South Sea Islanders and, recent studies of epidemics in the Faroe Islands all support the contention that most communicable diseases are spread by human carriers. Since transients are persons who have migrated, more or less re- cently, into communities other than those in which they were born, they have one characteristic, that of migration, necessary for the spread of communicable disease. That they are needy persons has no significance. But several other conditions are necessary to make a migrating group responsible for the introduction of a commun- 69 See (29). 70 See (10). 121 icable disease into an uninfected area. These factors are: (1) There must be at least one individual in the migrating group who has the disease in a form that is communicable; (2) there must be, in the area to which migration is directed, a means of transmission from infected to noninfected persons; (3) there must be, in that area, individuals susceptible to the disease. This discussion will be limited to the class of communicable dis- eases endemic in parts of this country and practically nonexistent in others. The distinction between these diseases and those that recur periodically is not entirely clear. Measles has been classified in this study as an endemic disease, that is, one existing at practically all times throughout the United States. Yet there are months in which no cases are reported from some States. This is also true of malaria, anterior poliomyelitis, and other diseases discussed in this section as not endemic in parts of the United States. This last group of dis- eases does, however, have this distinguishing characteristic: They are not expected to occur at fairly regular intervals in all States, while in the case of tuberculosis, measles, diphtheria, and the other conditions discussed previously, not only can it be predicted that cases will occur, but the expected number can be estimated with some degree of accuracy. It is on the basis of unpredictability, then, that the diseases discussed in this section are classified. The classification will serve and is used only to illustrate the influences of the intro- duction of pathogenic organisms into areas relatively free of the con- ditions caused by them. Malaria.—Probably malaria is the best example of this class of “unpredictable” diseases, both from the standpoint of economic im- portance and limited endemicity. The discussion of this disease will be used to illustrate the principles involved in introducing a disease into areas not ordinarily suffering from it. In the years 1936 and 1937 combined, 241,510 cases of malaria were reported to the various State departments of health and to the United States Public Health Service from 38 States. Of this number, 206,694 cases, or 86 percent, were reported from 4 States, Georgia, Mississippi, South Carolina, and Texas. Twenty-three other States in 1936 and 20 States in 1937 reported fewer than 100 cases each. While it is recognized that reporting of malaria is very incomplete, it is believed that data on the true incidence, if available, would not materially affect this picture of endemicity within the United States. There are certainly several States where, for a number of reasons, no cases of malaria occur during the average year. Some localities may lack a type of mosquito capable of transmitting the disease from one human to another. In most States, however, even in the 122 majority of those relatively free of the condition, mosquitoes capable of transmitting the disease may be found in the vicinity of human habitations; and, furthermore, the resident population is susceptible to malaria. In such communities, in order for malaria to invade the resident population, there is needed only the presence of persons with malaria in a stage easily transmitted, and opportunities for mosquitoes to feed on them and subsequently on the noninfected. No recent localized epidemics of malaria have been proved to be due to transients as such. However, since the only real difference between transients and other types of migrants is a matter of finan- cial status, which is not a factor with which the malarial parasite is concerned, epidemics apparently due to migrants and designated as “imported epidemics” will illustrate the situation satisfactorily. In the late summer and early fall of 1934, 37 cases of malaria were diagnosed in Aurora, Ohio, although prior to this epidemic no cases had been reported in the community since 1920. In the report of this outbreak the authors conclude: “It is probable * * * that the epidemic here reported was due to the introduction of an infected individual.” 71 In reporting an epidemic which occurred in Paw Paw, Mich., in August 1934, the health officer of the county says: “Several residents (of Paw Paw) have chronic malaria and some of their original infec- tions were contracted while visiting Central American countries.” 72 An epidemic of 30 cases of malaria occurring within a mile radius of Mills Fall Pond in Tazewell County, Va., in August and Septem- ber 1935 was believed by the investigator to have arisen from members of camping parties from eastern Virginia who spent 2 or 3 weeks on the lake during the summer.73 With reference to the small epidemic of malaria reported at Coving- ton, Va., in 1923, there is quoted below a portion of the Quarterly Report on Malaria Control, 1923, submitted by Clinton A. Kane, Director of Malaria Control, State Department of Health of Virginia: One small epidemic of malaria occurred in Covington and was investigated * * *. Twenty cases of malaria were reported in July from Covington, Alle- ghany County, Va. As this county has never before reported malaria, an investi- gation was made by Dr. Roy K. Flannagan, Assistant Health Commissioner, and later in August a survey in detail was made by the Malaria Department. Many breeding places of Cnlex were found in Covington but only in one section of the area was Anopheles breeding found. This was a large seepage area located in the section from which the malaria cases occurred * * *. In tracing the his- tory of malaria in this town it was found that (a railroad company) was doing excavation work and had imported laborers from the tidewater section of Vir- ginia, which, of course, is in the malaria belt. Upon further investigations it was 71 See (60), p. 1. 72 See (85). 73 See (52). 123 found that one of there men was boarding in the part of the town in which mala- ria later occurred. While living there he had a relapse, having had malaria previously to this attack. The infection was undoubtedly carried to Covington in this way. It would seem then that epidemics of malaria not only may but do occur in areas practically free of the condition as a result of the immigration of individuals who harbor the parasite. In this manner, a transient or any other type of migrant might introduce the infection and in so doing introduce a great danger to the resident population. Similarly, other diseases may be introduced into areas and popula- tions relatively free of them by the entrance of individuals harboring, in an infectious form, the respective pathogenic organisms. For example, trachoma (a disease relatively unknown there formerly) has been reported as appearing in California in migratory workers. Although knowledge of the method of spread of infantile paralysis is not complete, studies of epidemics suggest that it is transported from one locality to another by carriers of the virus, who might well be transients. CREATION OF UNUSUAL AND INCONSTANT DEMANDS ON PUBLIC MEDICAL FACILITIES In Part I the causes responsible for the enactment of legal settle- ment status and poor laws have been discussed. In Part II it was shown that the practice of agencies that dispense public assistance, whether under statutory provision or not, is, among other considera- tions, often directed toward the exclusion of nonresidents from public benefits. It has been further shown that when the number of tran- sients increases in relation to the general population, especially in times of general economic distress, the tendency is for States and communities to increase all requirements prerequisite to public assistance as residents. These are but natural human reactions. They are rooted in the impulse, almost an instinct, to protect one’s property. While the average man may have no objection to the assistance of individual nonresidents whom he sees and recognizes as needy, he has an aversion to increased appropriations and increased taxes to support or assist persons whom he considers outsiders. There is also the very wide- spread belief that public organized assistance to nonresidents may tend to attract still greater numbers of such persons. It is believed that this effect will come about in any area in direct proportion to the excellence of the quality and quantity of relief given to transients in that area, as compared with relief dispensed to needy residents in other areas. If badly needed assistance is available anywhere, people will move to the community in which it is available. The 124 force of this attraction depends both on the compelling nature of the individual’s consciousness of need and the relative amount of assistance available in another community. It is doubtful whether very many unattached individuals would migrate any considerable distance solely to secure lodging in a better municipal lodging house than the one in which they find themselves. The benefits received might not compensate them for the uncertainties of a change of locale and the difficulties of travel. But for the sake of a relatively much more expensive type of public assistance, the situation may be quite different. Hospitaliza- tion for tuberculosis will serve as an example. There are in the United States thousands of tuberculous persons who realize their need of hospitalization but are unable to finance their stay in such an institution from private resources or to gain admission to available free beds for the tuberculous. Let any State or community provide free sanatorium care for all tuberculous persons regardless of resi- dence status and it is likely that many persons will promptly migrate there when it becomes known that such care is available. If, in addition, that State or community were in the area reputed to have a salubrious climate for respiratory diseases, the number of tuberculous migrants attracted and their rate of migration would be increased. The same principles operate in the search for public medical care for ordinary conditions. The number of persons who migrate great distances for medical care is, however, small. Only 1.8 percent of the unattached interstate transients and 1.2 percent of the interstate transient families interviewed in 20 cities had started migration in order to seek medical care. If those interviewed in Hot Springs, Ark., are eliminated, the percentage is negligible. Migration for free medical care is principally rural-urban and intrastate. Kestrictions against transients are set up in the statutes and admin- istrative practices of practically all public hospitals and clinics. But, on the other hand, transients do receive some free public medi- cal care. It has been shown that in the 20 cities studied there were 206 agencies that gave medical care to transients. Of these, roughly one-third restrict care to transients with emergency conditions, an- other third limit the ordinary care given to transients to selected cases only, and about one-fourth make no restrictions. In the statutes and administrative rulings governing the admission policies of these institutions, one can usually find some such clause as “nonresidents shall not be admitted to (hospital or institution) except for emer- gency conditions.” Even if some such provision is not made in the law or by formal ruling, emergency transient cases are usually ad- mitted in practice. Considerable differences exist between communities in what is considered an emergency condition. The staff of almost any hos- 125 pital considers an acute case of appendicitis or a broken leg as an emergency condition and will admit all persons with such conditions to the hospital. In the one condition the danger to life or, in the other, the danger of permanent deformity is universally recognized and everyone agrees that the circumstances constitute an emergency. The distinction is not so clear cut in less dramatic or less drastic conditions. Then, too, there are conditions for which transients are admitted to the hospitals in order to protect the public health. Most States require that the criminally insane and those afflicted wdth smallpox, diphtheria, scarlet fever, and other dangerous communicable diseases be isolated. In such conditions no consideration is taken of the resi- dence status of the individual. What then are the effects on community health of this demand on the public hospitals and clinics by transients? It is believed that there is very little direct effect on resident health. It is doubtful that any significant number of residents are deprived of beds in hospitals, visits to out-patient departments, or attention in clinics because those services have already been rendered or must be rendered to transients. Certainly in city or county general hospitals, venereal disease clinics, or out-patient departments, one would not expect the staff to admit transients to the point that service to residents would be lacking in quantity. This might, however, occur occasionally in medical facilities under private and nonprofit association control. Many such hospitals set aside a certain number of beds for charity patients. It has been shown that some hospitals and clinics do not restrict the type of service given to transients, nor do some of them make any distinction between transients and residents. If such hospitals are the only ones offering free hospitalization and clinic care in a community and if an unusually large number of transients migrate to the community, indigent residents needing this type of care might well be refused the service because of prior application by transients. It was stated m one study that “The overcrowded hospitals which must take emer- gency nonresident cases sometimes do not have room for those who have legal residence.” 74 A more certain effect of the presence of transients on the health of the community is the drain on health funds and appropriations through the hospitalization and medical care that communities fur- nish to them. The study will not, at this point, consider the right of transients to medical care, regardless of residence status. Tran- sients are consuming tax funds and private contributions set aside by the residents of communities for the medical relief of indigent See (115), p. 31. 126 residents and only the effect of this financial load will be discussed. Little data are available about the amount of funds consumed by transients in this manner. No comprehensive data on the subject for the entire United States exist, but it may be stated with certainty that the amounts are generally proportionate to the number of tran- sients in the various communities. The Transient Case Study has shown that, out of 14,076 transients not eligible for Federal hospital- ization as United States veterans or merchant seamen, 430 were ad- mitted to hospitals as bed patients during a 3-month survey period. In order to estimate, for one area, the number of interstate tran- sients actually admitted to hospitals, the 66 county or nonprofit asso- ciation general hospitals in California were requested in March 1939 to furnish these data from their admission records or from estimates. California was chosen because it is known to have both relatively large numbers of transients and a rather complete system of county hospitals. Table 66 shows the results obtained from this questionnaire. Roughly two-thirds of the hospitals replied. Of the county hospitals that replied all had admitted interstate transients to bed service. The mean annual number admitted was 571 per county hospital. If the replies are accepted as accurate, using $4.54 as the daily per capita cost in general hospitals 75 and 12.5 days as the average hos- pitalization per patient,76 the average annual cost to the people in each of these 15 California counties for free hospitalization in county hospitals of interstate transients in 1938 was $31,000. Table 66.—Distribution of transients admitted as in-patients to 4% registered1 general hospitals in California, 1938, according to control of hospital Control of hospital All reg- istered hospi- tals 1 Hospitals replying to questionnaire Transients admitted2 to in-patient service, 1938 Mean annual number admitted by hos- pitals accepting any tran- sients Total Giving care to transients Not giving care to transients Total Free Part- pay Total 66 42 28 14 8,918 8, 294 624 318 County.. . 27 15 15 0 8, 660 8, 227 333 571 Nonprofit association 39 27 13 14 358 67 291 27 1 Registered with American Medical Association, Hospital Number, J. Am. Med. Assoc., 112/935-938 (March 11, 1939). Only hospitals under the control of county governments and nonprofit associations are included. 21 hospital reported number discharged. Only 13 of the 27 nonprofit association general hospitals replying to the questionnaire had admitted interstate transients to in-patient 75 See (117) for derivation of this figure. 7a Refer to (67), p. 909 for derivation of this average, 127 service and the mean number admitted annually was 27. From the replies it would seem that the load borne by county hospitals in California was much greater than that of nonprofit association hos- pitals. A study of transients applying for free and part-pay medical care in Los Angeles in 1937 showed that, of 1,011 applicants to 7 public and 9 private agencies during the period January 25 to February 24, 167, or 16.5 percent, were hospitalized, and 849, or 84 percent, were accepted for medical care “in spite of the established policy of the majority of the medical care agencies not to care for transients.”77 From these data it would appear that roughly 2,000 transient patients a year are admitted to free or part-pay hospital beds in these 16 medical agencies of Los Angeles, and that an additional 9,000 are given medical care other than hospitalization. It has been estimated th&t hospitalization of transients at Los Angeles County General Hospital alone costs about $170,000 annually and that 92 percent of it is free care. The most thorough available analysis of the cost of hospitalization of transients or “nonresidents” is that of the Department of Admis- sions of Louisville City Hospital. This department estimated in 1937 that “it means that the nonresidents cost the city $14,740.50 last year for care only. The taxpayer foots the bills.” 78 The annual report of this same department for 1938 79 shows that 427 nonresidents applied during the year for admission to the wards as bed patients. One hundred forty-eight of these were rejected because of lack of residence and 279 were admitted to the hospital and referred later to other hospitals, physicians, and fiscal authorities. The average length of hospitalization of all cases referred after hospitalization was 12.3 days and the average daily cost per patient $2.60. On these bases hospitalization of nonresidents in this hospital cost Louisville tax- payers approximately $9,000 in 1938. It should be noted that of all nonresident applicants 260, or 60 percent, were from Kentucky out- side Louisville. Kentucky has a small transient problem as com- pared with some of the southwestern States, which accounts for the high proportion of intrastate transients among these applicants. If plans are made for providing more adequate medical care to transients, consideration should be given to the financial burden now being carried by a relatively few States and communities in supplying public medical care to individuals who are largely the legal respon- sibility of other States. 77 See (25). 78 See (80). 78 See (79). 128 References (1) Anderson, Nels, and Lindeman, Eduard O.: Urban Sociology. Crofts, New York (1928). (2) Arizona State Board of Health: Arizona Public Health News. No. 145 (March 1938). (3) Baker, O. E.: Urban Migration and the National Welfare. Annals of the Association of American Geographers, 13 : 59-126 (1933). (4) Bauer, Catherine: We Face a Housing Shortage. Housing Officials Year- book, National Association of Housing Officials (1937). (5) Baughman, C. F., Chief, Sanitary Division, Kern County (California) Health Department: Survey of Kern County Migratory Labor Problems. Bakersfield (1937). (6‘) Beard, Charles A. and Mary R.; The Rise of American Civilization. Macmillan, New York (1933). (7) Beecroft, Eric, and Janow, Seymour: Toward a National Policy for Migra- tion. Social Forces, 16: 475-492 (1938). (8) Beveridge, W. H.: Unemployment, a Problem of Industry. Longmans, Longmans, Green and Co., London (1930). (9) Boutmy, Emile: Elements d’nne psychologie politique du peuple americaine. A. Colin, Paris (1902). (10) Brandes, E. B.: Transiency and Related Medical Problems. Presented-at a meeting of the Ohio Welfare Conference, September 16, 1937. Un- published. (11) Brown, Malcolm J., and Cassmore, Orin: Migratory Cotton Pickers in Arizona. Works Progress Administration. U. S. Government Printing Office, Washington, D. C. (1939). (12) Bruce, Isabel Campbell, and Eickhoff, Edith: The Michigan Poor Law. The University of Chicago Press, Chicago (1930). (13) Bruncken, E.: Die amerikanische Volksseele. F. A. Perthes, Gotha (1911). (Ut) Bryce, Janies: The American Commonwealth. Yol. 11, Macmillan, New York (1921). (15) Buck, Carl E.: Plealth Survey of the State of New Mexico. New Mexico Tuberculosis Association. New Mexican Publishing Oorp., Santa Fe (1933). (16) Buecher, Karl: Die Entstehung der Volkswirtschaft. H. Laupp’sche, Tue- bingen (1906). (17) Capen, Edward Warren: The Historical Development of the Poor Law of Connecticut. Columbia University Press, New York (1905). (18) Carpenter, Niles: The Sociology of City Life. Longmans, Longmans, Green and Co., New York (1931). (19) Carrington, P. M.: Interstate Migration of Tuberculous Persons. Pub. Health Rep., 30: 826-841 (1915). (Reprint No. 266.) (20) Cavan, Ruth Shonle: Suicide. University of Chicago Press, Chicago (1928). (21) Channing, Alice: Child Labor on Maryland Truck Farms. Children’s Bu- reau, U. S. Department of Labor. U. S. Government Printing Office, Washington, D. C. (1925). (22) Children’s Bureau, U. S. Department of Labor: Child Labor in the Fruit and Hop Growing Districts of the Northern Pacific Coast. U. S. Gov- ernment Printing Office, Washington, D. C. (1926). (23) Children’s Bureau, U. S. Department of Labor: Child Labor and the Work of Mothers in the Beet Fields of Colorado and Michigan. U. S. Gov- ernment Printing Office, Washington, D. C. (1923). (24) Children’s Bureau, U. S. Department of Labor; The Welfare of Children in Cotton-growing Areas of Texas. U. S. Government Printing Office, Washington, D. C. (1924). (25) Clinic and Hospital Section of the Health Division, Council of Social Agencies of Los Angeles: A Study of Transients Applying for Medical Care at Free and Part-pay Clinics in Los Angeles (March 1937). Mimeo- graphed. (26) Colorado Session Laws, Chap. 216 (1937). (27) Committee on Care of Transient and Homeless: After Five Years. New York (1937). 129 (28) Committee on the Health Problem of Transients in Cincinhati; Report to the Coordinating Committee of the Public Health Federation. Cincinnati (1939). (29) Cook, S. S.: The Incidence of Cerebrospinal Fever in the United States Navy as Related to Length of Service and Season of Enlistment. Am. J. Hyg., 23: 472-485 (1936). (3d) Creech, Margaret D.: Three Centuries of Poor Law Administration. A Study of Legislation in Rhode Island. University of Chicago Press, Chicago (1936). (31) Department of Industrial Relations, California: Second Biennial Report, 1930-32. San Francisco (1933). (32) Department of Public Health of California; The Health of Transient and Migratory Laborers in California. Weekly Bulletin, 16: 125-128 (1937). (33) Derryberry, Mayhew: Reliability of Medical Judgments on Malnutrition. Pub. Health Rep., 53: 263-268 (1938). (34) Dickie, Walter M.: Health of the Migrant. J. Am. Med. Assoc., Ill: 763-766 (1938). (35) Donnell, Charlotte C.: Settlement Laws and Interstate Relationships. Social Service Review, 4: 427-451 (1930). (36) Dublin, Louis L: Life, Death, and the Negro. American Mercury, 13: 37-45 (1927). (37) Dukelow, Donald A.: Report of the Medical History and Physical Exam- ination of the Applicants for Federal Transient Camps from June 7, 1935, to September 20, 1935, at the Minneapolis, Minnesota, Office. Unpublished. (38) Dukelow, Donald A.: A Serological Study of Transient Men, Minneapolis, Minnesota. Unpublished. (39) Dunshee, J. D.: Public Health in Arizona. Arizona State Board of Health, Phoenix (1938). (I/O) Farm Security Administration, U. S. Department of Agriculture: Monthly Report of Medical Director. Washington, D. C. (October 18, 1938). Typewritten. (Ill) Farm Security Administration, U. S. Department of Agriculture; The Problem and Ways of Meeting It. Mimeographed. (Jt2) Farm Security Administration, U. S. Department of Agriculture: Annual Report of Medical Director, July 1,1937, to June 30, 1938. Mimeographed. (43) Farm Security Administration, U. S. Department of Agriculture: Outline of Migratory Labor Camp Program, The California Medical Program. Mimeographed. (lilt) Farnsworth, S. F., Coordinating Officer of the State Department of Public Health of California: Personal communications. (lis) Faulkner, Harold Underwood: American Economic History. Harper, New York (1935). (46) Faverman, Anita E.: A Study of the Health of 1,000 Children of Migra- tory Agricultural Laborers in California. Bureau of Child Hygiene, California State Department of Public Health, San Francisco (1937). (.£7) Feiler, A.: Amerika-Buropa, Erfahrungen einer Reise. Frankfurter So- cietats-druckerei, Frankfurt a. M. (1926). (48) Franzen, Raymond: Physical Measures of Growth and Nutrition. Ameri- can Child Health Association, New York (1929). (If 9) Frost, W. H.: How Much Control of Tuberculosis? Am. J. Pub. Health, 27: 759-766 (1937). (50) Gillin, John L.: History of Poor Relief Legislation in lowa. lowa State Historical Society, lowa City (1914). (51) Goodrich, Carter, and others: Migration and Economic Opportunity. University of Pennsylvania Press, Philadelphia (1936). (52) Harper, Edgar 0., Deputy Director of Rural Health; An Outbreak of Malaria in the Mountains of Virginia at an Elevation of 1,800 Feet. Virginia Department of Health, Richmond. Unpublished. (53) Health Officers of the Respective Counties: Personal communications. (54) Health Program. Fresno (California) Bee and Republican, December 31, 1938, requoted from California and Western Medicine, 50: 158 (1939). (55) Hebbard, Robert W.: Unifoi’m Settlement Laws. Proceedings of the Na- tional Conference of Charities and Corrections, pp. 416-427. Fort Wayne Printing Co., Fort Wayne (1914). 130 (56) Heberle, Rudolf: Liber die Mobilitat der Bevolkerung in den Yereinigten Staaten. G. Fischer, Jena (1929). (57) Heisterman, Carl A.: Statutory Provisions Relating to Legal Settlement for Purposes of Poor Relief. Social Service Review, 7: 95-106 (1933). (58) Hirsch, Harry M.: Our Settlement Laws. State of New York, Department of Social Welfare (1933). (59) Holland, Dorothy F., and Perrott, G. St. J.: Health of the Negro. Milbank Memorial Fund Quarterly, 16: 5-38 (January 1938). (60) Hoyt, R. N., and Worden, R. D.: Malaria Epidemic in Aurora, Ohio. Pub. Health Rep., 50; 895-897 (1935). (61) Hyma, Albert: Europe from the Renaissance to 1815. Crofts, New York (1931). (62) The Interdepartmental Committee to Coordinate Health and Welfare Activi- ties ; A National Health Program. U. S. Government Printing Office, Washington, D. C. (1938). (63) Interstate Commerce Commission, Bureau of Statistics: Accident Bulletin No. 106, Calendar Year 1937. U. S. Government Printing Office, Washing- ton, D. C. (1938). (6Jf) Jernegan, Marcus Wilson: Laboring and Dependent Classes in Colonial America, 1607-1783. University of Chicago Press, Chicago (1931). (65) J. Am. Med. Assoc., 108: 1035-1122 (1937). (66) J. Am. Med. Assoc., 110: 959-1048 (1938). (67) J. Am. Med. Assoc., 112: 909-995 (1939). (68) Survey of Tuberculosis Hospitals and Sanatoriums in the United States. J. Am. Med. Assoc., 105: 1855-1913 (1935). (69) Kelso, Robert W.: The History of Public Poor Relief in Massachusetts 1620- 1920. Houghton, Boston (1922). (70) Kennedy, Louise V.: The Negro Peasant Turns Cityward. Columbia Uni- versity Press, New York (1930). (71) Kern County (California) Department of Public Health, Annual Report, 1937. Bakersfield (1938). (72) Kinberg, Olaf: On So-called Vagrancy—A Medico-sociological Study. Jour nal of Criminal Law and Criminology, 24 : 409-427, 552-583 (1933-34). (78) Kraeplin, Emil; Lectures on Clinical Psychiatry. Macmillan, New York (1913). (7-)) Department of Labor, Bureau of Labor Statistics and U. S. Children’s Bureau : Migration of Workers. U. S. Government Printing Office, Wash- ington, D. C. (1938). (75) Lanza, A. J.: Interstate Migration of Tuberculous Persons. Pub. Health Rep., 30: 1808-1826 (1915). (Reprint No. 283.) (76) Lescohier, Don D.; The Labor Market. Macmillan, New York (1919). (77) Lind, H. W.: A Study of Mobility of Population in Seattle. University of Washington Press, Seattle (1925). (78) Lorimer, F., and Osborn, F.: The Dynamics of Population. Macmillan, New York (1934). (79) Louisville City Hospital, Department of Admissions: Annual Report, 1938. Louisville (1939). Mimeographed. (80) Louisville City Hospital, Department of Admissions: Nonresidents Treated in City Hospital Ward in August 1937. Louisville (1937). Mimeo- graphed. (81) Malzberg, Benjamin: Rates of Mental Disease Among Certain Popula- tion Groups in New York State. J. Am. Stat. Assoc., 31; 545-551 (1936). (82) Maricopa County (Arizona) Welfare Board; Survey of Transient Tubercu- lous Persons. Phoenix (1936). Typewritten. (S3) Merriam, C., and Gosnell, H. F.; Non-Voting, Causes and Methods of Control. University of Chicago Press, Chicago (1924). (8-j) Mowrer, Ernest: Family Disorganization and Mobility. American Sociological Society, Proceedings, Chicago (1928). (85) Myers, T. R.: Malaria in Paw Paw, Michigan. Unpublished. (86) National Resources Committee; The Problems of a Changing Population. U. S. Government Printing Office, Washington, D. C. (1938). (87) National Tuberculosis Association: Tuberculosis Hospital and Sanatorium Directory (1938). (88) Ostrojorsky, M.: La democratie et les parties politiques. Calmann-Levy, Paris (1912), 131 (89) Perrott, G. St. J., and Collins, Selwyn D.: Relation of Sickness to Income and Income Change in 10 Surveyed Communities. Pub. Health Rep., 50: 595-622 (1935). (Reprint No. 1684.) (99) Perrott, G. St. J., Sydenstricker, Edgar, and Collins, Selwyn D.: Medical Care During the Depression. Milbank Memorial Fund Quarterly, 12: 99-114 (1934). (91) Pima County (Arizona) Welfare Board: Summary of Transient Cases. Tucson (1938). Typewritten. (92) Plumley, Margaret Lovell: Admission Policies for Out-Patient Departments. Hospital Management, 45: 20-22 (1938). (93) Plumley, Margaret Lovell: Location and Characteristics of 769 Out-Patient Departments. Hospitals, 11: 79-85 (1937). (94) Pollock, H. M., and Malzberg, B.: Expectation of Mental Disease. Mental Hygiene, 13: 138 (1929). (95) Queen, C. N., and Queen, S. A.: Obstacles to Community Organization. Journal of Applied Sociology, 8; 283-293 (1923-24). (96) Ravenstein: The Laws of Migration. Journal of the Royal Statistical Society, 48: 167-236 (1885). (97) Reed, Louis S.: The Ability to Pay for Medical Care. The Committee on Costs of Medical Care, Publication 25, pp. 61-62, University of Chicago Press, Chicago (1933). (98) Rosauoff, A. T.: Some Neglected Phases of Immigration. American Jour- nal of Insanity, 72: 45-58 (1915). (99) Schmid, O. F.: A Study of Homicides in Seattle, 1914-1924. Social Forces, 4: 745-756 (1928). (100) Shaffer, Alice, Wysor Keefer, Mary, and Breckenridge, Sophonisba P.: The Indiana Poor Law. University of Chicago Press, Chicago (1936). (101) Simmel, George: Soziologie. Duncker and Humblot, Leipzig (1908). (102) von Skal, Georg: Das amerikanische Volk. E. Fleischel and Co., Berlin (1908). (102) Smith, Adam: An Inquiry into the Nature and Causes of the Wealth of Nations. W. Strahan and T. Cudell, Loudon (1784). (104) Sorokin, P.: Social Mobility. Harper and Brothers, New York (1027). (105) Special Commission Report on Imperial Valley Labor Situation, National Labor Board, Leonard Report (February 11, 1934), (106) State Relief Administration of California: Migratory Labor in California. San Francisco (1936). (107) State Relief Administration of California: Review of Activities, 1933- 1935. Sacramento (1936). (108) State Relief Administration of California: Transients in California. San Francisco (1936). (109) Stone, Lee A.: What is the Solution to California’s Transient Labor Problem? Madera, California (June 22, 1938). Mimeographed. (110) Sweet, E. A.; Interstate Migration of Tuberculous Persons. Pub. Health Rep., 30: 1059-1091, 1147-1173, 1225-1255 (1915). (Reprint No. 269.) (111) Tauber, Conrad: Migration to and from German Cities, 1902-1929. Pro- ceedings of Int. Congress for Studies on Population, Rome (1932). (112) Thomas, Bordez Swaine; Research Memorandum on Migration Differen- tials. Social Science Research Council, New York (1938). (113) Thompson, Warren S.: Research Memorandum on Internal Migration in the Depression. Social Science Research Council. New York (1937). (114) Thornthwaite, C. Warren: Internal Migration in the United States. Uni- versity of Pennsylvania Press, Philadelphia (1934). (t!5) Underhill, Bertha S.: A study of 132 Families in California Cotton Camps. Division of Child Welfare Services, California State Depart- ment of Social Welfare, in conjunction with Bureau of Child Hygiene. California State Department of Public Health. San Francisco Califor- nia (1937). (116) United States Public Health Service: Annual Report of the Surgeon . . General. TT- Government Printing Office. Washington. D. C. (1938). (117) I nited States Public Health Service: Unpublished data from Business Census of Hospitals. Division of Public Health Methods, National Institute of Health. 132 (118) United States Public Health Service: Illness and Medical Care in Rela- tion to Economic Status. Sickness and Medical Care Series, Bulletin No. 2, The National Health Survey, 1935-1986, Division of Public HealUi Methods, National Institute of Health, U. S. Government Printing Ofhce, Washington, D. C. (1938). (110) United States Public Health Service: The Notifiable Diseases—l reva- lence in States, 1936 and 1937. Supplements Nos. 134 and 147 to Public Health Reports. U. S. Government Printing Office, Washington, D. C. (120) United States Public Health Service: Public Health Reports, 54:52 (1939) (121) United States Public Health Service: Control of the Venereal Diseases in the United States—Present and Future Plans. Supplement No. 10 to Venereal Disease Information. U. S. Government Printing Office, Washington, D. C. (1939). (122) Washington State College: Migratory Farm Labor and the Hop Industry on the Pacific Coast. Bulletin No. 363, Pullman, Washington (1938). (123) Webb, John N., Coordinator of Urban Research, Division of Social Re- search, Works Progress Administration: Data supplied by. (121/) Webb, John N.: The Migratory-Casual Laborer. Works Progress Admin- istration, Division of Social Research. U. S. Government Printing Office, Washington, D. C. (1937). (125) Webb, John N.: The Transient Unemployed. Works Progress Adminis- tration, Division of Social Research, Research Monograph 111. U. S. Government Printing Office, Washington, D. C. (1935). (126) Webb, Sidney and Beatrice: English Local Government, Vol. 7. Longmans, Longmans, Green and Co., London (1927). (121) Webb, Sidney and Beatrice: English Local Government, Vol. 9. Longmans, Longmans, Green and Co., London (1929). (128) Weeden, William B.: Economic and Social History of New England. Houghton, Mifflin and Co., Boston (1890). (129) Whitney, Jessamine S.: A Report on the Indigent Migratory Consumptive in Certain Cities of the Southwest. Pub. Health Rep., 38: 587-616 (1923). (Reprint No. 824.) (130) Whitney, Jessamine S.: The Tuberculous Migrant, A Family Problem, The Magnitude of the Problem. Proceedings of the National Con- ference of Social Work, pp. 249-257 (1929). (131) Willcox, W. F.: Distribution and Increase of Negroes in the United States. American Eugenics Congress, 2; 166-174 (1921). Williams and Wilkins, Baltimore (1923). (132) Wisner, Elizabeth; Public Welfare Administration in Louisiana. Univer- sity of Chicago Press, Chicago (1930). (133) Zimmerman, Carle; The Migration to Towns and Cities. Am. J. Sociol., 32: 450-455 (1926). (131/-) Leland, R. G.: Medical Care for Migratory Workers. J. Am. Med. Assoc., 114; 45-55 (1940).